“Hospital cleaning”
Agenda item 3 is a briefing by the Auditor General for Scotland on his "Hospital cleaning" report. The report is a follow-up review of the baseline report by Audit Scotland, "A clean bill of health? A review of domestic services in Scottish hospitals". That report, which was published in April 2000, made a number of important recommendations that were aimed at improving the quality and effectiveness of hospital cleaning.
The report that we will consider today assesses the progress that the national health service has made in implementing those recommendations. It includes a review of the levels of cleanliness that have been observed in hospitals and provides the first national snapshot of hospital cleanliness. The report investigates the reasons for the variations in levels of cleanliness and considers issues that were identified in "A clean bill of health?" Among the issues that it considers are the frequency of cleaning tasks, staff inputs to cleaning and monitoring, recruitment and retention of staff, management arrangements and the application of policies and procedures. The review also incorporates a baseline assessment of compliance with the standards for cleaning services that were issued by the Clinical Standards Board for Scotland in January 2002.
I invite the Auditor General to brief the committee on his report.
Mr Robert Black (Auditor General for Scotland):
When I presented "A clean bill of health?" in April 2000, I made a number of recommendations. NHS trusts were invited to consider those recommendations and to take action on them. It was agreed that I would revisit the issue in a few years' time. "Hospital cleaning" is the follow-up report. The first report did not name individual NHS bodies, but the new report does. That is because we consider that all trusts have had an opportunity to consider the original report and to make progress on delivering improvements.
It goes without saying that the cleanliness of hospitals is a priority for patients, for the health department and for everyone who works in the service. Therefore, it seemed appropriate to include a snapshot review of the levels of cleanliness that have been observed in hospitals. As well as showing a need for improvement in a number of hospitals, the review identifies the issues that make it more difficult for hospitals to achieve acceptable levels of cleanliness and makes recommendations that are aimed at improving the situation.
We looked at levels of cleanliness in 74 hospitals throughout Scotland. More than 70 per cent of the wards that were reviewed were considered to have achieved a very good or acceptable level of cleanliness. What I will go on to say should be seen in that context. In 19 per cent of the hospitals—one in five of them, roughly speaking—the review found a clear need for improvement in the cleanliness of at least one ward. In 16 per cent of hospitals, it found a clear need for improvement in the cleanliness of at least one public area. The findings are based on a snapshot review, which looked at cleanliness in a sample of wards and public areas at a particular point in time. Although it is possible that some hospitals might have been reviewed at a particularly difficult time or that they might have had only one ward in which cleanliness was poor, hospitals should be clean in all places at all times.
My report identifies a number of issues that make it more difficult for hospitals to achieve acceptable levels of cleanliness. In common with other public bodies, many hospitals have problems in the recruitment and retention of staff, which result in vacancies and high turnover rates. The number of sickness absences is also high in a number of hospitals.
In some hospitals, we found that staff had less time to do cleaning than the hospital had planned for. That was true in a quarter of the wards. In other words, although a standard had been set, hospitals were not achieving it because the necessary staff time was not being delivered. That makes it more difficult for cleaning to be as thorough as hospitals would wish.
I note that the Scottish Executive has recently agreed a pay increase with Unison and I hope that increased salaries for ancillary staff will go some way towards easing staffing problems. Ensuring sufficient staffing levels should be a priority for senior trust management. Trusts should agree and monitor key staff indicators, assess what action needs to be taken to improve performance against those indicators and put in place contingency plans that are backed by adequate resources to deal with staffing shortfalls.
We found variation in the levels of cleanliness, both in hospitals with in-house providers and in those with external providers. The terms of contracts made it more difficult for some hospitals with external providers to ensure that they had acceptable levels of cleanliness. Unclear and inflexible terms, limited penalties and lack of management information made it difficult for a few hospitals to manage their contracts appropriately.
The work of cleaners is an extremely important element in achieving clean hospitals, but it is only one of the requirements. There is also a need for proper maintenance facilities, so that cleaners are able to clean effectively. Poor maintenance contributes to low levels of cleanliness in some hospitals and also influences the public perception that hospitals are not clean.
Some cleaning tasks, such as the cleaning of external windows, inaccessible areas and clinical equipment, are not the responsibility of the cleaning staff but still need to be carried out to ensure that hospitals overall are at an adequate level of cleanliness. The review found that such tasks were not being carried out as necessary in a number of hospitals.
