Published: 02/06/2005, Volume II5, No. 5958 Page 17

Barbara Cassani who set up Go, the rival to budget airline Easyjet, says that when she worked for British Airways it was three years before she met a customer. Whisper it quietly, but it can be a bit like that in NHS management. When asked recently if they could nominate patients for a user discussion, one primary care trust replied, 'we do not know any patients'.

The plural of 'anecdote' is not 'evidence'. But if I was still an NHS manager I would now systematically spend time each week chatting to patients to hear first hand about life on the receiving end of my organisation's care. It is hard to escape the conclusion that managers who did this would be far more credible in challenging their own institutions to change.

My first taste of this approach came as an NHS management trainee in Newcastle in the 1980s.

The then chief executive of Newcastle City Health trust Lionel Joyce (in typically free-wheeling fashion) suggested I be 'admitted' overnight to one of his hospital's mixed-sex acute general psychiatric wards. By the time I left I shared his conviction that Victorian asylums are no place for modern mental health services.

I subsequently asked Edith Morgan, president of the World Federation for Mental Health, what she looked for when she visited psychiatric hospitals across the world. Her answer: the toilets. If they were clean and offered privacy, the chances were that the institution as a whole recognised the dignity of its service users.

Many of our acute hospitals still have a thing or two to learn from that insight. Is it so unreasonable for the public to judge the invisible parts of our hospitals based on the neglect they see in the visible parts?

Seen in this light, it is perhaps less surprising that hospital cleanliness received greater prominence in the general election campaign than any other health topic.

It also served as a prism through which various critiques of the NHS were refracted: MRSA as caused by waiting times targets (the Conservatives' charge); or by compulsory competitive tendering (Unison's riposte); or by nursing homes (say some hospitals); or by the absence of Matron (most tabloids).

But for all the confusion and public posturing, do not underestimate the degree to which these concerns are now worrying older patients as they contemplate hospital admission. The unpalatable fact is that fear of MRSA strikes at the heart of the trust and reassurance which the NHS is intended to deliver. So it is pretty clear that 'something must be done'.

And so to the Queen's Speech announcing that a bill is to be introduced in this parliamentary session to ban infection and outlaw dirtiness, or words to that effect. The difficulty will be in designing an effective legislative package for what is partly an issue of nursing practice.

It is hard to legislate for hand washing -which is what makes this simultaneously a very basic but also a highly complex problem to solve.

No doubt many of the reform mechanisms now in play can contribute. Higher infection rates will mean longer lengths of stay, which will be penalised by the tariff.

The Healthcare Commission could effectively withdraw a hospital's 'licence to operate' if standards fall too far. Patient choice means independent treatment centres may start advertising for patients on the basis that they are MRSA-free. But these influences will only stimulate, rather than deliver, changed frontline practice. That requires cultural and attitudinal change, which is far harder to engineer.

There are some interesting parallels with teaching. The approach taken to improving literacy and numeracy in primary schools in the government's first term was for the Department for Education and Skills to mandate a specific set of processes to be adopted by all primary school teachers. While the teachers initially hated them, as success became apparent, they (apparently) became more enthusiastic. This approach to change was summed up as 'specify behaviour, and attitudes will follow'.

Hand washing might be amenable to this approach. But much of healthcare delivery will not be, relying as it does on distributed decision-making by relatively autonomous professionals.

How, then, to tackle the wider challenge? What it is about an institution that makes its culture patient-focused and outwardlooking. And how do you turn around a hospital that is not?

One approach is to hire staff for their attitude, not just their competence. All well and good when you have people queuing up for the privilege of working for you, I hear you say. It would certainly make a huge difference in many outpatient departments where clinic clerks should be renamed 'directors of first impressions'.

Another route is to take a zero-tolerance approach to unco-operative or rude behaviour. In theory, the General Medical Council, for example, now requires that all doctors 'treat every patient politely and considerately; respect patients' dignity and privacy; listen to patients and respect their views; and work with colleagues in the ways that best serve patients' interests'.

Though how this is actually enforced is vague, to say the least.

One strategy, however, that will probably not work at all is just to put a new managerial veneer on top of the organisation, by merging a wellperforming hospital with an underperforming one. Some estimates suggest that two-thirds of mergers across the UK economy destroy value. Could this be true in the NHS, too? An interesting case study might well be North West London Hospitals trust, where the word on the street is that the high-performing Central Middlesex Hospital is being dragged down by Northwick Park. I have no idea if that is true. So answers to the letters page, telling it as it is...

Simon Stevens is president of UnitedHealth Europe and was the government's health adviser from 1997-2004. Simon_L_Stevens@uhc.com