Why banning white coats didn’t finish off hospital germs

There was a time when everyone knew how medical staff dressed. Surgeons wore suits; GPs wore tweed jackets; nurses wore things that were crisply belted and pleated. But since Alan Johnson, former health secretary, abolished the white coat in 2007, and instituted a “bare below the elbows” policy, with the intention of decreasing rates of hospital-acquired infection, the only people who have been confidently able to identify clinical staff at work are the staff themselves.

Dress for healthcare workers has become a confusing business. The changes in 2007 were prompted by studies showing various items of doctors’ clothing to be contaminated with microorganisms (white coats and ties were the worst offenders). This is not necessarily as worrying as it sounds – no one has yet managed to document an infection caused by a bacterium jumping from a soiled tie. Hand washing is the vital element in preventing the spread of infection, not garment laundering (hence “bare below the elbows”, a policy meant to make it easier for staff to wash their hands properly, without trying to keep their cuffs dry, and without germs being able to lurk beneath watches or rings). But the threat of infective clothing remains a powerful one.

A similar rationale – “informed common sense”, as Johnson described it, rather than any specific evidence – means most hospitals forbid staff from wearing their uniforms when they are away from the premises: people dislike seeing scrubs in Sainsbury’s, feeling the outdoors to be crawling with germs. But every hospital has its own microbial population.

Unfortunately, the no uniform off-site policy is rarely backed up with any practical facilities. Dressing and undressing usually has to be done in the staff toilet, standing on one leg and alert for possibly being crushed behind an opening door. And, in fact, your clothes would pick up less troublesome germs riding on the bus or shopping than they do in a couple of hours at work. The kind of organisms that flourish inside hospitals pose a greater threat to human health. Hospital germs have evolved to survive in a world of strong antibiotics. An Israeli study, in the post-tie era, found 65 per cent of doctors’ and nurses’ clothes still tested positive for potentially harmful bacteria.

In Johnson’s sleeveless, tieless world, doctors do not wear uniform, on the whole. A junior doctor is identifiable only by her youth, her stethoscope, and her name badge – which will invariably be hanging the wrong way round. A ward pharmacist looks much the same, except without the stethoscope. Medical students also look the same, except they generally have their coats and bags slung about their bodies as they have nowhere else to put them. Once you are into uniforms – as in surgery and A&E – the situation is even more confusing. There are no national standards: every hospital has its preferred outfits. In the operating theatre, the consultant surgeon, the surgical house officer, the surgical nurses and the anaesthetist all look alike, in gowns and scrubs (though anaesthetists have a penchant for white trainers). Elsewhere in the hospital, uniforms proliferate for the various grades of staff. On some wards, the chart hanging up by the door looks like a page from a butterfly guide, with each staff member identified by colour and pattern.

And, just as at school, uniform can easily be subverted. You can be ringless, watchless and commendably clean, but still sign prescriptions with a pen topped with a fluffy fluorescent gonk.

Sophie Harrison is a hospital doctor in South Yorkshire

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