I want to mention the work of the former Clinical Standards Board for Scotland, which is now part of NHS Quality Improvement Scotland. In 2001, the board was asked by the Scottish Executive health department to produce standards for health-care associated infection, which is sometimes called hospital-acquired infection. A sub-group was set up to develop standards for hospital cleaning.
The sub-group worked with Audit Scotland on a collaborative review of cleaning services. Local auditors were used to undertake all aspects of the review in local hospitals. The review, which included a baseline assessment of trusts' compliance with the standards for hospital cleaning, is an example of the benefits of good working between agencies, so that we avoid duplication and deliver a more comprehensive picture of the situation.
My report is complementary to and sits alongside the report "Improving Clinical Care in Scotland—Healthcare Associated Infection (HAI); Infection Control Standards". My report shows that, although many trusts have undertaken considerable work to implement the standards for hospital cleaning, further development is required. I understand that NHS Quality Improvement Scotland is also working with the Scottish centre for infection and environmental health on reviewing decontamination processes in trusts.
Arising out of my report, action plans have been agreed locally with all trusts to address the concerns that were found in the report. I expect those action plans to be a priority for trusts and I recommend that there should be a continuing programme of reviews of cleanliness to ensure that improvement is sustained into the future.
Both Barbara Hurst, who co-ordinated the study with colleagues from Audit Scotland, and I will be happy to answer any questions that the committee may have.
I thank the Auditor General for an excellent report that has certainly concentrated minds. I remind the committee that we should keep our questions general at this point, as we will look at the issue in detail under agenda item 6.
The Auditor General's report says that
"trusts should agree performance indicators and targets for staffing indicators such as sickness absence, turnover and vacancies. However, half of the trusts did not have these in place."
Is there a timetable for that work? Who will be responsible for delivering those results?
When we first reported some two years ago, we suggested that we wanted to see improvements in the areas that the convener has mentioned. It is disappointing that a number of trusts have not shown those improvements. I invite Barbara Hurst to comment on the extent to which we can anticipate plans being put in place with agreed timetables.
Barbara Hurst (Audit Scotland):
Following the first report, we would have expected serious consideration to have been given to those issues, especially because we know that there are difficulties in recruiting and retaining staff. We expect that our local auditors will carry on monitoring those issues to ensure that things are happening at the local level.
I want publicly to congratulate the staff in the Ayrshire and Arran NHS Board area. The Auditor General's report says that they achieved category 1 for both public areas and ward areas.
I have a number of observations to make about Audit Scotland's informative document. I am concerned that the perception out there is that every hospital has particular problems, despite the report's indication that 70 per cent of wards have achieved category 1. We should be congratulating people, but the press obviously thinks that we should be dumbing down that aspect. I am also concerned about the way in which the report has been put into the public domain and about the areas of the report that have been picked up. Perhaps that is not an issue for Audit Scotland, but it needs to be addressed.
I am particularly concerned about the comments that have been made on levels of cleanliness in hospitals that use external providers. I want an assurance that those contracts are examined to ensure that we continue to get best value—as we are supposed to—and that they are monitored against the measurements that were used by Audit Scotland. I want to know whether there is any way in which that issue can be addressed and how those contracts will be continually assessed.
I note the point about internal auditors' continually auditing the work that is being undertaken. My question might be asked more appropriately under agenda item 6, but what is the possibility of having that work reported in the performance assessment framework under which the NHS system is measured by the centre annually? Sometimes, individuals receive the reports, which, although they are topical for a wee while, go on to a shelf and gather dust.
I am not sure whether there was a question in there, but I will make a couple of comments that might help the committee.
As I said in my introductory remarks, 70 per cent of the wards were in category 1. When we release our publications to the media, we work very hard to achieve a balanced picture. However, for whatever reason, the media coverage tends to focus on the challenges and the failures in performance rather than report in a balanced way in all cases. We are well aware of that, and it is difficult for us to control.
With regard to the level of cleanliness in hospitals that have externalised services—if I can call them that—I emphasise that the number of hospitals that we considered in our sample was very small; therefore, it is not possible to generalise. One of the concerns was that, in a small number of cases, the information that was available to the client was not adequate to enable them to monitor the contracts well. It is a challenge for those hospitals to address that.
