Select Committee on Health Written Evidence

Memorandum by UNISON (PS 42)



  UNISON's response highlights the need for patient safety to be prioritised above private profit. There are serious issues in this regard relating to contract cleaning, the privatisation of decontamination services and the outsourcing of medical secretarial work. Our response also highlights some weaknesses in the proposed new regulatory and registration regimes embodied in the Care Quality Commission and the Independent Safeguarding Authority. Related to this is the need for a level playing field in the publication of performance data and the ability of new patient and public involvement structures to scrutinise independent sector providers in the same way as they can the NHS. Finally, we emphasise the importance of education and training in providing a workforce that is best equipped to deliver safe services for patients and service users.


  1.  UNISON is the major trade union in the health service and the largest public sector union in the UK. We represent more than 450,000 healthcare staff and 300,000 social care workers employed in the NHS and local government, and by private contractors, the voluntary sector and general practitioners. There is also a wider interest in the NHS among our total membership of more than 1.3 million people who use, or have family members who use, health and social care services.

  2.  This brief response is a summary of the main issues for the union under the main categories of the Committee's inquiry. Where UNISON research is referred to, the relevant website address is given in the footnotes for further information. UNISON would welcome the opportunity to expand on any or all of these points by giving oral evidence to the Committee.


  3.  The Committee asks about the role of public perceptions of risk in determining NHS policy. This is a pertinent question, particularly in light of the recent focus on deep-cleaning to tackle the spread of healthcare associated infections (HAIs) in hospitals. Any initiatives to tackle infection are welcome, but such a policy seems more designed to address public perceptions of dirty hospitals rather than tackling the root causes of infection—insufficient numbers of cleaners and a failure to prioritise cleaning within hospitals.

  4.  One thing that is necessary to give patients and the public the confidence they need in the health service is clarity about which bodies are responsible for monitoring the safety of the NHS. Proposals for the new Independent Safeguarding Authority (ISA) have so far provided insufficient clarity about cooperation between the existing regulators and the ISA scheme, or what the relationship will be with the Council for Healthcare Regulatory Excellence that currently has overarching responsibility for all health regulators.


  5.  The Committee poses the question about how far boards of NHS bodies have established a safety culture. Issues such as cleanliness need to be taken more seriously at the highest level. The Healthcare Commission's report on C Difficile at Maidstone and Tunbridge Wells highlighted, amongst a number of issues, the failure to prioritise infection control at boardroom level. It is therefore welcome that the Health Secretary has taken measures to address this. The proposed legal requirement, announced in September 2007, for chief executives to report infections to the Health Protection Agency must be rigorously monitored and enforced.

  6.  In terms of incident reporting, risk management and safety improvement, UNISON welcomed the commitment in Lord Darzi's interim report that Patient Safety Direct would be set up to provide a single point of access for frontline workers to report incidents. Likewise, the new ability for modern matrons to report any concerns they have on hygiene direct to the new regulator, the Care Quality Commission (CQC). These are important steps as they give staff the confidence to raise concerns about patient safety free from the fear of recrimination in the workplace.

  7.  Whilst UNISON does have concerns about aspects of the new "failure regime", one welcome part of proposals contained within the Department of Health's Consultation on a Regime for Unsustainable NHS Providers is the decision to assess foundation trusts on grounds more than merely financial failure. Moving beyond straight economic considerations, should allow foundations to be assessed on a more comparable basis to other NHS trusts when it comes to issues around clinical safety or hygiene.

  8.  The Committee also asks about the impact of the changing public-private mix in provision. This is a key issue for UNISON where patient safety is concerned. The privatisation of decontamination services within the NHS is an area that has taken on a higher-profile in 2008. Government plans for private decontamination super centres to replace existing in-house services present major problems for patient safety. In-house teams have the knowledge and the proximity to ensure sterilisation is carried out properly. In April 2008 the Royal College of Surgeons reported that since the privatisation of decontamination services, more operations were being cancelled due to broken, missing or just plain dirty surgical instruments.[245] Right from the start a UNISON report endorsed by the other unions was a part made clear that the whole programme setting up these supercentres was fundamentally flawed and that highly questionable financial incentives were involved.[246] The supercentres mean that highly specialised instruments will be travelling long distances and will be vulnerable to hold-ups because of basic practical considerations such as bad weather, roadworks, congestion and traffic accidents. In addition, packs contain delicate equipment that is easily damaged in transit. UNISON therefore welcomed the news in August 2008 that four hospitals in the south west had pulled out of a scheme to set up two privatised regional super centres for sterilising medical equipment, but it is clear that this policy must now be scrapped.

  9.  The outsourcing and off-shoring of medical secretarial work is another area where the changing mix of public-private provision puts patient safety at risk. The promise of cost savings by having medical notes typed up by private companies abroad ignores the potentially fatal consequences of a greater likelihood of typing errors. For example, the difference between treating hypertension (high blood pressure) and hypotension (low blood pressure) can be a matter of life or death. NHS medical secretaries have years of experience and are familiar with the consultants and their patients. They have direct access to patients' notes and are able to check any details which may be unclear directly with the doctor.

