What future for NHS laundries?

As laundry and linen service provision within the National Health Service in the UK moves into the next stage of its cycle, some within this sector believe the key to future viability lies in encapsulating the many developments proposed and using these to structure a more secure future.

Pivotal to these developments is the growing move within the NHS to nurture best practice models by benchmarking all elements of the service provided.

First, underpinning this article is the definition of benchmarking, which is: the identification, understanding, dissemination and implementation of best practice.

I am a laundry manager with experience of direct management of an NHS location, contract management of an NHS laundry for a private contractor, and commercial laundry management experience. While I do not proclaim to be an expert, I do feel well placed to give a balanced view on the historical position and the future potential for laundry and linen services within the NHS.

Over the course of the last 15 years the number of directly managed laundry plants has decreased significantly.The first graph shows the dramatic decline in NHS directly managed locations within the north west region from 1984 to the present day. It must be stressed that, while a reduction of approximately 75% during this period is quite dramatic, this region is in fact one of the more healthy. In some cases, particularly as you move towards the south, the position is much worse.

Wider picture

The specific reasons given for the various closures are wide and varied, dictated in most instances by the political issues surrounding each location. However, if you examine the wider picture they can generally be categorised into one of the following:

• lack of significant historical investment

• an inability (or local unwillingness) to allow for realistic future investment programmes

• politically-correct yet inflexible financial systems that led to an unequal playing field for all remaining NHS locations.

With the greatest respect to all the NHS laundries that have closed during this period, even if every influencing factor detailed above had been favourable, some would have, and most definitely should have, still been closed. On the other hand, an open – some may even go so far as to say sensible – policy could have seen a more balanced approach that would have benefited both the NHS and the commercial contractors.

Trust no one

From the NHS perspective, random indiscriminate closures of small on-site locations by “forward thinking”, radical, “go it alone” trusts could have been replaced with a more structured development programme that accepted that change was needed. This programme could have been developed along regional lines, allowing for the economies of scale surrounding each location/region.

From the commercial contractors viewpoint, they may not have been lured into this ongoing war of attrition that has resulted in continually bidding for work at the lowest price possible, in some cases uneconomically low. In doing this, they inhibited their ability to perform effectively and, more importantly, consistently.

As we move towards a new NHS designed by New Labour, there is a feeling of a positive future for the more optimistic of us. Within NHS support services in general, of which laundry and linen services forms a significant portion, the last two-year period has seen a number of key developments. If taken in isolation, they offer a small glimmer of hope. But if pulled into a consolidated package and used positively, they could provide a major lifeline for future viability and success.

So what has actually changed and why should we feel more optimistic? The diagram opposite details the key influencing factors and we must examine what each of the elements offers if taken in isolation, and decide if it could offer the service a future other than eventual privatisation.

First, consider the NHS Plan. While this comprehensive document is meant to provide the direction for the whole NHS for the next 10 years and beyond within its many pages, two key elements are pertinent to our service.

The continued reference to the former “swear word” – investment – is obvious and, for the first time in many years, the importance of clean wards and textiles suitable for use is actually identified as a future patient care necessity.

The second major development within the future policy direction of the NHS was the release of the National Performance Assessment Framework Document (NHS PAF) in March 1999. Again, it’s another substantial document to shape the future direction of the NHS, but one which actually features the area that includes laundry services. Specifically, it focuses on efficiency, in as much as it states: “That services will ensure effective care is delivered with minimum waste, and that the NHS uses its resources to achieve value for money.” This is a clear indication that the emphasis will be on confirming the viability of all future service delivery.

Performance groups

Thirdly, following directly on from the NHS PAF, and in recognition of the soon to be released “Value for Patients” document, a number of performance management groups are being established to enable the networking and comparison mechanism crucial for the benchmarking process to be successful.

The fourth factor, and perhaps the most significant, was the content of a press release from the Secretary of State for Health Alan Milburn on Wednesday September 27 last year. While shrouded in political verse, it gave the clearest indication that providers of in-house support services will be offered the opportunity to prove their viability and hopefully safeguard their future. In summary it stated that:

• a new contracting-out policy would put value ahead of cost cutting

• compulsory market testing of support services would be dropped

Allowing for all the elements above and by taking a holistic view of all the items, the north west region of the Society of Hospital Linen Services & Laundry Managers concluded that there may now be a glimmer of light at the end of this long dark tunnel. In August 2000 the society set about pulling all the elements described above into a useable model that could, in theory, be adopted nationally and used as the baseline tool for future viability.

