How clean is your ward?

At the end of February 2010 the Care Quality Commission (CQC) published findings from its enquiry into the standard of care provided by the Mid Staffordshire NHS Foundation Trust between 2005 and 2008. Their investigation was launched after abnormally high fatality rates were recorded at their Staffordshire hospitals over this period, with at least 400 extra fatalities amongst patients identified in comparison to hospitals with a similar case mix.
Although the CQC, the independent regulator of health and social care in England, could not state how many of the deaths were directly attributable to the poor quality of care, it concluded that the hospitals routine cut-backs on cleaning were likely to have been a factor. It linked the poor hygiene standards on the wards where patients contracted C. difficile infection, to an ingrained culture where patients were routinely supplied with insufficient care.
The origins of the situation were traced to 2006 when the trust set itself a target of saving £10m, roughly equivalent to eight per cent of its overall turnover. To achieve this over 150 posts were lost, including cleaners, despite the hospital already having comparatively low levels of staff. When the commission analysed the trust’s board meetings from April 2005 to 2008, it found discussions were “dominated by finance, targets and achieving foundation trust status”. The commission’s report also identified a culture of concealment: when the infection rate of Clostridium difficile nearly doubled in the early months of 2006, the information was not released to the board or the public.
The controversy surrounding the enquiries findings provoked several days of media debate about whether the early warning system, which is supposed to detect underperformance at trust level, is working effectively across the whole of the NHS. The hospital in Stafford, which employed its cleaners directly between 2005 and 2008, also became a focus of a discussion around the comparative merits of outsourced or in-house ward cleaning.

Achieveing the best results
Is it really fair to use an isolated case of inadequate care to shape the wider argument of how to achieve the safest and most efficient results within hospital cleaning? There are certain health authorities that are dogmatically against the outsourcing of cleaning services by the NHS. But NHS Scotland, which has a near complete ban on contract cleaning services, consistently scores worse on MRSA blood infection rates when compared with the health authorities amongst England (which has a mixture of contract and in-house cleaning).
Although hospital acquired infections (HAIs) fell by a third in the UK in 2008 in the wake of the government-ordered ‘deep clean’, they are almost impossible to eliminate completely, with facilities specialising in vulnerable patients and invasive care posing a greater risk to patients. And even though the stringent guidance issued by NHS Estates to manage the risk of HAIs applies to private contractors and in-house cleaners alike, the case specific nature of the issue means that we will always witness disparate results.
For every trust that has been deemed to be underperforming, there are many examples of excellent performance over a sustained period; NHS trusts in Royal Marsden and Poole have both seen their cleaning contractors rated excellently in independent appraisals.
Susan Anderson, director of Public Services at the CBI, said: “Independent polling consistently shows that a clear majority of the public do not mind who provides NHS services as long as they are high quality. We need competition between providers of all sectors – the public, private and voluntary – now because they are the best tools the NHS has to improve the value and quality of our health service.”
Ironically, the Mid Staffordshire enquiry concluded that the trust had provided substandard levels in order to hit government targets in order to achieve foundation status, which would allow it greater autonomy from the Department of Health. The major legacy of the failings outlined by the CQC will be greater monitoring across all NHS trusts. The Care Quality Commission said Mid Staffs was now safe to provide hospital services, but confirmed that it intended to place conditions on its registrations to ensure standards were met.
Steve Wright, Chairman of the British Cleaning Council, commented on the CQC’s report: “This example has uncovered a fundamental failure by the hospital to ensure patients received the standard of cleanliness and hygiene they need. While this was ultimately a local failure, it is vital that steps are taken to ensure that it is not allowed to happen again. Although the events were unacceptable, they do not reflect the efforts of the thousands of cleaners who work in the healthcare sector and serve with dedication and professionalism as they strive to reduce hospital acquired infections.”

Whatever their motivation, the real problem is underinvestment in cleaning, and the consequences of constant pressure on health authorities and NHS Trusts to achieve better efficiencies. Although the major political parties have recently offered reassuring commitments that they will protect frontline services in the NHS if they are elected, there is never much mention of ancillary staff. If, as expected, trust managers are forced to reduce their expenditure after the 2010 budget, the Mid Staffs example indicates that the consequences of this could be very serious indeed.
NHS hospitals should be equipped so that they can take every available measure to ensure that the threat of MRSA is contained. This means making the resources available to tackle the problem effectively, alongside stringent safeguards to ensure that they are implemented and maintained. The British Cleaning Council, which represents the interests of the cleaning industry, strongly recommends that cleaning in hospitals is protected by both budgets and political action, to ensure that the seemingly avoidable loss of life in Staffordshire is never repeated again.