In the same week that saw the Conservative party announce its plans for the
National Health Service came news that one in four NHS organisations in
England is failing to comply with basic hygiene standards. Survey after
survey reveals that patients are more concerned about catching an infection
in hospital than any other issue.
The rise of the hospital superbug is the visible sign of a bureaucracy in
crisis. Cases of MRSA in England and Wales have increased by 600% in the
past decade alone, according to government figures. Britain has one of the
worst records in Europe. The danger of contracting a bug here is more than
15 times higher than the next safest countries. Hospital-acquired infection
(HAI) affects 300,000 people a year, claiming as many as 20,000 lives, with
more than 5,000 a year dying of hospital superbugs such as MRSA.
Keeping a hospital clean does not require money or complicated equipment. It
does require will. It requires someone to exercise authority and take
responsibility. Florence Nightingale understood this when she cut the
fatality rate of wounded soldiers from 40% to just 5% by imposing basic
standards of hygiene and sanitation. She organised her nurses on almost
military lines and subjected them to military discipline.
What do we have instead? One former matron, now in audit work, pointed out the
difficulty of disciplining a nurse for incompetence in the NHS today. Modern
management is meant to “nurture” its employees. “You can’t bawl them out or
they’ll sue you for harassment,” she explained. Instead, “in a nice, soft
voice, you have to ask if that was the way she had been taught? Did she
consider it appropriate?”
The hospitals I visited during a year’s research appeared helpless to do
anything about their wards and staff. A sister in charge of a ward has
little say in how her ward is cleaned, when it is done or by whom. Certainly
she has no power to discipline cleaners. All she can do is complain to the
cleaning manager who deals with the outside contract cleaners.
One Filipina nurse complained: “No one tells the cleaner to change their water
when it gets dirty. If you don’t stipulate in the contract that the water
should be changed four times when you wash a particular ward, they won’t do
it.” She was shocked that her NHS hospital had no night cleaners as they do
in the Philippines, she said.
NHS staff themselves often fail to take the risk of HAI seriously. At a
hospital board meeting I attended, a consultant admitted: “I don’t get
stroppy with staff if they do not wash their hands.”
“I do,” replied another doctor. “But you are a surgeon,” pointed out the
first, “and I am just a gentle physician.” Stroppiness is not seen as a
virtue in the NHS.
I was standing outside a side room, containing a patient with MRSA, talking to
a matron and a nurse manager from infection control. Earlier I had been
shown the apron and glove dispenser at the entrance of the room. Every nurse
is supposed to put these on before touching the patient, then remove them
before leaving the room. Suddenly I noticed a nurse walk in, see to the
patient and then depart. She had not, despite the presence of her matron and
infection control manager, touched the dispenser.
Neither woman appeared to notice. In my astonishment I interrupted them. Had I
misunderstood? Was I being very stupid? It appeared not. The matron
tut-tutted. “You’ve got to have eyes in the back of your head with these
girls,” she said. The infection control manager nodded sympathetically.
“Doctors are far worse,” she added. There was no question of a reprimand,
let alone the sack.
Compare this with the enforcement of health and safety legislation elsewhere.
One industrial chemist, who found himself a patient of the NHS, was
horrified when he witnessed a similar scene. He would have been sacked on
the spot for not wearing the protective clothing or equipment provided by
his employers. NHS health and safety legislation, so powerful that it can
close down a hospital, does not – as the chief executive of one hospital
pointed out to me – even include infection control.
So will “autonomy and accountability”, the Conservative proposals for NHS
reform, do anything about our dirty buckets? The main feature of the report
is how little it differs from Labour’s own NHS reforms.
Patients, the Conservatives promise, can choose to be treated in the private
or public sector as long as the cost is the same or below that of the NHS.
If the cost is higher, patients cannot top up the NHS with their own money.
This is exactly what many might wish to do when they discover how the rates
of HAI in the private sector compare with the NHS. Infection rates for
hysterectomies, for example, vary between 0.74% to 2.8% in private
hospitals. In the NHS they are as high as 11%.
It is almost impossible for patients to make that comparison. Private
hospitals include the information on their websites or are happy to give it
over the phone. The matron of one told me proudly that its rate was 0% per
10,000 beds: “We often get inquiries and quite rightly so. I would want to
know.” In the NHS the Healthcare Commission provides information on trusts
but not on individual hospitals.
