Sunday, 14 October 2007

Observations on hospital hygiene

With hospital infection very much in the news, and various commentators expressing their views on the issue, it takes a Doctor from Barnsley in South Yorkshire to put his finger on a larger part of the problem.

This is Dr Tim Healey, and he writes:

The fault lies in the system. When cleaning staff were employed by hospitals, the cleaners' work was the responsibility of the hospital secretary and the matron. Now the cleaners are employed by an outside contractor, who is less able to tell how or if his staff carry out the work for which he and they are paid. I have seen a so-called cleaner casually push a dry mop over a narrow strip running down the centre of a ward, while a staff-nurse had to go down on her hands and knees to use paper towels to erase blood stains that had been on the floor for at least two days.
However, Dr Healey is only seeing the tip of the iceberg. Underneath lies a problem of massive proportions. At its heart is the fundamental problem that cleaning contractors are not in the business to clean. If they try to do so, they lose money. The whole industry, therefore, is devoted to "not cleaning", from which it derives its profit margins.

The arithmetic of this Faustian arrangement is brutally simple. Firstly, in an industry that is highly competitive, with hospitals – whatever they might say – selecting on lowest price, the pressure is on for bidding firms to cut margins to the quick. In fact, so intensive is the competition that bids are routinely submitted at such a low price that there is no profit to be made.

Once the contract is successfully gained, however, a deliberate "cost recovery" strategy is put into place. In the initial phases, the contract is maintained to the letter, while senior staff from the cleaning company "learn" the client's representatives – the contract supervisors - where they look, what their expectations are, how to flatter them and keep them generally schmoozled.

Once this is done, the contract managers can then start to cut corners. Cleaning staff that go sick are not replaced and no allowance is made for staff on holiday. Teams are cut back, by ones and twos, or diverted to other jobs, for whole or parts of their shifts. Areas which are "non-critical" or low visibility are cleaned at reducing intervals and, sometimes, not at all.

Gradually, the staff servicing the contract are whittled down, materials budgets are cut back and equipment is either diverted to other jobs or, if it breaks down, is not repaired or replaced. Then the contract starts making money.

During that phase, complaints start rising. But there is a calculated procedure for dealing with them. First of all, the "client" is schmoozled, with profuse apologies, regrets and promises. A "remedial" team is put in with great show to deal with specific complaints, all to satisfy the client that things are being done. Staff may even be "fired" – i.e., transferred to other jobs, the people displaced coming in as "fresh" workers.

Over time, however, corners continue to be cut, standards deteriorate and the excuses and showmanship cease to work. The client gets more and more fed up. But hey! It is a five year contract, and there are only two to go, so it is not worth fighting about it. It is made clear that the contractor need not apply for a renewal.

This is when the money is really made. There is now little pretence at maintaining standards, and the contract is milked for all it is worth. When the final day comes, the staff are laid off and the contractor's management depart. A new contractor moves in, hires the old staff and the cycle starts all over again.

The rub is that there are only about five or six really big players in the business who can handle the paperwork and bureaucracy of NHS contracts. And they are all playing the same game. So, as one player loses the contract, another – who as just lost a contract somewhere else – moves in. After ten or fifteen years, when client's staff have moved on and memories have faded, the original firm can get back in, and start all over again.

This is the way the system works. The "churn" rate is phenomenal as the same small group of companies cycle endlessly through the same group of "customers", all with one objective – to milk the system of as much money as they can before being chucked out, until it is their turn to try again.

Whatever else is wrong with the NHS, the system of contract cleaning cannot – and never will – work. Despite the apparent inefficiencies, directly employed labour under the control of hospital operational staff, are the only way to secure good standards of routine cleaning.

And how do I know all this? Well, in my third career, I was in the game, working for a "household name" international cleaning contractor. As a technical expert, I thought I had joined the firm to clean things. I was soon disabused of that. "We don't make money by cleaning things," I was told firmly. "We make money by not cleaning them."

It is a lesson I never forgot.