Recruitment and retention of estates and facilities staff in the NHS

Purpose – Agenda for Change is set to be the biggest reform of pay since the National Health Service (NHS) began in 1948. As well as introducing a standardised pay structure; it also aims to improve recruitment, retention and staff morale. Staff groups identified as having recruitment and retention problems include estates/works officers, qualified maintenance crafts persons and qualified maintenance technicians. The object of this research was to investigate recruitment and retention problems for estates and facilities staff currently experienced by Trusts. Design/methodology/approach – Focus groups were used as the primary method of data collection in an attempt to tap into the existing expertise of staff working at strategic and operational supervisory positions in a wide range of Trusts. Findings – Although our findings suggest that the main recruitment and retention issues fall into four main themes: social, financial, environmental and political; recruitment and retention of estates and facilities management staff is a complex problem involving a wide range of issues and these can vary from location to location. Furthermore this should also be seen as a series of issues that varies across employment groups including: domestic/housekeeping, trades, managers/officers and facilities directors, which need to be distinguished. Practical implications – There is a continuing need to raise the profile of estates and facilities management staff in the NHS to those levels enjoyed by Human Resource (HR) and Financial Management. Furthermore perceptions surrounding both recruitment and retention issues and the nature of work within estates and facilities management staff in the NHS can lead to a negative and self-perpetuating “cycle of failure” where there is an assumption of loss of control. However, there are some initiatives being undertaken that suggest it is possible to concentrate on internal matters such as more appropriate and flexible recruitment processes, improved support services for staff and greater flexibility within the job and that these can generate “cycles of success”. Originality/value – The paper looks in-depth at the current recruitment and retention problems for NHS estates and facilities staff. The paper would be of use to NHS estates and facilities managers who are currently investigating workforce issues, particularly surrounding recruitment and retention of staff. Keyword(s): Recruitment; Retention; National Health Service; Property management. Introduction Agenda for Change looks set to be the biggest reform of National Health Service (NHS)[1] pay since it began in 1948. Although doctors, dentists and senior managers will be excluded from Agenda for Change, over 1.2 million NHS staff will be affected including nurses, allied health professionals, radiographers, administrative and estates and facilities staff. Following a second ballot by the unions Unison and Amicus, the national implementation for Agenda for Change took place on 1 December 2004. In addition to introducing one standardised pay structure across the NHS, Agenda for Change also aims to “improve the recruitment, retention and morale of the NHS workforce”[2]. As part of Agenda for Change, Trusts will be able to incorporate a premium into rates of pay where market pressures would otherwise prevent them from being able to recruit and retain staff. The staff groups identified as having recruitment and retention problems include estates officers/works officers, qualified maintenance craft persons and qualified maintenance technicians (Department of Health, 2003). This paper reports on research designed to investigate recruitment and retention problems for estates and facilities staff within Trusts. It begins with a brief review of relevant literature looking at Schlesinger and Heskett's model of a “cycle of failure” that perpetuates high levels of staff turnover but also at how this might conversely be interpreted as a cycle of success. We also comment on research emphasising the importance of a sense of altruism or public service ethos to staff working in public sector areas such as the NHS. We describe the use of focus groups as the principal instrument for data collection and go on to discuss the results of these in terms of four emerging themes. We conclude that recruitment and retention is complex with issues that vary from Trust to Trust as well as by geographical location and across different staff groups. The research, however, did also uncover a number of initiatives at Trust level that do seem to be improving recruitment and retention. Often considered unimportant when compared with the clinical and medical functions of the NHS, estates and facilities represents a very significant part of the service. According to Inventures[3] the NHS has the largest property portfolio in Europe and is currently valued at £23 billion. There are approximately 12,000 “maintenance and works” staff in the NHS and 25 per cent of NHS spend is on estate and facilities management (NHS Estates, 2003, p. 3). The document “Working for the Future: an invitation to shape a National Workforce Strategy for Efm”[4] (NHS Estates, 2003) was the result of an NHS Estates[5] consultation exercise. The document was the first step in an attempt to tackle the recruitment and retention problems currently facing the NHS for its estates and facilities staff. As outlined in this document: Over two-thirds of Trusts report problems recruiting and retaining Efm staff, and many Efm staff report skills gaps in Efm management, in areas such as strategic planning and public finance skills. Almost every Trust has said the formulation of a national strategic approach to the training and development of Efm staff would be a positive way forward (NHS Estates, 2003, p. 3). The objective of our research was to investigate, and highlight recruitment and retention problems for estates and facilities staff that Trusts are currently experiencing. As part of the research Trusts were also