Even an NHS GP found it difficult to discover such information. He explained
that patients are on the “choose and book” system, but choice was restricted
to locality only.
The Tories agree that standards of information in the NHS are “lamentable”.
They promise to provide the public with information on the “prevalence” of
HAI – not only hospital by hospital, but also department by department. This
information is vital. Competition and patient choice will do more than any
government policy to force good practice up through the management hierarchy
of the NHS.
Meanwhile, we have allowed authority to absent itself where it should be all
important. Any politician contemplating healthcare reform must start with
the basics. And the basics are a clean pair of hands.
Managing Not to Manage – Management in the NHS, by Harriet Sergeant, is
published by the Centre For Policy Studies
If all hospitals were required by law to give their HAI infection rates to every patient requiring elective surgery or other treatments and procedures, patients would then be able to make a reasoned judgement whether to proceed or go elsewhere. Yes - this would produce 'league tables'-but why not. After all we have them for schools and there's no doubt they make staff try harder!! I would have gone to Europe for my bowel operation, probably The Netherlands, where patient safety is a priority. I had heard of MRSA but had no idea about the dangers from C.diff.
A few years ago, in Scotland, a butcher was prosecuted for
putting raw and cooked meats in the same cabinet. A number of people died from contacting a dangerous E-coli bacteria after eating cooked meats supplied by him. Shops, supermarkets and restaurants ALL have to adhere to strictly enforced hygiene laws, yet hospitals are allowed to get away with breaking all those guidelines which are supposed to ensure patient safety. Why?
Jenny A, Angus, Scotland
The state of hospitals is only one example of the general malaise of the society as a whole. No respect for experience, no one can be told what to do, no one expected to carry out the order. As a student nurse in a teaching hospital in the late 50s, I was expected to clean, I was told that the friction of scrubbing removed bacteria. In the late 60s the salesmen arrived, selling sprays, just a mist of some expensive spray to do the cleaning. Ill informed administration bought into this big time, thinking it would release staff for other work. Well it did....the nursing staff are sat in front of computer screens for most of the time. Of course way back then, nursing was spoken of as a vocation, it was more than just the job it appears to be today. Put nurses back in charge of the hospitals, get rid of these management types who have run the whole system into the ground. Put the honour and vocation back into the profession.
Jane Prior, Whiteway,
Why do so many people assume that the only way to get improvement is by harsh discipline? This is an old fashioned attitude that will not produce the same effect now as it did on the subservient workers of the past. Nowadays we need a more sophisticated psychology that engenders 'ownership' and the desire to take responsibility.
Tod, London,
This issue has been raised numerous times in numerous papers and on numerous websites but we still keep coming back to the same fundamental question of hygiene and being scrupulously clean. If the doctors, physicians ans surgeons, are incapable of keeping themselves clean, washing their hands and using gel dispensers and more especially on surgical wards, and if the nursing staff are not obeying guideline regulations on hygiene and wearing protective clothing then how the hell are you going to get the message across to the general public who only visit hospitals and, increasingly, very reluctantly? One must begin by re-introducing military style discipline and by disciplining staff who who not obey and follow health and safety instructions and, if necessary, send them for re-training. If they keep making the same mistakes then it is very simple, you sack them on the principle of 3 strikes and you are out. You cannot effectively control organizations, and people, without discipline.
Kenneth Armitage, Suffolk, England
This is a brilliant article. I am drawing it to the attention of my MP and I urge others to do the same. The author is quite right, it is the WILL to make hospitals clean which is needed, and staff cannot do this if the organisation is wrong.
ja, london,
Almost 30% of the healthy population carry MRSA. The best way of avoiding infection is for patients to be nostril-swabbed for the bacterium on admission (this was my experience the last time I entered a dazzlingly clean NHS hosptial). Perhaps rather than a clean pair of hands, a clean pair of nostrils is the target?
Diotima, London, UK
Absolute truth - ward cleaning, in yesterdays, was in the control if the ward sister operating on a daily, weekly, monthly rota. One "ward maid" and all staff executed such cleaning.
Michael, Bridgwater, UK
The nurture strategy is followed through to the Healthcare Commission also. After waiting two years for the HC to investigate my complaints about NHS hospital treatment, having upheld most of my complaint, they simply asked the hospital if they followed a certain method. They replied they had been and that was an end to it. The Healthcare Commission is just a toothless tiger and a waste of money.
