A toilet like the one in the film Trainspotting was just one of the horrors flushed out by hospital cleanliness inspectors, but will government clean-up plans get to the root of the problem, asks Alison Moore

Cleanliness is very much on the government's NHS agenda, with£30m handed over to hospitals to kickstart a clean-up campaign, plus unannounced inspections of trusts, and action plans which are meant to be carried out by April. But will the changes be only skin deep?

A small number of hospitals will have started the new year with a nasty surprise - the news that their standards of cleanliness are so poor that a team of facilities managers is to be drafted in to advise them how to improve (see news, page 4, 4 January).

The 10 to 20 hospitals involved are at the far end of a spectrum which includes eight exemplar hospitals and many others which demonstrate good practice, others with a mixed record and more than a third that have been identified as 'red' - failing to meet certain core targets. Hospitals have been allocated grades under the government's 'traffic light' scheme, following a series of inspections last year.

The patient environment action teams went far beyond examining just cleanliness and instead looked at the whole environment the patient was likely to encounter - from the car park to how well the gardens and grounds were maintained.

Trusts were given 48 hours' notice of the visits, which were carried out by about 200 professional volunteers plus patient representatives. Each trust will be given a follow-up unannounced visit by the end of February.

Of 699 hospitals visited, 250 were given red status, 291 yellow and 158 green, suggesting there is still a lot to be done. At each hospital 50 patients were given questionnaires to return.

These were then passed to chief executives.

'I know there have been one or two concerns about some of the ways the visits were organised, ' says Brian Gibbs, facilities director at Bassetlaw District General Hospital, one of the exemplar sites. 'They were intended to be supportive and developmental, and I think the vast majority were, but not all. Some were seen as a chance to tell hospitals how to do it.'

But Patients' Association assistant director Simon Williams, who took part in 30 inspections, says some trusts were reluctant to learn from the experience. 'They should have valued more the support we offered them - they found it threatening, ' he says.

Mr Gibbs thinks some hospitals were shocked by their 'ratings', which differed from their self-assessments.

'There are a hell of a lot of trusts who are pale red or yellow who are working very hard to get into green by 31 March, ' he says. But he thinks some could take two or three years to get off red status.

The inspections were just one indication of the government's interest in cleanliness: earlier last year hospitals were each given a one-off sum of between£50,000 and£150,000 to improve hospital cleaning.

Some hospitals used this for straightforward cleaning.

Chris Gray, managing director of Medirest (formerly Granada Healthcare and the Bateman group), says a number of trusts asked for a thorough clean with their share of their money.

According to NHS Estates, other popular options were 'deep cleaning' of certain areas, repairs, minor refurbishments and improved signage. But some hospitals - especially those which felt more confident about the basic cleanliness of their environment - have taken a much broader view of how the money could be used to improve patients' experience.

Hanging paintings in corridors and stairwells has been one use of the money.

Improved access to the facilities department - so problems are reported quickly - is another. Trust boards have also been ordered to pay more attention to the patient environment, with a board member designated to take on the issue.

Performance management criteria have also been drawn up and hospitals have until 31 March to implement their own action plans. If this does result in improvements, will they be sustainable in the long run? One concern is that the government's initial expenditure was a one-off and trusts may be expected to maintain the same standards without ongoing extra cash.

'Because the money is not re-occurring, very little has been spent on staffing, ' says Health Facilities Management Association chair Geoff Callan.

Problems may be worse because of years of underinvestment in cleaning services. Ean Coates, deputy chair of the Association of Domestic Management, which represents both inhouse and commercial cleaners, says cleaning is one of the non-clinical areas badly squeezed over the last few years. 'What money has been available has dictated the contract rather than what does the service really need, ' he says. 'That attitude will have to change.'

Wilson Barrie, managing director of private contractor Sodexho's healthcare division, agrees: 'Compulsory competitive tendering has led to a situation where price has overtaken quality. The impact is there for everyone to see.'

Many hospitals are already looking at their cleaning specifications to see if they are adequate - even some exemplar hospitals are looking at the frequency of cleaning, for example. And this is happening regardless of whether cleaning is carried out by an in-house team or a private firm, as happens in around a third of hospitals.

'A number of our customers are coming to us to increase the work we are doing, ' says Mr Gray. 'With new business, a lot more care is being given to ensuring the specification is up to scratch. They are paying much closer attention - they are asking us whether we think the specification is enough to ensure the standards required. That is encouraging.'

