7 February 2017
A new research paper finds that patients’ surveys on cleanliness in NHS hospitals in England gave higher ratings on the standard of cleaning in their wards and bedrooms shortly before or during ‘unannounced’ inspections. The share of patients who gave a top rating of ‘very clean’ (excellent) was found to be between 2.5 to 11 percentage points higher just before and during inspections compared with the period afterwards. The paper remarks that inspection teams are mainly made up of hospital staff members rather than a mixture of staff and patient volunteers (due to a lack of volunteers); and it is widely believed that trusts know far in advance when inspections will take place. In the first study of its type, the paper says we can assume that ‘gaming’ is happening as there are incentives to clean better before inspections and let standards slip afterwards. This pattern was more marked in hospitals using outside cleaning contractors than those employing in-house cleaners, says the study published in the journal, Health Affairs.
The researchers from the University of Oxford and the London School of Hygiene & Tropical Medicine, analysed existing NHS patient surveys (from the Picker Institute). They matched data on patients’ perceptions of cleanliness with dates of cleaning inspections from Patient Environment Action Teams and Patient-Led Assessments of the Care Environment for 205 English hospitals between 2011 and 2014 where all the three datasets were available. The datasets were combined to calculate the average percentage of patients rating cleanliness as ‘very clean (excellent)’ for each hospital by month and year. The study finds that, on average, patients’ reports of excellent cleanliness were 10 percentage points higher in inspection months compared with other months (81.5 percent versus 71.9 per cent in other months).
The paper explains that hospital cleanliness is a priority for the National Health Service. Consequently, since 2000, there have been ‘unannounced’ inspections at hospitals although the paper notes that in practice staff always receive 48 hours’ notice of when spot checks will take place within the following month. The authors add that information they obtained from two trusts under freedom of information requests revealed that both trusts had had between two and five months’ advance notice of such inspections. Other freedom of information requests to hospitals also revealed that in the months during inspections, those hospitals had performed a series of detailed pre-inspection checks a few days before the actual inspections, which revealed longstanding problems which were then addressed.
Lead author Veronica Toffolutti, from the Department of Sociology at the University of Oxford, said: ‘Our conclusion is clear, in any regulatory system, such as the NHS, it should be assumed that gaming will take place. The system should, however, be designed in ways that minimise this, and apparently inspections do not serve this purpose.’
Co-author Professor Martin McKee, from the London School of Hygiene & Tropical Medicine, said: ‘This paper is the first to confirm what many have long suspected, that the current system of hospital inspections encourages gaming. This raises questions about whether it is really fit for purpose.’
The pattern was found to be more prominent in hospitals that outsourced cleaning services to private contractors, with a rise of 11 percentage points in higher cleanliness scores in inspections months. The researchers found no statistically significant link between cleanliness scores and inspection months in hospitals using in-house NHS cleaners.
The paper remarks that concerns about inspections of NHS providers have been noted on several occasions by the UK House of Commons Public Accounts Committee. The authors conclude that inspections are designed to ensure hospitals maintain high standards of quality and this is especially important when services, including cleaning, are outsourced to private contractors to save money. They say there are ‘implications for policy… and for systems of regulation and inspection’ as hospitals appear to invest ‘considerable resources in preparing for an inspection’ when, ‘arguably, they should be investing those resources at all times’.
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Notes for editors:
- The paper, ‘Evidence points to “gaming” at hospitals subject to National Health Service cleanliness inspections’, is due to be published in the journal, Health Affairs. Once live, it will appear at http://www.healthaffairs.org/doi/10.1377/hlthaff.2016.1217
- The authors are Veronica Toffolutti, a postdoctoral researcher in health economics at the University of Oxford; Martin McKee, a professor of European public health at the London School of Hygiene & Tropical Medicine; and David Stuckler, a professor of political economy and sociology at the University of Oxford.
- Most of the patient surveys were done between June and August each year, when each trust sends a questionnaire to 850 patients who have spent at least one night in one of their hospitals.
- The term ‘hospital staff’ as used in reference to the inspection team includes nurses, matrons, doctors, catering and domestic service managers, executive and non-executive directors, dieticians and estates directors.
- Study limitations: researchers note that they did not have the exact date when a patient was discharged, only the month; also, that the results suggest only ‘modest effects’; and that the study cannot identify individual hospitals that are gaming, but points to characteristics, such as outsourcing cleaning services that may render a hospital more likely to game.