Dave, Flitwick, Beds. UK
I can't see the point of cleaning hospitals more thoroughly,unless you ensure staff and visitors obey certain hygiene rules. Nobody knows ,for example,what someone may have picked up on their shoes before they walk into the hospital.Some procedures must be put in place to inspect visitors and staff before they enter the wards to ensure they are not bringing in more germs.
Mike, Dunstable, England
"Primun non nocere" ( in Latin) !!
julio klein, Pampatar, Venezuela
I have frequently seen Nurses in my local petrol station in the UK filling their cars up with fuel whilst dressed in thier uniforms - a situation which would be unthinkable in Norway .
grahamh, Oslo, Norway
Bring back matrons with real powers to run hospitals that are safe and clean
Jean Fraser, newcastle upon Tyne, england
It does involve money as well as will. The outsourcing of cleaning to contractors means that the contracts are often extremely 'competitive'.
This means that the contractors pay the individual cleaners as little as they can get away with.
Which means cleanerswho do as they are told and no more which is good for the contractors as their margins are so tight they must not use more time or detergent or materials than they can possibly keep to a minimum.
Which means a cleaner who won't refill buckets or change cloths or use more detergent.
Which means dirtier wards.
But I agree with your article otherwise.
Michele, Wales,
One does not need a degree in some discipline, to work out the problem or to identify a solution . Agreed, it is not rocket science. It is a management problem, in the implementation of basic hygiene standards, Despite, now years of publicity, the NHS hospitals have still not closed the problems down. I suspect it is largely down to the cavalier attitude of doctors, who swan around in their 'civilian clothes', and fail to wash their hands in between patients. Despite their status, they should be made to adhere to a Health and Safety at work Discipline for hospitals, as the rest of the work force do in their own workplace. Yes their is evidence of efforts being made to combat MRSA, but cleaning toilets then serving meals, is still a widespread practice. They obviously need to pull in a management consultancy company at great cost to identify the way forward.
Peter Mace , Eastbourne, England
The biggest problem is buying contracted cleaning using a cheapest quote system, this is killing people. It is also costing the NHS millions more in the long run.
The low contract price means cleaners are paid peanuts.
Pay peanuts and you get monkeys.
David Thijm, Stourbridge, UK
Why stop at cleaning up "dirty " hospitals ? How about a campaign to improve cleanliness in trains ,public toilets and suburban roads.
The first thing that strikes you about some countries {such as Germany, Switzerland and Sweden } is their immaculate public areas as one drives from their airports to the city centres.
Let's have a Minister for Clean public areas . Any volunteers ?
Abdul Jaleel (Dr.), Darlington, UK
I was in hospital for the day recently. The cleaner used her mop to clean a large ward but did not appear to even put the mop in the bucket again to rinse it out. Also the tea was passed to patients by two members of staff with their hands on the rims of the mugs. I pointed this out. The reply was roughly this. ' We all need a few bugs, some homes are too clean and that doesn't help with our immune systems'. My reply was 'This is not a home IT'S A HOSPITAL.
I spoke to a delightful young Asian doctor who said Scandinadian doctors who came to the hospital were appalled at the hygene and thought it more like the third world.
The concensus was that no one person is in charge of a ward and therefore no one takes responsiblity.
Jane Laing, Iver Bucks,
Get rid of all the "administrators" and bring back Matrons with a staff who can use carbolic soap as in the old days - little cross infection then - !
Tom Canning, Agassiz, Canada
100 copiess of this article should be sent to Gordon Brown today and every day until things change.
One change could be a law stipulating cleaning standards together with the right, even duty, of the NHS to summarily dismiss any and every person, or contracted company, which fails on any occasion to obey the cleaning standards law. It could also be stipulated that every single person or company employed by a hospital falling below certain standards could be dismissed with minimal notice and replaced with a completely new team.
Bertie Johnston, Overijse, Belgium
I am a nurse in the USA. Medicare, our entitlement health care plan for seniors, is just now beginning to address how hospitals deal with hospital acquired infections. However, many hosptials have self imposed processs - patients and families are encouraged to remind their caregivers about hand washing. In a hospital where my mother was recently a patient hand washing stations are posted outside critical care units and on every nursing care floor.
Now, if we could only convince doctors that they too play a role...
