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Housekeeping: redesigning a role

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Jenny Kay, BA Hons, RGN, RSCN, MBA.

Director of Nursing, Dartford and Gravesham NHS Trust, Darent Valley Hospital, Dartford, Kent

The NHS housekeeping initiative was announced as part of The NHS Plan, following extensive consultation with patients, staff and stakeholders (DoH, 2000). The aim is that by 2004 over half of all trusts will have a ward housekeeping service (NHS Estates 2001; 2002).
The NHS housekeeping initiative was announced as part of The NHS Plan, following extensive consultation with patients, staff and stakeholders (DoH, 2000). The aim is that by 2004 over half of all trusts will have a ward housekeeping service (NHS Estates 2001; 2002).

The scheme, which received a warm welcome in focus groups that we held, appears to offer a solution to many of the problems of the NHS - better responsiveness to patients' and relatives' needs in the ward, more support for hard-pressed nursing staff, and a welcome emphasis on the quality of 'hotel' facilities for patients.

Pilot scheme
The staff at Dartford and Gravesham NHS Trust, with its brand new 400-bed Darent Valley Hospital, were keen to bid for funding for pilot status, which would help us work on a strategy that could then be rolled out to the NHS as a whole. We received funding in early 1991.

Darent Valley Hospital is run as a private finance initiative (PFI). The concept of a PFI is now familiar to many, but it does create some new complications, especially in a project of this nature. The hospital building is owned by a consortium, the Hospital Company (Darenth) Ltd, which is repaid by the trust on an agreed charge for 'availability' - in layman's language, the principle is that of a mortgage or a lease. However, the contract is complex and includes a legal 'concession agreement' whereby all facilities management services are provided by a partner, in this case Carillion Services plc.

A steering group was set up, including the director of nursing, director of personnel, and the director of corporate services. Our head of dietetics agreed to be project manager for the pilot stage of the housekeeping service. The general manager of Carillion was also invited to join the steering group.

The housekeeping role
Our first task was to establish what role the housekeeper would fulfil, and whether it would duplicate or complement existing roles (both in the NHS and Carillion) and, if so, to what extent. Would the housekeeper be an NHS employee, or employed by Carillion Services plc?

Other staff roles
In the wards, under the PFI concession agreement, Carillion provides two staff - a 'housekeeper' whose duties are chiefly cleaning, and a 'service team assistant', who takes the main responsibility for serving meals and drinks. The terms of the concession agreement are that all facilities management is provided by Carillion - that is, cleaning, catering, laundry, estates management and so on.

All wards have a ward clerk, whose job is to welcome visitors, handle enquiries, manage all patient notes and records, and assist with ward administration, This work might include telephoning the helpdesk to get repairs done, for example.

And while our health-care assistants spend most of their time on direct care to patients, they also provide an element of the new housekeeper role - for example, keeping the ward tidy and presentable, tidying away supplies, greeting visitors and answering the phones if needed.

It was clear at this early stage that some elements of the housekeeping role were already carried out in part by all these different people, but the system lacked the leadership and co-ordination inherent in the NHS housekeeper's job description. Whatever we agreed would have a potential impact on the work of existing groups of staff.

While the concession agreement appeared to point to employment of the new housekeepers by Carillion, the steering group was pragmatic. We felt at the outset that it was important to gain the understanding and support of NHS and Carillion staff to this potential major change. We also wanted to test out some of the assumptions that we might have been making about who did what, and what level of change the staff would wish to support. The view of the patient was central to our thinking. It would help us all to avoid old-fashioned professional protectionism between different staff groups. If we could keep the patient's needs at the centre, the project would succeed. The views of the ward sisters would also be critical as the people charged with running the ward and co-ordinating all aspects of clinical and non-clinical services in the ward.

Focusing on the issue
The decision was made to host a series of focus groups with staff and patients. They were co-ordinated by Bill Davidson and Laurie Bryant, external facilitators recommended to us by NHS Estates project management team. The focus group objectives were to:

- Give staff an opportunity to voice their opinions on the role of a ward housekeeper

- Think afresh outside the current traditional roles

- Discuss and agree basic job content/training issues and role development needed

- Clarify the lines of communication/relationships between staff and, in particular, between Carillion and the trust

- Consider and plan towards two ward areas being used as pilots before going ahead fully.

We invited the following groups to take part in the focus groups:

- Ward sisters

- Patients

- Health-care assistants

- Ward clerks

- Service team assistants

- Cleaners (currently called housekeepers)

- Domestic supervisors

- Catering staff.

The focus groups were held in January and February 2002. Their comments helped provide the steering group with a depth and breadth of information about the strengths and weaknesses of the current system. There was much enthusiasm about the new role of housekeeper, which staff felt would enhance patient care, and address some of the existing tensions between Carillion and the ward teams.

Key issues
Key issues were:

- Pay: while some existing service team assistant and cleaning staff were excellent, and could be developed into a 'housekeeper' role, current rates of pay were seen as too low to attract and retain good staff

- The housekeeper role was currently undertaken to some extent (but not fully) by many different people - but the new role could not be achieved simply by re-organising or re-labelling existing staff. Nor could wards afford to lose existing staff or roles in order to create a housekeeper role

- There was a need for clarity in introducing a new role. For example, job descriptions, core competencies, and common training were necessary

- The chain of command needed to be clear. At present, while the ward sister is the ward boss, and many ward sisters direct the work of Carillion staff, line management of Carillion staff is through a Carillion domestic supervisor.

The focus groups set out seven key principles (Box 1).

The findings of the focus groups helped the steering group to gain a much better understanding of the issues that would need to be addressed to move forward. The most important of these was funding - the findings were clear that using existing staffing resources differently, while a possibility, may not provide a solution that would meet the NHS housekeeper criteria.

Funding issues
The project manager therefore worked up a detailed costed options appraisal. The cost of implementing the NHS housekeeper project throughout the trust is large. The preferred option includes higher rates of pay and more hours. Less expensive options have been considered, but these would tinker at the edges of the present system, rather than provide the radical change desired.

Throughout the 1980s and 1990s the NHS attempted to function with cheaper cleaning and domestic services. Whether services are contracted out, provided by a PFI partner or by an inhouse NHS contract, rates of pay for ancillary staff are very low. In the south-east, with its high living costs and high employment levels, it is difficult to attract good staff with low pay. If the NHS and its users want a housekeeping service that brings quality improvement, we will have to pay for it. But is the scheme affordable given other NHS Plan priorities?

While continuing to seek full funding, the trust will use the learning from this project to good effect. We are working to strengthen the role of the ward sister and modern matron in directing the work of the existing ward-based Carillion staff. We are seeking to involve patients in helping us monitor the quality of cleanliness, food and the environment. The relationship between managers and Carillion has been enhanced, and this will continue through groups such as the 'Better Hospital Food' group.

Most importantly, the patient-centred approach has shown all involved the importance of the 'fundamentals' to patients.

Ward sisters have heard directly from patients of the importance of good communication, the value of a friendly and knowledgeable approach from nursing and facilities staff, and the difference that high standards in food, cleaning and service delivery can make to the patient experience.

Department of Health. (2000) The NHS Plan: A plan for investment, a plan for reform. London: The Stationery Office.

NHS Estates. (2001) Housekeeping: A first guide to new, modern and dependable ward housekeeping services in the NHS. London: The Stationery Office.

NHS Estates. (2002)Process Mapping the Housekeeping Service: A toolkit for change. London: The Stationery Office.
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