The other question concerned how we could monitor in the future. This was a one-off exercise for us, using external auditors who are not professionals in the service and working with a peer group to get a snapshot of data. All that the exercise does is draw attention to the variations that we found. Nevertheless, that is a significant achievement. The challenge is now for hospital management to put in place adequate monitoring procedures and for the boards—probably at unified board level—to take an interest in cleanliness and cleanliness performance. That is where accountability should lie primarily. There may also be an issue for the committee to consider with the health department regarding whether the overall performance assessment framework should ensure that proper questions are asked of boards to ascertain whether they are monitoring the issue as carefully as they should be.
I have two questions. First, in evaluating hospital cleanliness, were the same standards applied to old buildings as were applied to much more modern buildings? Secondly, the interface between hospital cleaning and maintenance is a grey area. The convener and I were at a health board meeting on Friday, at which reference was made to maintenance of windows. Maintenance is also an issue in relation to clinical equipment. To what extent do you feel that that issue needs to be re-examined?
I invite Barbara Hurst to comment on that.
The standards that we used for the spot checks—which is probably the most powerful part of the report—were agreed with hospital cleaning managers and the checks were carried out by those managers in liaison with external auditors, as the Auditor General said. We applied those standards in the same way, irrespective of the age of the buildings, because we felt that although older buildings will be more challenging to clean, there is no reason why they should not reach the same level of cleanliness as new buildings. It is interesting to note that we have a number of older hospitals that are clean and a number of newer ones that are causing concern. We did not think that it was our place to apply the standards differently.
What about my second point, which was about the interface with maintenance?
That is an interesting point and it is clearly the most challenging issue for hospitals on receipt of the report. We made it clear that we were examining not only the quality of cleaning, but the cleanliness of the hospital, irrespective of who was responsible for that. There is a real issue about maintenance and ensuring that areas that are not cleaned by cleaners are clean. Mr Raffan is correct that we should pay attention to that significant point.
I am delighted that the hospitals in Grampian came out well in the study. However, within those hospitals, some of which I visited on Monday, there is quite an age difference—buildings range from being very new to being almost on their last legs. If one board achieves a good result in the study regardless of the status of the buildings—I am sure that some boards have done that—that flags up to me that there is an attitude of dealing with the issue in that board.
I assume that some of the boards commented back after the previous report. Did they comment at the start of the present investigation on what they had done since the first report was dished out roughly two years ago? Did the boards comment to the audit teams on the measures that they had taken?
Do you mind if I check with the person who knows the details?
Please do.
Direct communication is always preferable.
It will come from the horse's mouth, as it were.
This is our last port of call. If we do not get an answer here, we are sunk.
We know the feeling.
Tricia Meldrum (Audit Scotland):
The auditors had a list of questions and topics to look at with the trusts that they visited. One question was what had been done to put into practice the recommendations in the previous report, and some of what had gone on previously was picked up.
Did your people pick up the fact that there was a divergence in the approaches taken by different trusts after the first report?
Yes, there was variation in what they had done and how they had approached the matter.
That gives my brain something to think about before item 6.
The report was useful. I would like to pick up on the Auditor General's comment that the matter should not be constantly monitored nationally, but should be monitored by the unified boards. Is that the right framework? It is appropriate for the unified boards to identify their priorities, but there must be benchmarking. It would be easy for boards to set lower standards that were easier to achieve. How can the process be developed so that, if there is a similar report in a couple of years, there will be a demonstrable improvement and more information will be available on, for example, externalised services? How can we raise everybody's game?
It is important that we try to avoid driving too much from the centre, which is why the national report is accompanied by a report for each NHS trust that was covered. A number of the local reports present local management with challenges for improvement. An action plan is in place that should be followed through if standards are to be improved. The exercise undertook a lot of groundwork, on which trusts and unified boards can pick up as a base for the future. They could draw on our methods to ensure that current, good-quality information about what is happening in hospitals is received locally.
I thank the Auditor General for his briefing. We must give credit where it is due, which is to the hospitals that have produced and continue to produce high standards. However, I am sure that we wish to guarantee the highest standards for Scottish patients. I thank Audit Scotland for its work in producing the first national snapshot of hospital cleanliness. I am sure that the work will continue, to the benefit of staff and patients.
Our next witnesses will be with us in six minutes. Therefore, I suggest that, in accordance with rule 7.8 of the standing orders, I suspend the meeting until 3 o'clock, when the committee will reconvene to take evidence.
Meeting suspended.
On resuming—