Mary Knight, RN , Kennedy Twp, PA/USA
A recent stay in the local NHS hospital pointed up the problem perfectly. In the wards and corridors every 20 feet or so were the hand washing materials and the large notices asking all visitors and staff to cleanse their hands. So far as I could observe on my daily visits the notices were almost universally ignored by both staff and visitors, without any consequence whatsoever.
Bring back Matron.
Peter FitzGerald-Morris, Rochester, England
The enemy is false economy. Contract cleaners clean and leave; the sooner the better. When they were employees of hospitals there was someone always around to properly clean up when, for instance, a patient yarks on the floor. They also developed an understanding of the culture of hospital cleanliness.
Rollingthunder, Hunter,
The article by Harriet Sergeant hit the nail on the head when she said that there is no-one prepared to discipline or sack the staff responsible for the poor standard of cleaning. Further to this is the fact that cleaning, though essential, is a menial job done by people who who would find difficulty in doing anything more demanding.
Cleaning should be taken away from contractors who will employ anyone who can walk, and should be staffed by a dedicated team recruited by a Manager who would take responsibility for the cleanliness of the Hospital and be required to spend his day walking the corridors and wards,checking on his workforce and not being afraid to tell them to do it again.
Has anyone ever seen the door handles or banister rails cleaned on the stairs? I open doors with my elbows or with a paper handkerchief.
Harry Kennard, RYE, UK/East Sussex
The managements responsible for hygene in hospitals should have visits and discussions with food manufacturers as part of their drive to remove all the bugs from hospitals, perhaps if they concentrate they may be able to learn something.
The use of cleaning contractors should cease immediatly and every person involved with cleaning everything in a hospital, should be employed by the hospital . The ward managers should be given the responsibility to enforce the high standard required.
I saw the way that low paid cleaning staff carried out their jobs in the non -food production parts of a food production factory. All they did was slop their mops around the floors with dirty buckets of water overloaded with stinking pine disinfectant which made some people choke. When rubber floor mats were lifted there was a well formed rectangle of filth because they were too idle to move them, the cleaning jobs were timed and they had to be out of the factory and on to the next cleaning contract.
Phil de Buquet, Newport, England
I have to go into hospital for a mastectomy. When I enquired about the rates of infection at the NHS hospital that I would be referred too, I was told by the breast cancer unit that all hospitals had MRSA and that i could look up my local hospital on the internet. Having the option I am going private.
Mary Bolton, Surbiton, UK
i once worked at a factory that was untidy, in places filthy, and therefore needed cleaning. in a round table discussion this was raised - the answer? another cleaner? no; another manager to co-ordinate the existing technical staff to keep tidy. result, more expense for a manager on 4 times the cleaners wage, technical staff diverted from essential work to clean, again on far higher pay than a cleaner. alice in wonderland!
Phil Barnes, Preston, England
My son contracted MRSA in 2003 aged 19 following emergency surgery for a sports injury and has been left disabled as a result.
Despite continued assertions that combating HAIs is a key issue, even the government now admits that the total number of HAIs has risen over the last four years.
Professor Barry Cookson of the HPA is unequivocal in his belief that the level of bed occupancy is the pivotal factor in the fight against HAIs and that performance targets directly militate against good infection control. Prof. Cookson's advice is quoted several times in Hansard - that bed occupancy of less than 85% is the single most effective measure in reducing hospital infections and yet the NHS routinely run at over 90%,
In a reply at PMQ in November 2006 which asked for assurance that combating HAIs would not be compromised by the current financial pressures in the NHS, Mr. Prescott stated “The Government’s record on the NHS is very good and is there for all to see.â€
Indeed.
Ruth Wollacott, Hornchurch, Essex
Responsability rests with the Secretary of State.
Robert, London, UK
A very good article. Of course it won't be easy to change the NHS system - reform of any sort never is! But we need a politician who is prepared to stand up for what is right! Why is it that we always have to wait for some terrible tragedy to happen before the nation wakes up to the obvious? We should act now, before it is too late. The current state of NHS hospital infections as per the article is unacceptable.
J. Manning, Hong ,
Let me see, I have zero authority and zero resposibilty and I cannot be fired. Sounds like a Government job to me.
Desmond Taylor, Houston, USA Texas
All well and good, but you can have a ward absolutely spotless (down to the microbiological level) but it takes one visitor to not wash their hands/use hand gel and it's there again.