asked to discuss initiatives that they have implemented in order to combat problems. Literature review Schlesinger and Heskett (1992) present a “cycle of failure” model that offers a framework where companies or organisations become trapped in a self-perpetuating cycle of high staff turnover. The cycle of failure seems to ensure continuing deterioration of service quality, managerial headaches, and long-term decreases in outputs. The starting point on the cycle is when organisations tolerate high staff turnover and expect their employees to be dissatisfied. Service workers are paid low wages; their job is simplified, repetitive and boring and requires little training. The organisation lowers its expectations in terms of levels of dedication and loyalty from its staff and, accordingly the organisation gets what it expects. High staff turnover and motivation become worse as management do not want to invest in staff who will not stay with the organisation. The self-perpetuating cycle produces poor service and motivation from staff, and customers have a poor perception of the service. Customer dissatisfaction fuels further decreases in employee satisfaction, thus encouraging turnover. Schlesinger and Heskett (1992) talked to managers who seemed to assume that the cycle of failure is beyond their control and inevitable. They are often resigned to failure. Such assumptions are even built in to the strategic plans of some organisations. They assume that to get good people would cost too much and you cannot pass on these cost increases to customers. It is not worth training frontline people when they leave so quickly and high turnover is simply an inevitable part of the business and you have to learn to live with it. Clark, however, reinterprets this cycle of failure into a cycle of success. This is shown in Figure 1. Clark argues that as staff become more motivated, their confidence increases which further fuels motivation. Motivated workers are less likely to leave the organisation, or be absent on short-term sickness and that results in reduced costs. Customer service (or other service levels) increases because staff are motivated which leads to an increase in service deliverables, and this along with reduced costs leads to greater profits, or for the NHS better budget control or further reduced costs and increased services. The reduced costs (or higher profits) become available to provide higher levels of training and this in turn contributes even further to increased worker motivation. Figure 1 Cycle of success or failure Motivation is also affected by a sense of value (positively) but also (negatively) by external perceptions. In an interview and questionnaire-based study of 28 managers from large London-based NHS Trusts, Merali (2003) concluded that altruism was still an important shared core value for workers in the NHS. This places emphasis on patient care, a commitment to the NHS, the provision of public services to the community, improving health and free healthcare for all. These values survived despite the increasing “business-like emphasis in the NHS” (p. 557). But the study also examined managers' perceptions of their public image with the following findings. The general public believe that only clinical staff were motivated by altruistic values. The nature of the management job was low profile and suffered from unfavourable comparison with “the more glamorous and emotive image attached to the doctors and nurses' public image”. They also believed that clinicians and politicians propagated a poor image of managers as a means of scapegoating “for the failures and inadequacies in the NHS” (p. 558). Similarly, in an investigation into the public library workforce in the UK, Usherwood et al. (2000, p. 64) found that salaries generally were low but an important factor attracting staff was “the public service ethos”. However, recruitment and retention problems there also included negative image and limited opportunity. Methodology Focus groups were used in the research as the appropriate data collection instrument. Not only is this cost effective it also taps into the wealth of experience and knowledge of participating staff. There is considerable theoretical support for the use of focus groups as a means of data collection. Johnson (1996), however, suggests that it is possible to use group interviews to access tacit uncodified and experiential knowledge, opinions, meanings and the role of the individual as part of a larger organisation. Osteraker (1999) describes the successful use of what she terms “reference groups” of employees to construct a new motivational survey in the workplace. She found that involving employees generated a sense of ownership but stresses the need in the workplace context to ensure there is no conflict between different levels of management. McDougall (1999) provides further evidence of the use of groups with homogenous membership to encourage coherence and trust. Two focus group sessions were undertaken, one in the south and one in the north of England. Seven staff attended the southern focus group from a range of Trusts (representatives attended the focus groups from Acute, Mental Health and Primary Care Trusts) all of whom were in senior management positions within estates and facilities management or other relevant strategic roles. For the northern focus group the researchers selected staff operating at more operational management levels. It was hoped this would provide contrasting evidence reflecting both strategic and operational concerns. The focus group discussions were transcribed, providing an accurate verbatim record of what was said during the interviews. The transcribed data were analysed using thematic content analysis based on coding using computer-based techniques. The purpose of this analysis is the generation of units of meaning from the data that can then be classified or categorised and ordered to identify emerging themes and interpretation of the data. This process of analysis started with open “coding” of the transcripts to produce a list