Daily Mail, 8 December 2003

The Health Secretary, Dr John Reid, has announced that ‘bug-buster’ officials are to be appointed in every English hospital to combat the alarming rate of infections caused by poor standards of hygiene. And what is the most crucial purpose of this urgent, £12 million ‘call to arms’? Why, the need to ensure that hospital staff actually wash their hands!

The sheer, jaw-dropping incongruity and inappropriateness of the government’s response to the incredible filthiness of our hospitals is enough to make one weep. The Chief Medical Officer, Sir Liam Donaldson, has published a plan, entitled ‘Winning Ways’, to reduce hospital infections.

Just look for a start at the list of people at whom this plan is targeted:

‘PCT CEs, NHS Trusts CEs, SHA CEs, DsHSC, Medical Directors, Directors
of PH, Directors of Nursing, PCT PEC Chairs, Special HA CEs, CCDCs,
CMOs, Royal Colleges’.

This blizzard of initials and titles represents senior NHS managers and other medical bigwigs. In other words, this is bureaucrats talking to bureaucrats. But the only people who actually matter are those who run -- or should be running – the actual cleaning of wards, operating theatres and rest of the hospital buildings.

Sir Liam then solemnly proceeds to list all the initiatives the government has already tried to reduce hospital infections. There was a report and guidance in 1998; then a circular in 1999; then a control assurance standard on infection control in 1999; then an infection control circular in 2000; then a decontamination control circular in 2000; then further detailed guidelines on the prevention and control of infection; then a mandatory surveillance scheme for serious (bloodstream) infections; and then more guidelines produced this year by the National Institute for Clinical Excellence.

This is bureaucracy gone stark, staring bonkers. All these initiatives -- and yet 300,000 patients per year still suffer hospital-based infections which cost the NHS £1 billion a year, prompting the Health Secretary to set up yet more initiatives costing more millions, which boil down to how to tell staff to wash their hands.

Failure to meet this elementary standard of hygiene, says Sir Liam, is believed to be down to laziness or carelessness. So does he say staff should be told to behave more responsibly and should be disciplined if they do not? Good gracious, no.

The real reasons they don’t wash their hands, apparently, are inadequate facilities, lack of time and a ‘paucity of hand hygiene agents’. Dear oh dear; is Sir Liam seriously suggesting that thirty years ago when the wards were spotless there was any less of a ‘paucity of hand hygiene agents’ (such as soap and water)?

This prize piece of gobbledegook obscures the real source of the problem – the breakdown of anything remotely resembling effective hospital management. Sir Liam says ward staff now control their own ‘environment’ budgets. Big deal, since these staff have no say in awarding or ending cleaning contracts, and cannot discipline or fire cleaners who don’t do the job properly. Instead, these ‘budget-controllers’ spend their time pushing paper around.

The result is that no-one is properly held to account. No-one tells the cleaners not to use dirty water to wash the floors; the contract is with the cleaning company, and so the hospital staff disclaim responsibility. No-one can tell the nurses what to do. If anyone is bawled out, the chances are they’ll sue for harassment.

In a blistering, utterly shocking and true report on the NHS for the Centre for Policy Studies entitled ‘Managing not to Manage’, Harriet Sergeant provides chapter and verse on the NHS calamity.

A consultant anaesthetist wrote last year (in this newspaper) how, when she became a hospital patient herself, she found in the toilets a pile of faecally-soiled paper underwear, a blood-stained theatre gown, a filthy toilet bowl and pubic hair in the shower. In three weeks, she never saw a cleaner bring a mop into the bathroom. She caught the superbug MRSA.

A retired GP, visiting his wife in hospital, was shocked to find sweet-papers, old bits of Elastoplast and the tops of disposable syringes behind the bed. His wife died from blood poisoning after contracting MRSA. In another hospital, an anaesthetist related how no-one cleaned the blood-splashed operating theatre between operations, and infection rates were accordingly high.

Dr Reid has attacked Ms Sergeant’s report as ‘brutally tendentious’. It is not. Shamefully, it is all too true. And much of the reason is rooted in a deep-seated problem with modern nursing.

Of course, nurses are under enormous pressure with rising demand and too few staff. And of course, there are many examples of first-class hospital care. But there are also many, many instances of really shocking neglect. This is particularly true if you are old or inarticulate, leading to a breakdown in the most basic level of care, as anyone who has witnessed the sometimes heartbreaking way in which the elderly are treated in NHS hospitals can testify.

The rot goes back to the 1980s when nursing became ‘professionalised’. Care, kindness and common sense went out of the window. They were displaced by the doctrine that nurses should have parity with doctors and should not be asked to do anything that might demean their status as women – such as ensuring the wards were clean. Instead of being taught how to feed, toilet and dress patients to make them comfortable and preserve their dignity, in came politically correct concerns with poverty, ethnicity, class and gender. And out went concepts of hierarchy and discipline as affronts to the autonomy of the nurse.

‘Modern matrons’ are supposed to be responsible for ensuring high standards of infection control and cleanliness. But ‘modern matrons’ do not have the power of old-style matrons, because the continuing rejection of authority figures in nursing means no-one is able to tell anyone else to do anything.

For decades, our hospitals had remarkably low infection rates, despite their systematic underfunding and primitive facilities, because iron control was maintained over hygiene. Unlike the ‘modern matron’, her old-style predecessor exercised control over every nurse, cleaner and porter and she knew every patient under her care – because she understood that it was her care they were under and for which she was accountable.

She ran her hospital like a military exercise. Today, that is impossible because nurses find that approach anachronistic and unacceptable. The result is sloppiness, a culture of excuses and gross dereliction of managerial duty, and patient infection.

What is needed is a return of the old-style matron, ward sisters with clout and a hierarchy of management where the people in charge actually connect to the front-line.

Instead, Dr Reid’s lamentable ‘call to arms’ is to be answered by the new Directors of Infection Prevention and Control and the new Inspector of Microbiology – not to mention the National Patient Safety Agency, the Commission for Health Care and Inspection, the Health Protection Agency, the Clinical Governance Support Team, the Modernisation Agency and the chief executives who run the hospitals.

None of this scandalously bloated bureaucrats’ bonanza, of course, will tackle the crisis in professionalism on the front line, the only thing that will actually make any difference.

Posted by melanie at December 8, 2003