Audit Committee, 30 Sep 2003

Meeting date: Tuesday, September 30, 2003

Official Report 215KB pdf

---

“Hospital cleaning”

Item 3 is on the Auditor General's report "Hospital cleaning". I invite the Auditor General and the relevant members of his team to give a brief report.

In April 2000, I published a baseline report that made a number of recommendations that were aimed at improving the quality of hospital cleaning. At that time, national health service trusts were expected to take action on those recommendations. I asked Audit Scotland, with the support of the committee, to follow up and report on progress. The report that we are discussing is a follow-up progress report. Trusts are named in the report because they have had the opportunity to make improvements during the past couple of years. The report was published in January and, as the convener will be aware, was discussed by the Audit Committee at a meeting in February. It was decided not to take evidence then because of the pressure of other business.

The report describes our findings on hospital cleaning. I do not intend to go into them in detail, but I am happy to answer questions or to give the committee a fuller briefing. In general, we found that half of hospitals had very good or acceptable levels of cleanliness in all areas reviewed, but that there was a clear need for improvement in almost 20 per cent of hospitals, with the remainder having shortfalls in some areas. The report identifies some of the issues that seem to make it more difficult for hospitals to achieve acceptable levels of cleanliness.

My only other introductory point is that, since the report was published in January, action has been taken nationally. First, the Scottish Executive Health Department wrote to all health boards and trusts asking them to implement the report's recommendations. Secondly, the hospital-acquired infections task force, which is chaired by the chief medical officer, has recently published two key documents for consultation. The first is a code of practice on infection control and the second contains technical requirements for processes to be used in the NHS specifications for cleaning services. Finally, NHS Quality Improvement Scotland is due to undertake a round of reviews against the cleaning standards, with reports due for publication in 2004. We also know that a number of trusts have put in place improvement plans for cleaning and that, where local follow-up audits have taken place, improvements have been found. As ever, there has been a moving picture since the report was published in January.

The report's conclusions state:

"There is no clear association between the level of cleanliness and any one of the factors investigated."

The report lists a number of factors that make it more difficult for hospitals to achieve high standards of cleanliness. To turn the question round, what are the key factors that result in hospitals having a successful cleaning regime? That seems to me the fundamental issue.

That is a good question. I ask Caroline Gardner or Barbara Hurst to answer it.

I will have the first go. In our findings, no single factor is associated with acceptable levels of cleanliness, but trusts that did not have problems with any of the four points that are set out in the briefing paper were much more likely to be able to assure cleanliness for patients who use their hospitals than trusts that had something wrong in one or more of those areas.

We considered all the factors that one might expect, such as whether the cleaning service was provided by an in-house team or an external contractor, the specifications used and whether those specifications focused on frequency of cleaning or on outputs. We found that not having problems with those four points was the best predictor of acceptable cleanliness, but that, in one or two hospitals, things were going wrong in spite of that. The matter is complex, but those four points are the most important drivers of acceptable levels of cleanliness in hospitals.

The report states:

"A number of hospitals, such as Yorkhill, Queen Margaret … Royal Edinburgh and Belford (Fort William) achieved generally high levels of cleanliness while having high levels of sickness absence and staff turnover."

How did those hospitals manage that?

They monitored regularly and were prepared to be flexible about the way in which they used available staff, rather than sticking to the original plans.

So the fundamental difference came down to management of the available resources.

Clearly, it is harder to achieve high levels of cleanliness if sufficient resources to deliver cleaning are not routinely in place.

I understand that.

We found that hospitals that were able to overcome high levels of sickness absence and staff turnover had managed the situation better than the ones that could not overcome those high levels.

So the key was the quality of the management.

At the end of the day, that made the real difference.

I assume that the reverse was true for hospitals that appeared to have no particular difficulties with staffing inputs and turnover but which failed to achieve acceptable levels of cleanliness, such as Bonnybridge hospital, Falkirk and district royal infirmary, Inverclyde royal hospital and Whyteman's Brae hospital. Was the management extremely poor in those cases?

