News

Cleaning up the NHS

The issue of cleanliness in the health service has and always will be key to delivering high quality patient care. Despite this, there have been many cases where Trusts have let patients down by not maintaining the cleanliness of their facilities and equipment. National Health Executive asked Andrew Large how the situation could be improved

Nobody wants to work, let alone be treated, in a dirty hospital but sadly this is the case in some NHS facilities. Rather unnervingly, there are many cases of poor cleanliness, with Trusts regularly being chastised by regulators for carrying out sub-standard cleaning programmes.

The cause of these failures does not lie with individuals but rather with a number of smaller problems building up over time, according to Andrew Large, chief executive of the Cleaning and Support Services Association.

“It is very hard to single out one issue in particular. Rather, it is lots of small issues which are a matter of concern.

“Firstly I believe that there is far too much autonomy given to each individual Trust with regards to cleanliness. Whilst local autonomy does have some merit, the problem is that cleaning does not become a priority because Trusts are more concerned with matters such as hitting targets and making efficiencies.

“In many cases this results in them not investing properly in cleaning and this leads to differences in standards, with some Trusts being cleaned excellently and others not.”

Andrew believes that there are still too many barriers preventing trusts from outsourcing their cleaning, which he believes can drive up standards.

“The amount of outsourced cleaning contracts in the NHS has remained fairly static at around one third. Whilst I would not take a fundamentalist approach and say that all hospitals should outsource their cleaning, I think that many more should than currently do.”

So does this mean that outsourced cleaners perform better than their public sector colleagues?

“I would say yes, but obviously others might contest that viewpoint.”

To support this position, Andrew refers to research carried out by the CSSA in 2008 which compared the Patient Environment Action Team scores (given by patients) for Trusts which outsourced their cleaning services and those which did not.

The research showed ‘excellent’ PEAT scores were achieved by only 12.9 per cent of acute Trusts with in-house cleaning teams received but by 21.2 per cent of acute trusts with contracted cleaners.

The same study also revealed that nearly two thirds of the instances of non-compliance with HCC Standard C21 in acute Trusts occurred in in-house cleaned hospitals, even though only 53.8 per cent of them were in-house cleaned at the time. This has led the CSSA to believe that in-house cleaned hospitals have a disproportionate number of non-compliances with the government’s own standards for cleanliness.

“This research was carried over a year ago but we have recently received information from the Department of Health about which trusts outsource their cleaning services so we are about to begin a similar piece of research.

“Leaving aside the argument of whether outsourced cleaners perform better or not, there still needs to be contestability in the market place in order for people to raise their game. It follows that once a contract is outsourced, then the client can change service provider and this keeps the cleaning contractor on their toes and keen to maintain high standards.

“However, when cleaning contracts are kept in house, there are subtle barriers which can prevent outsourcing which means that the in-house service is never subject to competition, which leaves them in a rather featherbedded position.”

Andrew explained that there are also financial differences between how outsourced and in-house contractors tender for work.

“When an outsourced contractor tenders for a contract they will take into account all of the costs involved whereas the in-house provider may be able to hide some overheads. They do this by saying that certain overheads are contained within other department’s budgets within the trust.”

There is also an issue around the pensions of the cleaners, as private sector contractors have to put aside around 30-40 per cent of salaries for pensions, whereas in-house employers only have to put aside around 14 per cent.

“This means that there is not a level playing field and we are hoping that the new government will work towards allowing a level playing field in the tendering process.”

The issue of how the government goes about dealing with the issues around cleaning brings us back to Andrew’s first point about autonomy being too localised. The issue of central control is one which is hotly debated and politicians often make promises about ‘handing back control’ to local people.

“I think that the argument about local accountability is a red herring, because clean is clean. People who live in Liverpool should not have to put up with dirtier hospitals than those who live in Lancaster.”

Andrew believes that the way in which cleaning is measured isn’t helping the situation.

“The National Specifications for Cleanliness are an output specification which means that a Trust is required to do as much cleaning as necessary to produce ‘x’ amount of cleanliness. This is fine, but it allows people to start with 100 per cent work, so achieving 100 per cent cleanliness. Then they think ‘well we can just cut the work level to 95 per cent and then to 90 and then to 80’ and so on.

“The trouble is that they still believe that they are delivering to the specification but as the cleaning is cut more and more something like an outbreak occurs. This is when the CQC descend on the Trust but by then it is too late because people have died.

“To stop this from happening, central government has to set a minimum level of cleaning activity. Once that has been agreed, there should be some local discussions as to whether they want to do more than that, not less. The government is not doing this at the moment and as a result Trusts are getting away with doing too little.”

For the people who die as a result of Trusts carrying out shoddy hospital cleaning, there is, of course, no ‘get out’ clause.

Tell us what you think – have your say below, or email us directly at [email protected]