The 'traffic-light' inspections found problems not just with hospital cleanliness but issues such as parking and signage. Are they being tackled, asks Alison Moore

Dirty wards may hit the headlines, but the patient's environment in hospital is about far more than just cleanliness.

Finding dust on the bedside cabinet is worrying, but patients may be more concerned about other aspects: parking conveniently; finding their way to the ward; whether wards are mixed-sex; and the last time the waiting areas had a lick of paint.

This wider patient environment has been high on the government's agenda for the past year, with patient environment action teams (PEAT) inspecting every hospital in England twice - once announced and once unannounced.

After the initial inspections, hospitals were given a red, yellow or green rating - partly relating to their cleanliness, but also taking into account aspects such as parking, signage, state of grounds and garden and so on.

Just over a third of hospitals were graded red, with a few causing particular concern.

Teams of experienced facilities managers were sent into poorly performing trusts to advise existing managers.

Earlier this month, the government publicised the results of the inspections: only 40 hospitals are now graded red, with about a dozen a particular cause for concern because they have been slow to improve. In some cases, the hospitals are earmarked for replacement. The Department of Health stressed that some problems were not related to cleanliness but were about issues such as age and condition of furniture and parking.

Although the inspections often been painful, many facilities managers welcomed the emphasis on support services. According to Geoff Callan, director of facilities at Milton Keynes General trust and chair of the Health Facilities Management Association: 'it has brought these issues to the top table of trusts'. Trusts have had to nominate a board member to lead on these issues, and there is political pressure to deliver.

This may explain why the patient environment has improved in many trusts since the PEAT teams began work last autumn, while previous initiatives have had limited success. Mr Callan says: 'I think there has been a vast improvement. For directors of estates and facilities people, it has been a wonderful chance to shine. '

But Simon Williams, assistant director of the Patients Association, is more circumspect. The money pumped in by the government has led to some improvements, he says, but it has been patchy.

And some key issues remain.

As part of the inspections, thousands of questionnaires were distributed to patients.

Although on the whole they were satisfied, one area that came up again and again was parking and transport.

Problems included too few spaces, insufficient space to drop off patients at the main entrance and queues to park.

NHS Estates believes some of the problems can be tackled on the ground - for example, some hospitals use minibus services to bring people from the furthest corners of the car parks.

Will the improvements continue? Money is one factor that will influence their speed.

Last year's funding was distributed regardless of need and allocated by size. But very large hospitals, such as some in central London with myriad problems, still only got£150,000. The money was symbolic of the government's concerns and, most importantly, ring-fenced.

But while the government is putting in a ring-fenced£30m this year, there is no guarantee of continued funding. That means improvements tend to be one-offs, rather than investment in staff, which will have to be funded from general budgets in future years. So a hospital looking to help patients find their way around may opt for improved signage rather than a 'meeter and greeter' to give directions, regardless of the merits of either solution.

Nor is it clear how this year's money will be distributed. 'I am sure they are going to have to invest in red trusts, ' says Mr Callan. 'But are you then rewarding the poor trusts that have not managed it well?'

In some cases, existing resources are simply not being used. Mr Williams says very few hospitals he inspected had heard of the guide on wayfinding produced by NHS Estates.

1And sometimes the NHS is not good at looking outside for solutions, he adds.

Ward refurbishments can be much harder than in the past, says Mr Callan. For hospitals at close to 100 per cent capacity, closing a ward may mean cancelling operations.

There may also be diminishing returns. Tim Carter, head of hotel services at Guy's and St Thomas' trust in London, says: 'You could throw an awful lot of money at things to improve them, but the more you do the less impact you have. '

REFERENCE

1 NHS Estates. Wayfinding - guidance for healthcare facilities. HMSO, 1999.