Securing maintenance funds

Patient safety must be a priority for all healthcare providers, but to an untrained eye, safe maintenance is often not seen as an integral part of that agenda. While the NHS may not have borne the brunt of October’s Government Spending Review, its finances are constantly being squeezed so much so that it was told in June that it must find £20bn savings by 2014, putting some of its frontline services at risk.

By its very nature, maintenance is the effort to keep everything in safe and efficient order, clean and in good repair. Within the context of patient safety, that is simply not something that should be ignored, avoided or left under-resourced.

Maintenance isn’t a headline grabber and that’s because it shouldn’t be. It should be the pacemaker that keeps the vital organs of a hospital working, without anyone other than the people who are directly concerned with it actually noticing what it does. At its very best, it is an invisible, essential function of a trust.

Protecting people
Healthcare employers have a duty of care morally and legislatively to staff, patients and visitors, to make sure facilities and equipment do what they should and don’t pose an unacceptable level of risk. The very things which should be assisting people in recovery or better health shouldn’t risk causing them harm. To do this, every member of staff, including the board, needs to be assured that everything within the organisation from the medical devices, equipment and furniture, to the fabric and structure of the care and working environment are maintained to the highest standards.

As this suggests, maintenance rears its necessary head in every conceivable area of a well-functioning healthcare organisation. It ranges from architecture and engineering services – how buildings and wards are designed and equipment installed – to site services, on-site roads and car parks. All these must be put in place in a way that makes them easy to maintain to ensure they are kept in a good, fit for purpose and safe condition.

Medical gas pipeline and hot and cold water systems are all the responsibility of an estates and facilities department. There have been past examples where lack of, or poor systems of maintenance have lead to patient fatalities and interruption to trust services, such as cases of legionella or faulty medical devices.

Heating, ventilation, electric services and lifts can also fall foul of poor maintenance systems and processes. Sometimes simple lack of maintenance is a root cause of fire incidents, which can mean loss of facilities, equipment and essential services.

Legal implications
Hospitals have faced prosecution and claims for compensation issues in the past where one or more of these functions have failed. In 2007, Bath’s Royal United Hospital (RUH) was fined £80,000 because of a patient who died from a disease he caught through the shower system. This was linked directly to poor maintenance.

In 2009, patients at Royal Blackburn Hospital, Lancashire, were evacuated when sulphuric acid used to clean a drain leaked through a pipe into a ground floor store room. Fumes from the chemical affected electrical wiring and the damage repairs caused a huge amount of additional pressure on trust resources, not to mention stress to staff and to patients who had to be moved to the second floor of the building to safety.

When hospitals experience similar incidents, the long-term damage to reputation and the confidence of patients, relatives, people in the local community and healthcare economy can be hard to repair. There is often a big price to pay for under-resourcing the maintenance needs and requirements of healthcare organisations.
The courts have and will penalise hospitals when they fall foul of the essential standards needed to keep people safe from the effects of poor hygiene, disrepair and bad maintenance. Where a director is prosecuted under health and safety legislation, they can also be banned from holding that position for a number of years.

Supporting maintenance costs
This said, it cannot be denied how difficult it is for some trusts to balance and prioritise spending with so many factors impacting on resources. The conflicting pressures created by trying to preserve budgets without risking patient safety do sometimes fail. Where cuts in maintenance are made the possibility of incidents happening in some areas may appear to be minimal, but nevertheless, the risk is ever-present.

We are now in a position where it is time to drive home the message that the cost of maintenance must be absorbed, supported and ring fenced. This will be far less painful than the cost of legal bills, damage to trusts’ reputations, loss of directorships, not to mention lives caused by accidents.

The law requires that facilities, equipment, devices and systems are maintained (cleaned as appropriate) in an efficient state, working order and good repair. What some organisations may fail to understand is that “efficient” in this case means from a health, safety and healthcare, rather than a productivity or economic perspective.

Hospital furniture needs to be well maintained to prevent it from reaching a point of disrepair. The NHS shouldn’t wait until equipment like this needs replacing, but ensure regular maintenance saves this cost by earlier and more timely intervention. In a recent health and social care prosecution, a vulnerable patient fell out of an unsafe and ill-maintained wheelchair and lost their life, due to the fact the brakes no longer worked.

Ensuring cleanliness
It’s not just how and whether equipment works that can become a maintenance issue – cleanliness must be considered in the same bracket. Thorough cleaning means harmful bacteria and dirt is constantly removed rather than left to a point where it will never be able to be recovered back to a safe state.

Generally, the NHS is good at making sure hygiene standards are met and it has done a lot to ensure harmful virus strains like MRSA are no longer easily able to thrive within a healthcare setting. Good hygiene maintenance means trusts have less chance of falling foul of infectious outbreaks and the accompanying bad publicity.

Maintenance covers a variety of medical equipment from heart monitors and surgeons’ microscopes to resuscitation equipment, both of the latter having been involved in patient death incidents in the past. There are sufficient legislation and healthcare standards available which make very clear the responsibility to maintain medical and general equipment.

The consequences of breaking the law through use of hazardous equipment should not be the only factor that exposes the importance of healthy maintenance coffers. It should be the threat of the devastating effect that poor maintenance can have on people’s lives that rubber stamps its value in ensuring a safe patient journey and experience. However, the law does show the need for the NHS to fulfil its duty of care to all in this area.

Duty of care
The Corporate Manslaughter and Corporate Homicide Act 2007 is clear on what a breach of the duty of care constitutes where a company or organisation has a responsibility to keep people safe from harm. In the context of the NHS, if the way a hospital is managed or organised causes a death, it becomes a gross breach in its duty of care because it has not taken the steps reasonably required to safeguard staff, patients and any other visitors. Similarly, the Health and Safety at Work etc Act 1974 is clear that buildings, equipment and the systems that affect them are maintained properly – this is part of the duty of care trusts should show. Workplace Regulations 1992 takes a comparable line that the maintenance of equipment, devices and systems should leave them in an “efficient” state.

Even the Provision and Use of Work Equipment Regulations (PUWER) 1998 says that the medical devices and equipment it covers must be maintained in an efficient state. The issue of maintenance has also been identified as part of the Care Quality Commission (CQC) essential standards. Regulation 15, outcome 10, relates to safe facilities and regulation 16, outcome 11, to safe equipment.

All these laws and regulations make the same point under different guises; patients and staff shouldn’t be put at risk by the buildings, functions and equipment that they trust will work as a matter of course.

Following practices
When a trust is successful in ensuring that people stay truly safe, it is partly because the equipment they provide is maintained as part of an everyday, integrated, regulated activity. Systems and processes need to be in place to ensure this will be followed in practice by everyone concerned and those maintenance systems and processes are monitored, audited and reviewed on an ongoing basis.

All this considered, it is then imperative that the NHS does not bring its axe down on its maintenance budgets.

Things will breakdown and go wrong – this is a part of life, but if patient safety is compromised because of poor maintenance, poor control procedures, and inadequate management of those whose job it is to ensure maintenance, organisations and individual managers will have no defence.

Patient safety, including indirect patient safety must sit at the top of any trust’s agenda.

Healthcare organisations must strive to retain funding to service maintenance needs, even in economically challenging times. Well-maintained maintenance budgets will ensure NHS hospitals have the ability to continue to provide safe, efficient, quality services and do not pose a risk to the very patients’ health that they are trying to improve.

About the author
David Halicki is a chartered member of the Institution of Occupational Safety and Health (CMIOSH) and member of the national IOSH Healthcare Group Committee

For more information:
Web: www.iosh.co.uk