It is not fair to make such a sweeping generalisation. The report also mentions that, in some places, problems with the fabric of buildings make it much harder to keep them up to the acceptable level of cleanliness.

Is that because the buildings are old?

Some are old; others have out-of-reach areas. One hospital has difficult-to-access stairwells and windows that are hard for cleaning staff to reach.

The report highlights rates of absence and staff turnover as key points. How do those rates compare with rates in other sectors of business? Are they higher or lower than the norm? Does the NHS have particular problems?

Barbara Hurst has information on that.

We have done similar work in other sectors—a comparator might be home care workers in the local government sector. The rates are comparable—we found high turnover and sickness absence rates. Part of the reason for that might be the nature of the job.

Is that true regardless of whether private contractors or directly employed in-house staff do the work? Was there any differentiation?

The main factor affecting turnover appeared to be the availability of other jobs in the area. As one would expect, where there was competition from private cleaning jobs or from companies such as Tesco, the turnover rate tended to be much higher.

The response that we have received from the Executive—Trevor Jones's letter dated 20 February and John Aldridge's letter dated 28 January—indicates that the Executive is ensuring that the trusts and other parts of the NHS system throughout Scotland will be required to report on cleaning in the tick-box part of their performance assessment framework. Is Audit Scotland happy that that is the way in which the centre will undertake continuous measurement? Are you satisfied that trusts are fully aware of their obligations under the two letters? Page 9 of the report, under the heading "staff turnover and absence", says:

"many trusts had still to put in place a programme to reduce sickness absence to the national target of 3%".

That national target has existed for some time and I assume that there is a box for it in the performance assessment framework, but nothing appears to have been done on that. If we compare performance on the target that has existed for some time with what we are now asking trusts to do, how much confidence do you have that we will move the matter forward?

The short answer is that we have not audited since the publication of the report and we therefore do not have objective evidence with which to give you a full answer to that question. However, as I indicated in my preliminary remarks, the Health Department has been active in putting in place explicit standards and requiring NHS bodies to apply those standards through action planning.

I support what the Auditor General has just said. The most powerful part of the report was the peer review—the actual consideration of the cleanliness of hospitals. We note that the hospital-acquired infections task force has picked that work up and wants to develop it. We support that, because, although all the management processes can be examined, clean hospitals are what we all really want. The power of work such as the report lies in providing an on-going way of checking cleanliness.

I come from an area in which all the hospitals are in the "very good" category—perhaps I should declare an interest. I know how much staff involvement and how much finance went into achieving that, including—if we are considering the situation as a whole—finance invested in the fabric of the buildings. The other trusts face the same pressures as those in Ayrshire and Arran, but the trusts in Ayrshire and Arran have managed to meet the objectives while others have not. How can we share their good practice? It would be interesting for me—because I have been away from the matter for too long—if you would identify what percentage of the contracts for hospitals in the poor category are external contracts. That would assist us.

We considered the correlation between the nature of the contract and the level of cleanliness and did not find any statistical relationship between the two. Nevertheless, we found that a large number of external contractors were at the poorer end, although some were at the good end. The picture was not clear. We did not push the nature of the contract as a major factor in the report, although we said that, if monitoring of external contracts is not good and good clauses are not built into those contracts, there is quite a big risk factor. We were careful to highlight that as an issue in the report.

I am interested in the point that Margaret Jamieson made. Barbara Hurst returned to the difficulty of ensuring quality across the range of service providers. Do you consider that to be an issue that the health bodies need to address?

When we did the review, which is a little while ago now, we were aware that a number of trusts were bringing their services back in house, as they had identified some issues with the external contracts. The balance between external and in-house contracts will be quite different now. Nevertheless, peer review—checking the cleanliness—can be done irrespective of the nature of the contract. We need to keep up the major push on that.

That is what I was going to explore. The key is ensuring that adequate systems exist for quality control and monitoring, regardless of who the provider is.

Yes.

