Courting controversy – outsourcing NHS cleaning services9 May 2014
Against a backdrop of austerity and public cuts, healthcare facilities are continuing to contract out their facilities management and clinical services. But, the practice remains deeply controversial. Practical Patient Care talks to Jane Lethbridge, director of the Public Services International Research Unit about cleaning services and the history of NHS outsourcing.
With headlines like "MRSA 'out of control and getting stronger'", "Family's fury after amputee girl gets MRSA" and "Children in peril from flesh-eating MRSA", the country's primary place of care has come to be seen as one of its biggest danger zones. But, back in the early '00s, hospital hygiene was a major public concern in the UK. Deaths relating to MRSA - the most feared of the superbugs - dominated the headlines with stories of young children and pregnant women contracting the virus.
These stories had a certain tabloid edge to them; they were sensationalist, predominantly anecdotal, and were tied to a particular view of the NHS as a failing institution. One Daily Mail columnist even renamed the UK's beloved institution the "National MRSA Service".
It was an absurd claim, but the figures it was responding to were real enough. Between 1993 and 2002, the number of deaths caused by MRSA infections rose from 51 to 800. Total infection rates in hospitals soared to 5,000 in a single year. Something had gone seriously wrong.
A study published by the Health Service Journal laid the blame on poor hygiene standards; finding hospitals full of rubbish, uncollected left-over food in canteens and dirty linen strewn over bedroom floors.
It was an explanation that did little for the image of the NHS; once described as the "nearest thing the English have to a religion" by a Tory chancellor. But, were lazy cleaners and doctors with dirty hands really to blame? For some critics, this provided a convenient scapegoat for a much more complicated story, obscuring many of the structural changes that had forced the NHS into a new world of market bureaucracy.
"There has been a 20-year history of asking the NHS to produce efficiency savings," said Nigel Edwards, then director of policy at the NHS Confederation. "Cleaning and catering... have suffered the brunt of the major cuts in provision".
This may sound surprising. Debates over MP Andrew Lansley's current reforms often ignore the long history of NHS restructuring. For all the talk of privatisation, the demand for competition and cost-saving has been an almost permanent feature of public health policy since Thatcher.
These changes started in earnest in the early '80s, when competitive tendering was introduced for cleaning, catering and other ancillary non-medical services, and were extended in the '90s under the NHS and Community Care Act - the first piece of legislation to introduce an internal market into the provision of healthcare.
This was followed by the Private Finance Initiative in 1992, and, since 2000, a big increase in the contracting out of clinical and administrative services. Lansley's currents reforms - premised on increasing the diversity of providers in the management of the NHS - represent only the culmination of this legacy.
"The new NHS legislation couldn't have happened without a lot of the changes that took place in the previous 20 years," says Jane Lethbridge, director of the Public Services International Research Unit (PSIRU).
The impact outsourcing has had on cleaning services has been a constant source of tension since those early reforms. While trade unions and medical professionals have consistently argued against it, business leaders have always rejected any connection between outsourcing, infection rates, and declining standards.
"The basic business model is that a company puts in what it hopes is the lowest priced bid, and with a nodding acceptance that there has to be some form of quality control," Lethbridge says. "A lot of these services are labour intensive, and the only way they can cut costs is by attacking workers."
The result of this process, for Lethbridge, was a major decline in the "public sector ethos". A direct link between infection rates and outsourcing may be hard to establish, but the pressure to reduce costs created a fractured workplace; one where well-paid professionals rub shoulders with an increasingly casualised part-time and precarious work force.
"Cleaning became very low paid," Lethbridge says. "Contracting out pushes wages down, creates a high turnover of staff and problems with general recruitment. Other processes that result from outsourcing - particularly the pressure on time and the focus on specific tasks - also lead to a very fragmented way of delivering the cleaning service.
"What is required is good teamwork between infection control teams and the cleaner. Before cleaning services were outsourced, the cleaners would have taken more time, talked to nurses, chatted to patients, and there would have been a much greater degree of teamwork in the ward and hospital."
In Scotland and Wales, this kind of advice was heeded. After a number of bad experiences, the devolved governments of Scotland, Wales and Northern Island all abandoned outsourcing their cleaning services. But, in England, the process has continued with gusto.
"The devolved governments of Wales and Scotland run the NHS in a slightly different way," Lethbridge says. "They haven't been influenced by outsourcing in quite the same way as the conservative-led coalition or New Labour."
Cuts and contracts
This hunger for outsourcing - inside and outside the NHS - is unlikely to change any time soon. Cuts and austerity in the UK are usually articulated through the lens of welfare reform. But with huge budget cuts to local government spending, public sector outsourcing is as central to the present government's ideological strategy as anything else.
Since 2010, the number of large-awarded contracts has increased by 47% with tens of thousands of workers in various sectors - health, defence and IT - being transferred to corporate employers like Serco, Capita and G4S. The UK's public sector has become the largest outsourcing market in the world, accounting for around 80% of all public sector contracting in Europe.
Alongside catering and portering services, contracts on cleaning make up a large part of these companies 'involvement in the NHS. Only recently, G4S was awarded a five-year £56-million contract for Pennine Acute Hospitals NHS Trust. These contracts are awarded on the basis of efficiency and competition, but the size of the companies involved suggests something else is going on.
"In the '80s, a number of small cleaning and catering companies did get contracts in the NHS," Lethbridge says. "But, as they became more successful, multinational companies took them over, and now the NHS facility management service is dominated by a handful of very large multinational companies. It doesn't necessarily lead to greater competition. In fact, these companies are not particularly interested in competition; they're interested in being in a monopoly position where they can dominate the market."
Nor has their wider record been particularly impressive. At the beginning of the year, Serco, one of the largest outsourcing companies in the UK, saw its shares plummet by 17% after massively overcharging the British Government for an electronic tagging contract. Two years before, G4S, another large multinational, described its role in the London Olympics as a "humiliating shambles" after totally failing to fix the security services they'd been contracted to provide. These scandals seem to occur on an almost daily basis, and yet growth in the public sector outsourcing market shows no signs of slowing.
"There has been a process of state capture," Lethbridge says. "The original 1983 legislation allowed multinational companies to get to know how the government worked. Initially, the NHS was planned by encouraging private sector companies to deliver clinical services in a small scale way. That enabled the private healthcare providers to get to know the Department for Health. There was a moving door with advisers from the private sector going in and civil servants from theDepartment for Health going out."
Whether it takes another major infection outbreak to change the status quo is hard to say. Cleaning services
as they stand are fragmented and low quality, and yet the trend is for more outsourcing not less. With local authority cuts and austerity set to continue well into the next parliamentary term, it's hard to see a way out.