Realistic and flexible

One of the key protocols adopted at the beginning of the exercise was that the tool had to be both realistic and flexible enough to cater for as many of the various service methods actually available. A common statement from all members of the group was that in all but a few isolated cases, the surveys that had been requested in the past had always failed to grasp fully the real issues pertinent to the laundry service.

It was determined that certain key objectives had to be met in order to set this tool aside from its predecessors. Principally these were:

• to provide a model that was useable for both providers and users of a service

• to ensure the model was focused at the correct level within the organisation

• to develop a model that had a synergy with all the external influences and did not fight them

• that provided a balance between cost and quality

• a model that was dynamic, realistic and was real time

• a model that could be swiftly and easily updated

• that would provide any user with the ability to benchmark to any degree with comparable locations

With this in mind, after a small number of relatively unproductive, if interesting and enlightening, debates, the group agreed that there needed to be two main themes – cost and quality.

To this end the group was effectively split into two. For convenience those still operating NHS plants, the smaller group, were tasked with developing a model for the cost structure and those receiving a service from an external contractor were tasked with developing the quality model.

Approximately two months later the groups presented their initial findings to the regional meeting. These findings were taken away and the first draft benchmarking model produced.

All parties had various views on different elements of the models, but a consensus was reached at this stage that we had something we could take forward and develop. A series of sub-meetings and group meetings were actioned, which took the initial draft and moulded it into what we have today.

What does this model offer? At the time of writing this article, the model is still in its virgin state and will remain so until service providers and users pick up the tool, use it and are willing to share information.

In the simplest of cases it requires a minimum of two similar organisations to complete the model and compare outcomes. Ideally, the people involved with developing this tool would wish to see a national network of benchmarking groups established that is able continuously to interpret, update and communicate the information generated from across the country.

In operational terms it offers a simplistic, easy to interpret and use series of audit questionnaires. These questionnaires have been designed to be flexible to allow for most, if not all, service delivery methods.

Suited to services

These audit tools have been developed from the lowest possible level and structured in such a way that it is possible to use any permutation of audit tool to best suit specific services. Also crucial to the model is the ability, in a structured fashion, to substitute any misleading anomalies with best practice norms where appropriate.

Once the audit tools have been selected and completed the tool then drops down into a simple scoring system that enables an accurate assessment of the standard of service being provided. From this initial scoring system an effective action plan can be developed based on the specific requirements of each establishment.

The tool, in line with the initial objectives, is simple and easy to use, focused at the correct level and provides a realistic analysis of laundry and linen service provision.

It should be stressed that none of the involved managers believe this is the finished article; it does, however, provide a sensible starting point. The purpose of the tool is to establish a base that can be easily and swiftly updated. It is also hoped it will provide a consistent model, which if formally adopted will become the “benchmarking tool” for future controlled development of laundry and linen services to the NHS.

No soft option

Under no circumstances should this tool be seen as ensuring the soft option for NHS laundry managers. If anything, managers should treat it warily in the first instance as it may expose inefficiencies. However, if managers enter into the exercise with an open mind and a willingness to act on the results, then it may prove to be a less painful route than closing your laundry and allowing the decline to continue.

If we examine the work undertaken in relation to the benchmarking definition detailed at the start of the article, this tool in its raw state allows for the identification and understanding of best practice. The dissemination and implementation will only happen if people pick up the tool and, together with like-minded colleagues, use it in the spirit in which was developed and written.

I am under no illusions. The previous 15 years will not be reversed, and I believe I speak for many of my colleagues when I offer this view: what is hoped by producing this work is that the remaining establishments throughout the UK are allowed the opportunity to fight their battles on a reasonably level playing field.

Hopefully, gone will be the days of persistently losing battles with the capital team as to where next year’s allocation goes – the laundry batch tunnel washer or the MRI scanner. Gone also will be the extraordinarily inaccurate and varied capital charge levies that seldom resemble the value of the laundry equipment in operation. Gone too will be the £20,000 per year trust overheads for the annual substantial input time of, say, 20 hours from a particular support department.

We can only hope for a brighter and more viable future. We, the north west region of the Society of Hospital Linen Services & Laundry Managers, hope we have done our little bit to help.