NHS Estates says it is not aware of any trusts which have incurred extra costs as a result of re-negotiating contracts.

The NHS plan says cash for cleaning will be distributed as from now as part of the normal allocation process rather than being earmarked.

That means cleaning may have to compete with dozens of other priorities. But even if the cash to employ more domestic staff is available, recruitment may be difficult.

'We have a north-south divide in getting staff, ' says Mr Coates, who works at Broadmoor Hospital Authority in Berkshire. 'In the south we can't get them - the same as nurses - and we are all working at 20 per cent below establishment.

'I am competing with people like Tesco, Marks & Spencer and computer companies who are all paying£6 an hour.'

In some areas, trusts are offering domestic workers higher pay rates than the Whitley scale to attract them.

'We pay staff up to£4.16 an hour, ' says Mr Callan, facilities director at Milton Keynes General trust. 'Milton Keynes has 1.5 per cent unemployment. We can't recruit and the city centre is offering jobs at£2 to£3 an hour more.'

Another problem is the infrastructure of the NHS - many hospitals (not all old) are difficult to keep clean.

'You can clean all day but if a surface is worn out, whatever you do it is not going to look clean. A lot of money needs to be spent on things like flooring, ' says Mr Barrie.

Putting cleanliness higher up on everyone's agenda may help - new hospitals, refurbishments and equipment can take ease of cleaning on board at the design stage - but this is a long-term solution.

The government is also keen to see ward sisters given the power to ensure their wards are properly cleaned, a throwback to the old days when cleaning staff were often under their direct supervision.

But it is far from clear how this will work on the ground.

In some trusts, cleaning staff have already been devolved to individual wards, but there may be times when the cleaner is off duty - although there are proposals for rapid-response teams that sisters can call on round the clock.

In some cases, sisters may not want to take on the responsibility of directly managing cleaning staff - especially if they are already satisfied with the level of cleaning, suggests Mr Gibbs.

Domestic staff also need to feel a valued part of the team and should not be used just as skivvies, adds Mr Callan.

Where outside contractors are employed it may be hard to give ward sisters 'control' over domestic staff.

Mr Barrie suggests a detailed specification for cleaning individual wards may be key - and ward sisters could help with drawing it up.

'We have no issue in working closer with ward sisters to get the job done - we welcome it, ' he says. 'The key to it is service-level agreements.'

Dee May, the Royal College of Nursing's infection control adviser, believes that the involvement of ward sisters is essential.

'It is their environment and they have to manage it in its totality. They have to pick up the pieces when beds are closed or outbreaks of infection occur, ' she says.

No-one wants to be treated in a dirty hospital - but the effect may not be just aesthetic. Dirt can be a reservoir for germs and may contribute to the spread of hospital-acquired infections.

Dee May, infection control adviser at the Royal College of Nursing, says infection control was one of the driving forces behind the current campaign on cleanliness. Standards of hygiene in the NHS have deteriorated dramatically since the mid-1980s, she says. Infection control specialists were frequently not involved in the competitive tendering process, which usually saw contracts awarded on a lowest-cost basis.

'It is known that organisms such as methicillin-resistant staphylococcus aureus (MRSA) and C. Dif live very well in the environment for significant periods of time, ' she adds. 'One can hypothesise that poor levels of environmental cleaning can assist in the spread of organisms, which then go on to produce outbreaks of infection.'

She welcomes the current emphasis on cleaning and the extra money put in to 'pump-prime' the system, but is concerned about whether it will continue.

And will cleaner hospitals reduce the level of hospital-acquired infections? Ms May says it is difficult to pinpoint the effect of one variable. 'I think an increased awareness of the issues can only contribute to an overall reduction in the problem.'

Footprints on the path to cleanliness Hospitals were given£50,000,£100,000 or£150,000, depending on their size, to improve the patient environment.

Each trust had to nominate a board member responsible for cleanliness issues, who will report to each board meeting.

Hospitals had to 'self-assess' their current conditions between August and October last year and develop an action plan to improve standards. This is meant to be achieved by April.

All hospitals were then inspected at 48 hours' notice by a patient environment action team. They were subsequently given red, yellow or green status, plus feedback and the results of patient questionnaires.

Unannounced inspections are now taking place and should be completed by the end of February. Regional offices are monitoring the outcomes of these, and assisting hospitals which do not meet their performance management targets.

New national standards for cleanliness are being incorporated into the NHS performance assessment framework.