of descriptive codes or labels enabling the data to be broken up. The next stage was to check the coding for accuracy and, at the same time delete, merge and rename codes which where then grouped under higher order and increasingly generic headings or “categories”, producing a hierarchy or tree of codes. The categories were further grouped into emerging themes. One of the main concerns within this thematic analytical approach is its inherent subjectivity. Bias is built into this type of data that cannot be assumed to be valuefree or neutral. However, there is increasing support for the view that bias and subjectivity are an inevitable part of qualitative research and that this subjectivity needs to be acknowledged. However, by using the two focus group sessions the researchers hoped to be able to demonstrate convergent results leading to greater confidence in the findings. Furthermore to build validity checks into the analytical process both interviewers undertook initial data coding independently to check for convergence/divergence of initial codes. Results and discussion Data from the focus groups have been summarised and presented under a number of descriptive categories. These main categories are grouped under one of the four emerging themes: 1. social; 2. financial; 3. political/strategic; and 4. environmental/building. These themes emerged from the data. Each of the themes and the categories within them are considered in the following sections. Social Application and recruitment process There is evidence that internal application and recruitment systems and processes, sometimes imposed by HR departments, result in unnecessary delays. Bureaucracy can increase the length of the recruitment period, and, it is claimed, results in the loss of potential recruits to other employers. People, who were actively seeking work, could, it was suggested, gain employment much faster with other organisations such as supermarkets that can recruit and offer jobs much faster. In addition, although necessary, the criminal records checking process also causes delays in appointing staff. This adds to the overall recruitment time as checks and references tend to be undertaken sequentially. Standard HR processes can lack flexibility. Several Trusts stated this was a problem when trying to recruit facilities and estates staff. For example, some Trusts had not been authorized to advertise and recruit speculatively so that potential recruits could be held on file until a suitable position becomes available. Again with standard processes applied across the whole Trust it is suggested that the number of forms, signatures and approvals required also adds to the delays. Some Trusts reported that the statutory induction period for staff was inflexible, particularly for staff recruited to evening, part-time positions. For example, housekeepers[6] or domestics who applied for a 20 hour evening shift (because they had family commitments and these hours were convenient in terms of their family arrangements) were still required to attend the Trust induction over a two weeks period, Monday-Friday, 9am-5pm. Some respondents also complained that recruitment and assessment tests for low paid workers were unnecessary and deterred potential recruits from applying. In one particular example a Trust's HR department required a 45-minute interview accompanied by separate aptitude tests. This was seen as intimidating and off putting for the type of candidates concerned. Standards of recruitment/quality of staff recruited Problems attracting the required calibre of staff meant that overall standards were dropping with a decline in qualifications and competence. This in turn has both increased the supervisory and management requirements of senior staff and damaged the profile of the facilities/estates departments. This facilities director, for example, felt poor staff quality caused senior facilities staff to get bogged down by operational issues: I believe my role is not to run the operational estates and hotel services, my role is actually to add value to the discussions at our executive group and Trust Board. With respect, not whether the boiler is twenty years old or twenty-five years old. What they (The Trust Board) want to know is what am I doing about the choice agenda, the financial flow agenda and the environmental agenda. Economy/workforce profile/demographics During the research the economy, the profile of the national workforce and demographics were discussed. Trusts were reporting increasing difficulty in recruiting trades staff. As one estate manager pointed out: Over the last ten or fifteen years when big (construction) projects finished you used to get people knocking at your door, (asking) “are there any electrician vacancies”? That has not happened, particularly for the last two and half, three years. I cannot get trained staff. I've got no electricians, and up until very recently had four fitter vacancies. Whilst not all Trusts encourage the appointment of recruits from the private sector who want to “retire” into the NHS, some hospitals have relied on a pool of recruits from those moving into the later stages of their careers who did not want to continue contracting. These same workers were now being enticed to continue employment in the private sector due to the enhanced pay and conditions on offer. The problem was heightened by the lack of young people entering into trade apprenticeships, although anecdotally respondents believed this might reflect the general decline in actual apprenticeships on offer. In general across all facilities and estates departments, Trusts reported an aging workforce profile resulting from staff leaving and not being replaced. As one facilities manager pointed out “we're almost always in a complete state of flux”. With an increasingly fluid workforce, especially amongst the unskilled ancillary staff group, the organisation is losing skills and knowledge. Finally, the impact of the black economy was highlighted as a factor affecting recruitment of facilities and estates staff. In