  10.  UNISON continues to campaign for hospital cleaning services to be brought back in-house across the UK. The government's suggestion as a result of the recent National Policy Forum process that full consideration will be given to in-house cleaning services is a start, but it is not sufficient.

  11.  There is a growing consensus, particularly with C Difficile, that there is a definite link between infections and cleanliness: the National Audit Office has highlighted a "growing recognition of the relationship between the effective cleaning of hospitals and the health and safety of patients and staff."[247] Recent infection-specific measures are helpful, but the use of alcohol rubs, for example, only helps tackle MRSA and the use of water and soap only helps tackle C Difficile. Equally, a deep-clean is effective as a temporary fix rather than a long-term solution. What is needed is a more general and sustained approach to cleaning hospitals that raises the overall level of cleanliness. This can only be brought about by raising the number of cleaners, which is best achieved by bringing hospital cleaning back in-house.

  12.  There is a definite link between the contracting out of cleaning and the numbers of cleaners: the number of equivalent full-time cleaning posts has almost halved from 100,000 in the mid-1980s (when the Thatcher government introduced compulsory competitive tendering) to just 55,000 twenty years later.[248] The fact that cleaning standards in hospitals have fallen as a result of contracting out was acknowledged by the government in 2001 when it ended the compulsory element of competitive tendering of cleaning services in the NHS. The then Health Secretary stated that "compulsory competitive tendering has gone because it failed to raise standards".

  13.  It is also important to note that the issue is not just one of public versus private; the contracting regime has had a wholly detrimental effect on the performance of in-house teams as well, as they are forced to compete with the private sector.

  14.  Another failing of contract culture is that it atomises functions within hospitals, an issued highlighted in the Healthcare Commission's Maidstone and Tunbridge Wells report, alluded to above. This contributes to the breakdown of the team-based approach that should unify clinical and non-clinical staff, thereby damaging flexibility and overall effectiveness. The Chief Medical Officer recently remarked that infections can only be tackled effectively by "working together as a team that encompasses the entire healthcare journey".[249] Contract culture works against this. Further, a larger number of cleaners integrated with the rest of the workforce would allow cleaners to pass on their expertise, given that they arguably have greater knowledge of environmental cleanliness than even infection control nurses or modern matrons.

  15.  Prior to the Welsh Assembly Government announcing that all cleaners in Welsh hospitals would be employed by the NHS, Wales already led the UK with the lowest levels of MRSA, with all but one cleaning contract operated by the NHS by 2007. Ideally all hospital cleaning would be brought back in-house in the rest of the UK, but at the very least the suggestion of the previous health minister Andy Burnham that trusts should be encouraged to bring cleaning back in-house should be implemented; and all Strategic Health Authorities should insist on there being in-house bids where contract cleaning is concerned.

  16.  In terms of specific national policy initiatives, Lord Darzi's interim report acknowledged the importance of cleaning to the healthcare effort, which was an important and long overdue step. Ambitious plans from the interim report to introduce MRSA screening for all elective admissions (and subsequently all emergency admissions) are also to be welcomed.

  17.  Darzi's final High Quality Care for All report also contained a number of important contributions to enhancing patient safety. Notably new enforcement powers for the CQC to tackle infections from April 2009 and plans for national campaigns to make care safer through the National Patient Safety Agency, such as tackling catheter-related bloodstream infections and drawing up a list of so-called "never events" that the NHS will attempt to eradicate, such as wrong-site surgery.

  18.  There could be some unforeseen consequences around the development of another new national policy, the Independent Safeguarding Authority. UNISON is committed to public protection but the fact that ISA registration fees would have to be paid by staff is likely to impact on the recruitment and retention of staff within the NHS (and other public services), which could mean that some health institutions end up with unsafe staffing levels. This needs to be reassessed.

  19.  The role of national bodies is particularly important in the drive to ensure the highest possible level of patient safety. UNISON has a number of concerns in this regard relating to the remit of the new Care Quality Commission. The constant pressure for regulatory bodies to drive down costs seems likely to result in fewer inspections. Continuing moves towards light touch regulation could have massive implications for patient—and staff—safety. At a time when more providers are encouraged to enter an increasingly diverse market, rather than greater scrutiny this is being met by less regulation. Contrary to the views of providers, UNISON does not believe that "reducing the burden of regulation" is appropriate when it affects vulnerable people in health and social care. Patient and service user safety and quality of life should be the priority of the CQC.

  20.  The union has further specific concerns where the registration of providers are concerned. For instance, non-urgent patient transport services (PTS) should not be excluded from registration, as suggested by the DH's Framework for the registration of health and adult social care providers. The prime factors in determining the necessity for registration should be patient safety and quality. PTS have the potential to seriously impact on both. The conveyance of patients, especially those with mobility difficulties inevitably requires personal physical contact. When taken together the hands-on nature of the job and a care setting lacking any immediate supervision should put PTS high on the list in terms of patient safety.