The table on page 19 of the report shows those trusts that managed to meet the cleaning, supervision and monitoring standards, those that achieved less than planned and those that achieved more than planned. Is the amount that each trust spent linked to those figures? Did you make a comparison to find out whether finance, absence rates or management was the driver? Could you give us some idea why the variations occurred and what the key drivers that made the difference were?

The key driver is not finance, in that what was planned was budgeted for and therefore the money to provide the planned input was available.

Was the budget spent?

The budget would not necessarily be spent if a trust did not have the staff. When a trust does not get its full level of staff, the problem tends to be that it cannot get hold of bodies to do overtime or to fill the gap. It obviously cannot just pull somebody off the street—some training is needed. As soon as the turnover rate becomes high, a problem with achieving the planned input occurs.

An interesting question then arises: did you examine the output for the money spent, for example the square metreage cleaned versus the amount spent? You say that lack of staff is the fundamental problem. Full employment is probably what is behind the recruitment problem. Did you examine outputs—what was achieved given the manpower available and the money spent?

We started to do that, but we decided that we did not have an accurate enough measure. We could use square metreage, but the square metreage for a hospital with high ceilings is not the same as that for one without. There would be other problems if we measured old hospitals against new. Also, different floor coverings take different amounts of cleaning. Several different factors affect the amount of input that is needed. It is not just a matter of the efficiency of the cleaning operation.

What, then, is the point of having the figures from the information and statistics division—the blue-book costs? Those give us the square metreage costs throughout Scotland, and everybody is told to keep to the average. If those figures are made up of comparisons that are not like for like, why do we collate them? Why did you not use them in the report? I appreciate fully what you say about the fact that any two hospitals can differ in age, layout and the way in which patients use them. There is a difference, but that difference calls into question the blue-book cost.

I am not here to speak about the blue book. However, I point out that the intention is not that everybody should keep to the average cost in the blue book, but that they should know how they compare against the average and take account of their position. A new hospital that is easily cleaned should be better than average. A poor or old hospital that is harder to clean would expect to be worse than average. What is of interest is how much worse than average it is.

It is another tick box.

I will return to cleaning contracts and probe a little further into contract specifications and monitoring. Can you add anything further to give us an indication of whether problems generally exist more in respect of one or the other? In other words, in recognising the need for contract specifications that set out appropriate standards and good monitoring, did you find that there were more weaknesses in one area than in the other, or was the situation caused by a combination of weaknesses in specification and monitoring, which varied across the country?

I hazard the answer that it was a combination. One would expect the clarity of good contract specifications to help to deliver cleaner hospitals, but that does not mean that one should not monitor against those specifications. It is an interrelationship between the two factors.

I noticed that one trust did not make its cleaning contract documents available because of commercial confidentiality. That seems a rather unusual line to take, given that only one trust did so. Did the issue come up frequently? Why was the trust able to withhold that information?

It depends on the wording of the contract whether the trust can withhold such information.

That response is probably relevant to my next question. Do you have, or plan to gather, information about any distinctions there might be between private finance initiative contracts and straightforward external cleaning contracts? I notice that the list of hospitals in the report mentions only one PFI hospital.

The list contains a few PFI hospitals.

Were you able to differentiate between PFI contracts and externally provided cleaning services that are not provided as part of a PFI contract?

I do not think that we specifically separated out cleaning services under a PFI contract. However—John Simmons will correct me if I am wrong—we found that the PFI aspect raised issues about the transparency of the contract, the amount of monitoring that was carried out against it and the penalty payments that would be charged for not achieving particular standards.

As there are only a few PFI hospitals, making sweeping judgments about the matter is not statistically viable. However, I should point out as an example that in one health board with two PFI hospitals, one of the hospitals did very well and the other poorly. As long as information is available and monitoring can be carried out, I do not think that PFI is necessarily a problem or that it necessarily leads to poor cleaning standards.

That ends a fairly extensive discussion of the Auditor General's report on hospital cleaning. Members have obviously taken a keen interest in the subject. We will revisit the issue later in the meeting and decide how to take forward our response to the report. I thank the members of the Audit Scotland team for their answers to our questions.