relation to cleaning/domestic staff, for example, Trusts faced competition now from private employers “because there's an awful lot of professional couples both working now and an awful lot have a cleaner in for a couple of hours, and it's cash in hand”. In certain areas of the country the going rate for domestic cleaners is as much as £8.00/hour. Trusts also identified the lack of affordable housing as major obstacle when trying to recruit facilities and estates staff. This includes staff at both management and ancillary levels. The most severe problems occur in the London and the south east where labour and housing costs are highest. Perceptions of NHS as an employer and estates and facilities management careers Respondents felt that the NHS was perceived as only offering clinical careers. This highlighted three critical issues. First, it was implied that a common misconception from the general public was the NHS only offered clinical careers such as doctors and nurses and that potential recruits were unaware of the careers offered in estates and facilities departments. Second, it was suggested that (in general) the public is largely unaware of what functions the “facilities” and specifically “hotel services” departments undertake. This adds to the problem that estates and facilities have in raising their profile. In addition, some respondents felt careers in facilities and estates were perceived as unexciting and lacking in appeal. The third issue concerns “aspirations”. Unlike colleagues in nursing or hospital administration, it is quite difficult for NHS estates and facilities representatives to visit schools and colleges to promote careers as porters or domestics. Respondents felt that the NHS was no longer perceived as a “class A employer”. The result was a negative impact on recruiting staff, and as one manager pointed out they can no longer rely on altruistic motivations: Essentially levels of pay and conditions of service from the rest of the employment market has caught the Health Service up. The Health Service is no longer a class A employer. I don't think anymore you get staff going to the NHS because they want to get the feel good factor of being part of healthcare. Some Trusts reported that staff, particularly those working as domestics and porters, were concerned about being “contracted out” to the private sector. Exit interviews conducted at one Trust illustrated this, with staff reporting feelings of insecurity about working for a private contractor with a “hire and fire” culture. Although the impact of private finance initiatives (PFI) was not discussed in any detail during the research, respondents felt PFI schemes and private organisations (awarded contracts to operate hospital support services) were contributing to the perceived lack of job security within NHS estates and facilities management jobs. Respondents believed that in the past perceived “job security” was a strong incentive to work for the NHS. The research indicated that some Trusts believed their reputation as employers, especially the working conditions and the type of work offered to domestic staff, deterred potential recruits. As one manager pointed out: Why do they want to work in a crappy loony hospital when they can work in a nice new shopping centre where they get perks and the discounts and all the other things that come round; and in relation to the type of work: I can go and work for that book shop or I can clean that school next day, I'm not in the blood and guts there. The local competition for trade staff was also cited as a specific problem. Again largely due to the current vibrant construction industry, Trusts reported difficulties in recruiting builders. Some Trusts believed they were also competing with local authorities who were able to offer preferential pay and conditions for trade staff. Financial Agenda for Change Discussions centred on Agenda for Change featured heavily during the focus groups. Agenda for Change has been positioned under the “Financial” theme although it is probably also significant for the “Political/Strategic” theme. In general, there was a lot of concern regarding the impact Agenda for Change would have on the current workforce and future recruiting. Respondents felt that re-grading would be a problem, and specifically highlighted the re-grading of trade staff as an issue. The Trusts that had already graded their estate/trade staff have found that the pay under the new system was lower than anticipated. Chefs were another staff group singled out as potential losers after re-grading under Agenda for Change. Rates of pay The issue of staff pay and conditions is intrinsically connected to Agenda for Change. However, at present some Trusts felt that the low rates of pay offered for estates and facilities management positions did have an adverse effect on recruiting staff. Respondents highlighted that the low pay advertised on job adverts meant it was difficult to get good calibre estates and facilities managers to apply and attend interviews. Trade staff and domestics also fell into this category. The low pay offered to directors of estates and facilities was also highlighted, and in some cases it was felt the remuneration packages offered to senior staff did not match the level of responsibility for the job. This had a further detrimental effect on the overall profile of estates and facilities in the NHS. Impact of clinical resource problems Some respondents felt financial problems within their Trust's clinical departments were impacting on their ability to recruit staff. For example, one estate manager felt that the Trust's over-reliance on temporary agency staff to fill clinical posts caused an over spend on labour costs. This resulted in the Trust Board imposing a recruitment freeze for all departments. During the research some managers pointed out that new staff starting in estates and facilities departments, particularly hotel services, viewed such jobs as “a foot in the door” and a route into nursing and clinical careers. While most respondents viewed such