  21.   High Quality Care for All stated that all GP and dental practices would be brought within the scope of the CQC. This is a sensible move, particularly with more care likely to be provided through GP-led health centres and polyclinics in the future.

  22.  Education for health professionals is another area within the inquiry's remit and is an essential component in ensuring patient safety. The focus on education and training contained within High Quality Care for All and the accompanying A High Quality Workforce is to be welcomed. The doubling in investment in apprenticeships is a good move and it is refreshing that Darzi recognised that "healthcare support staff—clinical and non-clinical—are the backbone of the service". Similarly the draft NHS Constitution contains welcome pledges to staff on, amongst other things, learning and development. Such positive moves could be further enhanced by an explicit recognition of the link between education / training and good patient care outcomes.


  23.  An essential part of ensuring the future safety of patients in the NHS is to make sure there are safe staffing levels across the service. UNISON has recently highlighted the impact that financial hardship is having on health students, with more than half considering quitting their studies due to debt.[250] Urgent action is needed to avoid a serious skills shortage developing, given that a third of nurses are due to retire within the next ten years and fewer health professionals are coming from overseas to work in the UK. Proper consideration should be given to paying health students a salary rather than the current bursary arrangement.

  24.  The Committee asks whether current measures to improve patient safety are supported by an adequate evidence base. Where hospital cleaning is concerned, there is a growing body of scientific research that supports the case for expanding hospital cleaning.[251] Such findings suggest that it is insufficient to merely target hand-washing due to the importance of airborne MRSA to the spread of infection and the fact that a third of surfaces in hospitals harbour MRSA in endemic and outbreak infection situations. Likewise, deep cleaning does not completely eradicate MRSA from the clinical environment. The evidence shows that whilst hand-washing may be an important control measure, it is impossible to get everyone to clean their hands at the most appropriate time and even if they did the benefits are eroded if the environment is heavily contaminated with MRSA. Studies show that thorough and continuous attention to ward hygiene and the removal of dust is necessary to terminate prolonged outbreaks of MRSA on general surgical wards. Dr Stephanie Dancer's ongoing research for UNISON (to be published later in 2008) has used microbial growth tests to identify the sites where MRSA resides, meaning that additional targeted cleaning would have a dramatic impact on MRSA incidence.

  25.  Beyond MRSA, the value of cleaning has also been demonstrated to be particularly important for tackling C Difficile, A Baumanii and Norovirus. Given that C Difficile primarily thrives in a dirty environment, this is even more clearly related to the contracting process than MRSA and harder to tackle with specific interventions.[252]

  26.  The Committee asks about measurements and the publication of data. There is a need to provide continuity and consistency across the private and voluntary sectors with the data collection of safety incidents. This is part of a more basic need for better publication of data from independent providers so it can be checked against NHS standards. The Health Committee's 2006 report on Independent Sector Treatment Centres (ISTCs) highlighted this disparity and the Healthcare Commission pointed out in 2007 that ISTCs are failing to meet the requirement to submit performance management data. A recommendation of the Commission's report was that provision of good quality data should be a registration requirement under the CQC once it comes into being.[253]

  27.  In terms of engaging patients and public in ensuring the safety of services, it is important firstly that the new Local Involvement Networks (LINks) become operational as quickly as possible, something which is evidently not happening in every part of England. Secondly, it is essential that LINks are not impeded by a two-tier approach to health scrutiny. The commitment by the government that new independent sector providers must have the obligation to cooperate with LINks written into their contracts must be rigorously enforced to ensure a level playing field and give the public greater confidence that all providers of NHS services are conforming to appropriate safety standards. Thirdly, the DH may need to act to block conflicts of interest that could put patient safety at risk; for example, the recently reported case of Gateway Family Services being appointed to host Birmingham's LINk despite the fact that they also provide health services locally.[254]

September 2008

245   Royal College of Surgeons, "NHS operations cancelled because of failing new instrument cleaning centres", 24 April 2008, Back

246   UNISON / Amicus / GMB, Joint trade union report to the Department of Health national decontamination strategy, January 2006, Back

247   National Audit Office, Improving patient care by reducing the risk of hospital acquired infection: a progress report, HC 876 Session 2003-2004: 14 July 2004 Back

248   UNISON, Hospital contract cleaning and infection control, Steve Davies, 2005, Back

249   Department of Health, "Chief Medical Officer launches the third year of the cleanyourhands campaign", 15 November 2007 Back

250   UNISON, Reaching breaking point: UNISON national survey of nursing students 2008, September 2008, Back

251   See, for example, recent work by Dr Stephanie J Dancer, "Importance of the environment in meticillin-resistant staphylococcus aureus acquisition: the case for hospital cleaning", The Lancet, October 2007 Back

252   Ibid. Back

253   Healthcare Commission, Independent sector treatment centres: the evidence so far, July 2007 Back

254   The Guardian, "`Conflict of interest' dogs scrutiny role", Saba Salman, 17 September 2008. Back

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