Image: the evidence on privatised hospital cleaning has been mixed - til now.
Outsourcing of hospital support services (like cleaning, catering, and laundry) is extremely contentious. Private corporations undercut traditional in-house operations, making profits by driving down wages and conditions of service. This is obviously attractive to cash-strapped hospitals.
But does it matter for patients?
Does cheaper mean worse, or can the private sector square the circle by providing better service for less? So far, the authorities in Scotland, Wales and Northern Ireland have been unconvinced. They have insisted that the existing in-house services be retained, ensuring that cleaners are part of the ward team, with a shared commitment to patient care, rather than casual, low paid, and often transient extras. In marked contrast, the NHS in England believes that outsourced services can provide value for money.
So far, the jury has been out. Now, we have solid evidence that should make the NHS in England reassess its position.
Back in 1983, cleaning services were among the first parts of NHS to be outsourced to private contractors. The Conservative Manifesto that year justified the outsourcing, saying it would “make the maximum possible savings by putting services like laundry, catering and hospital cleaning out to competitive tender. We are tightening up, too, on management costs, and getting much firmer control of staff numbers”.
It soon became clear that there were problems. There were numerous reports that contractors seeking to save money, for example by employing fewer staff, with poorer working conditions and hence motivation, were achieving lower levels of cleanliness than the in-house NHS staff they replaced. Yet these fears among frontline workers who could see what was happening were dismissed. The Business Services Association, a lobby group representing outsourcing companies, claimed to widespread incredulity that “There is no evidence to suggest that outsourcing cleaning services causes increased rates of infection” ).
So what does the evidence show?
Do NHS Trusts employing private cleaning services experienced more cases of MRSA, a ‘superbug’ that can cause life-threatening infection which has been previously linked to poor cleanliness? We brought together a number of data sources that, surprisingly, had not previously been combined to ask the question. We had data on 126 NHS trusts during the period 2010-2014.
We found clear evidence that Trusts which outsourced their cleaning services reported significantly more MRSA cases. Yet that was not all. Fewer patients in these hospitals reported that levels of cleanliness were excellent and staff reported fewer handwashing stations.
The one way in which outsourcing achieved its intended goal was cost. Cleaning in these hospitals was about £236 less per bed each year. Of course, that does not account for the excess human and economic costs of infections, and we were only able to measure one type, those due to MRSA. It would be surprising if what we found was limited to one type of bacteria.
Why are these findings important? Privatisation of NHS services is now high on the political agenda, as the impact of cuts to health and social care bite. Outsourcing corporations are eyeing the opportunities and the current government in Westminster is sympathetic to their wishes. Their sympathymight be influenced by prospects of following their predecessors to work for these corporations.
Former Prime Minister David Cameron argued for outsourcing in 2011.“It shouldn’t matter if providers are from the state, private or voluntary sector as long as they offer a great service” and “It's about ending the old big government, top-down way of running public services and bringing in a Big Society approach; releasing the grip of state control and putting power in people's hands,” Cameron wrote in the Open Public Services White Paper.
Unfortunately, we have shown that, as far as cleaning services are concerned, it does matter who does it. When the money is tight, as it is in the NHS, it can be very attractive to seek the cheapest option in the short term, even if this is at a cost to patients and, ultimately, to the NHS. When these full costs are taken into account, contracting out may prove to be a false economy.
The paper, Outsourcing cleaning services increases MRSA incidence: Evidence from 126 English Acute Trusts, is to be published in the journal, Social Science and Medicine. It can be viewed here.
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