progression as a good thing, and agreed it attracted some potential recruits, this had cost implications for estates and facilities departments. Of course existing hotel services staff were ideal recruits into nursing, “What better person to recruit than someone who knows the hospital, who knows the ward, who knows the job's not glamorous”. However, the concern for estates and facilities managers was that their best staff were taken by the clinical teams and they were then responsible for finding the resources to replace them. Political/strategic Separated strategic approach The document “Working for the Future: an invitation to shape a National Workforce Strategy for Efm” was produced by NHS Estates (2003) to look at the problems in recruiting and retaining estates and facilities management staff. Some respondents felt the strategy outlined in the document does not go far enough in tackling the current problems faced by Trusts in recruiting and retaining estates and facilities management staff. Some respondents suggested that at a strategic and national level there needs to be a separate approach to tackle the NHS recruitment and retention issues across estates and facilities management staff groups. There are specific factors and problems associated with each staff group that cannot be tackled within a single policy. It was recommended that estates and facilities management staff be separated into three groups before any national or local strategy could be implemented: 1. trade staff; 2. manager/officer level; and 3. facilities director. Graduate recruitment schemes A major concern voiced by managers during the research was the lack of a national graduate recruitment scheme for estates and facilities management staff, as one manager pointed out “We're the third biggest employer in the world ... , the biggest in Europe. Facilities is 25 per cent of (the NHS budget) and we don't have any graduates”. Some respondents felt that the profile of facilities and estates needed to be raised to the same level as HR and Finance and an appropriate graduate recruitment scheme introduced to reflect this. It was suggested that any graduate recruitment scheme had to take a broad approach in attracting applicants from technical and building backgrounds but also business backgrounds. One respondent felt that the NHS needed closer links with universities in order for facilities management graduates to feed into professional positions. It was suggested that there is no clearly established career path for staff to move into senior management positions. As one manager explained “It's almost saying there is no framework for us. There is no career development in facilities”. Estates and trades positions were another staff group singled out for a lack of career structure. Government initiatives Respondents identified government initiatives such as cleanliness standards and inspections as adding unrealistic expectations onto staff who would not have such pressures working for alternative organisations. As one facilities manager pointed out: A domestic working in a local school is not going to have somebody from CHI[7] coming out and inspecting their work... The pressure is increasing and the shop floor staff pay and conditions are reducing. The impact of Trusts merging was discussed during the research and respondents who had recently gone through a merger felt one of the crucial success factors, related to retention of staff, was to level out the pay discrepancies across the merged Trusts. During the merger period another problem some managers experienced was a freeze on recruiting to permanent positions. Foundation Trusts Until the first wave of Foundation Trusts was operational, respondents were unclear whether the new organisations would impact on recruitment and retention in the NHS. However, some concerns were expressed around Foundation Trusts not being constrained by Agenda for Change pay scales and therefore able to offer preferential pay and conditions. This would mean the first wave of Foundation Trusts would be able to attract quality recruits from non-Foundation Status NHS Trusts and the wider pool of potential employees. However, the Department of Health has stated that Foundation Trusts will implement Agenda for Change and they will not be able to use unfair competition to attract staff[8]. However, that such uncertainty exists at all does suggest that there is a communication problem. Environmental/building Workplace conditions and environment Respondents felt that the perception of the NHS from the outside was one of a lack of investment in the physical infrastructure. The result was that potential estate and facilities management recruits could get jobs with other organisations where resources are less of a problem. As one manager puts it: A known factor outside is that the (NHS) estate has always had to save money. People in the profession recognise that if they go into a hospital they're not going to sit around. They're going to work and they can do a lot less for a lot more elsewhere. This perceived lack of investment was also a factor contributing to perceptions about conditions in the NHS. This deterred staff, particularly domestic staff, who could work in alternative organisations with better workplace conditions. However, in spite of these perceptions surrounding NHS workplace conditions, this was seen by some as perversely attractive, representing a challenge. The location of some new healthcare buildings was reported as a factor in recruiting staff. For example, respondents highlighted new mental health units that were constructed some distance away from town centres resulting in increased transport costs for staff. For lower paid staff, such as domestics, this could be a substantial deterrent. This is compounded where facilities and estates departments need to employ staff on early morning or night shift patterns. Where Trusts do offer services such as transport, these may not be available to staff on non-standard hours. As one hotel services manager pointed out “The crèche doesn't