While berating the state of the hospitals, the general public visiting these hospitals need to realise that they also play a significant part in curtailing these organsims: it has been reported that MRSA lives on 30% of the population.
Hacked off student midwife, London, London
That is all very well but the social climate in the UK to-day
makes it more than difficult to improve things. Discipline is enforced through the use of fear. In the days of the matrons who enforced Florence Nightingdale's legacy of scrupulous hygiene, enforcement was draconian. Anyone trying that on to-day would find themselves condemned by industrial tribunals for the modern crime of "bullying".
J. Carter, Berkhamsted, UK
This issue has been raised numerous times in numerous papers and on numerous websites but we still keep coming back to the same fundamental question of hygiene and being scrupulously clean. If the doctors, physicians ans surgeons, are incapable of keeping themselves clean, washing their hands and using gel dispensers and more especially on surgical wards, and if the nursing staff are not obeying guideline regulations on hygiene and wearing protective clothing then how the hell are you going to get the message across to the general public who only visit hospitals and, increasingly, very reluctantly? One must begin by re-introducing military style discipline and by disciplining staff who who not obey and follow health and safety instructions and, if necessary, send them for re-training. If they keep making the same mistakes then it is very simple, you sack them on the principle of 3 strikes and you are out. You cannot effectively control organizations, and people, without discipline.
Kenneth Armitage, Suffolk, England
Way back in the 50s, as a student nurse I was expected to scrub and clean. I was told I needed to know it was done properly and that the friction of scrubbing destroyed bacteria. In the 60s the salesmen arrived selling 'cleaning' sprays, quick mist of this would clean all? Administration bought into this myth believing it would release staff for other work....well it did, they are sat down scrolling through the computer most of the time. We were forbidden to wear any article of uniform unless on duty, there were surprise uniform inspections to ensure that we always looked professional. I strongly feel if you look the part, you are more inclined to play the part. Way back then nursing was spoken of as a vocation, more than just the job it appears to be to day. Put the nurses back in charge of all, expect and demand more of staff...put the vocation and honour back into the profession. Banish the management types to secondary, helper status. They have tried but failed miserably..
Jane Prior, Whiteway, Canada
Having nursed in the NHS as a junior nurse to nurse manager i have witnessed a gradual decline in the standards of cleaning within the areas in which i had worked. In my first job in a large district general in the affluent borough og Kingston upon Thames the nurses during 1999-2001 were expected to perform all cleaning duties, including scrubbing toilets and mopping floors! This is no lie!
The 'selling out'of cleaning and domestic services to private companies has in my mind been the down fall of the NHS infection control standards. Years ago (not that many) wards employes their own cleaners who were part of the team, they had high standards, noone would cross them, not even the consultants, dare them to walk on the wet floor!
The staff that are now employed to clean our hospitals have minimal training, near invisible supervision or discipline and absolutley no incentive to attend work let alone to do a decent job.
Katie, Birmingham,
I have seen precisely the same problem in adult mental health care. The nurses and ancillary staff in an in-patient ward hung around in the nurses station, talking to one another, rather than being out among the patients doing anything remotely constructive.
This is a problem of basic management and is endemic in public services.
As someone involved in public sector reform, I spend my life trying to arrange for first line supervisors and managers to be coached in management. The problem is that the current Government is obsessed by high cost/high tech solutions, or else legislation, rather than thinking about the huge performance / cost-saving potential available through simply doing basic tasks right.
Zanzibar, London SW1, UK
Having been part of a MRSA enquiry team during 2005 as an unpaid volunteer I feel qualified to comment.
Cleanliness is a central part of the patient experience and key in reducing the incidence of MRSA.Key player to this is the Matrons Charter,which identifies resonsibilities for all aspects of cleaning and food safety.The Trust I was allocated to had produced a 3rd Draft of this charter?and it was unclear if this would be agreed by both clinical and facilities staff!!!!!!!!!! I did ask the local health authority on numerious occasions if this draft had been agreed?needless to say no answer was ever forthcoming.I feel very strongly that this is not a goverment issue but an internal management one.The rules for infection control are very clearly defined by the goverment, enforcement is key to reduction of this very serious infection.How many of the trusts in the country have agreed their cleaning protocals?
M E Hoult, Leeds , Yorkshire