open until half past eight and some of our ancillary staff start at six am”. Conclusion The recruitment and retention of estates and facilities management staff is a complex problem involving a wide range of issues. It is also important to recognise that our findings vary from Trust to Trust and there is also evidence of geographical variation. Four different main themes emerged from the data as significant factors surrounding the recruitment and retention problem; social, financial, political and environmental. Within and across these themes there are a number of key areas of focus. One of these inevitably is Agenda for Change whose impact at the moment is unclear. This lack of clarity reflects in part the second key point, a lack of communication. This can be illustrated by the mixed messages about the implementation of Agenda for Change within Foundation Trusts. There is a view that Foundation Trusts will be able to offer preferential rates of pay and thus divert potential staff away from other Trusts who are bound by Agenda for Change. On a more positive note one of the things to emerge from the research, in terms of examples of good initiatives on recruitment and retention, is the necessity for drawing out the complexity of the problem and identifying these internal and external factors. External factors are those over which managers can have little or no control. These will include the state of the economy and the buoyancy of competitors. Such factors can only be monitored. It is important to know, for example, that the reason for difficulties in recruiting domestics is that professional couples are offering up to £8.00 an hour cash in hand, compared with NHS pay for domestics at or around the minimum wage. Internal factors, on the other hand, can, with a little effort and energy, be addressed. Initiatives emerging from the research show, for example, how recruitment processes can be speeded up by removing some of the red tape, and can be made more user friendly and less intimidating by changing application forms and offering more suitable selection processes. Other initiatives demonstrate that is possible to offer staff more of the services they require and greater flexibility within the job. Separating out internal and external issues is one means of addressing the recruitment and retention problem. Another way in which it is possible to begin to recognise and understand the complexity of the problem is to see it not as a single issue but as a series of problems affecting different staff in different ways. What has emerged from the research report is the need to recognise what was termed a separated strategic approach dealing with NHS estates and facilities management staff in four distinct groups each with its own different recruitment and retention issues: 1. domestic/housekeeping; 2. trade staff; 3. manager/officer level; and 4. facilities director level. This is seen as one possible way to tackle the complexity of the problem and may help to determine appropriate local and national strategies for implementation. Finally, there is a continuing need to raise the profile of estates and facilities management to those levels enjoyed by human resources and financial management, for example. Given the size of the NHS as an employer, and within that the size of estates and facilities management, it is somewhat surprising that there is so little emphasis on graduate recruitment within estates and facilities management and that there is such a limited and haphazard career structure for estates and facilities management staff. The NHS also needs to place more emphasis on training and staff development for estates and facilities management staff. Notes 1. The National Health Service, set up in 1948 provides heath care services free at the point of delivery throughout the UK. Under the Department of Health, a central government department, services are delivered by local Trusts who run hospitals and other local health facilities. 2. From the NHS Modernisation Agency web site – www.modern.nhs.uk/agendaforchange/Afcplain.pdf 3. From the Inventures web site – http://inventuresweb.co.uk/. Inventures provide consultancy to the NHS in healthcare and capital planning, property and project management. They were responsible for disposing of surplus NHS property (to date over £1 billion). 4. As defined by NHS Estates, Efm refers to “Estates & Facilities Management”. It is intended to cover the whole range of services that support clinical care – including estates management, “hard FM” such as engineering and maintenance and “soft FM” such as hotel services. 5. NHS Estates is a government executive agency responsible for providing advice and guidance on all aspects of estates and facilities. 6. In 2000, the UK government advocated the introduction of a “ward housekeeper” role in at least 50 per cent of hospitals by 2004. This is a ward-based non-clinical role centred on cleaning, food service and maintenance to ensure that the environment is right for the patient. The introduction of this new role gave responsibility of all (ward-based) facilities services to one member of staff and allowed the nurses to concentrate on the clinical care for the patient. Facilities departments provided advice on the technical services provided by the ward housekeeper, and in some cases were responsible for managing sickness, holidays, training, etc. 7. On 31 March 2004 the Commission for Health Improvement (CHI) ceased operating. All its functions have been taken over by the Healthcare Commission. The Healthcare Commission promotes improvement in the quality of the NHS and independent healthcare and has a statutory duty to assess the performance of healthcare organisations, award annual performance ratings for the NHS and coordinate reviews of healthcare by others (www.healthcarecommission.org.uk/Homepage/fs/en). 8. From the DoH web site, Foundation Trust page FAQ – www.dh.gov.uk/PolicyAndGuidance/OrganisationPolicy/SecondaryCare/NHSFounda tionTrust/NHSFoundationTrustArticle/fs/en?CONTENT_ID 1⁄4 4062962&chk 1⁄4 iSS/eK