Hospital cleaning has suddenly become a key issue of political debate on the NHS – and for two reasons.
The first is a growing concern about MRSA and other hospital-acquired infections that cause suffering to about 100,000 patients a year and kill about 5,000. Ministers have pledged to raise the quality of ward cleanliness as part of a drive to contain the superbugs. Never since the days of Florence Nightingale has the issue of clinical hygiene had such a high public profile.
The second reason why this previously unfashionable subject is becoming a hot topic in Westminster is the government’s commitment to root out “two-tier working” in the NHS. This problem affects about 50,000 staff working for private contractors providing cleaning, catering and support services. Those who used to be NHS employees before the work was contracted out were protected from loss of pay or conditions under the TUPE legislation (the Transfer of Undertakings and Protection of Employment regulations.) But new starters, undertaking the same work, often got less pay, shorter holidays and inferior conditions of employment. This created a two-tier workforce that was regarded by the trade unions as manifestly unfair.
In July, the union leaders made a high-level deal with ministers, known as the Warwick accord. The government promised it would act during a third Labour term to eliminate two-tier working. The implication was that thousands of non-medical staff working for contractors must be elevated to NHS pay scales.
However much the contractors might complain about extra costs, there was no maybe about this deal. As Tony Blair put it in his speech to the TUC in September: “Because there is today, rightly, far greater interaction between public, private and voluntary sectors to deliver public services, we have agreed a new deal to tackle the two-tier workforce. In local government, we have already acted to end the two-tier workforce. At Warwick, we made the commitment to end it across the public sector; and we will fulfil that commitment.”
In the minds of the union leaders, there was a strong connection between the problem of MRSA and the unfairness of two-tierism. They think the spread of the infection was assisted by cuts in the standard of hospital cleaning caused by contractors’ penny-pinching and the disaffection of a demoralised workforce. As Dave Prentis, general secretary of the public service union Unison, said at its healthcare conference in April: “The spread of the superbugs in hospitals is directly related to contracting out of cleaning services and the massive reduction in the number of cleaners in hospitals.
“It’s not rocket science. And to our bug-busting directors I have a message: the only way we are going to get cleaner hospitals is to employ more cleaners and to employ them directly in the NHS on decent pay and conditions, and to make them a true part of the NHS team.”
The government does not accept there is a direct link between high rates of infection and contracting out. Health minister Lord Warner published figures in December analysing standards of cleaning at 1,184 hospital units in England, including 440 with contracted-out cleaning, 707 with in-house arrangements and 37 with a mixture.
He said 11 per cent of the contractors and 10 per cent of the in-house teams produced cleaning of an excellent standard. A good standard was achieved by 36 per cent of contractors and 40 per cent of the in-house teams. This could hardly be said to be a vote of no confidence in contracting out.
But there was some ammunition for Unison in the black marks given to a minority of the contractors. They were responsible for the cleaning at the only three hospitals where the standard was deemed to be unacceptable (all in mental health trusts) and at 15 of the 24 hospitals where the standard was rated poor. Those companies will come under pressure for improvements, but there seems to be no appetite among ministers for using the MRSA scare as an excuse to stop contracting out completely.
That leaves a massive practical problem for all sides. Contractors originally bid for the work assuming they could keep the wage costs of new staff below the nationally agreed NHS level. They would obviously want to renegotiate the price of the contract if they were obliged to pay the full NHS rate. It seems that the government agrees and is willing to foot the bill.
But when should this renegotiation take place? Administratively, the most convenient time would be when the existing contracts expire. Most will run out within two years, but some were long-term deals fixed for seven years and a few were due to last 10. It is inconceivable that Unison members could tolerate such a long delay in implementing their Warwick accord triumph.
The government is expected to publish proposals – probably in January – giving its view on the matter. But the timing of renegotiation is not the only problem. Those former NHS employees with protected rights under TUPE will be well aware of the big improvement in pay and conditions that was accepted by the NHS unions last month.
This so-called “Agenda for Change” package will provide about one million nurses, therapists and non-clinical staff with an above-inflation pay hike worth £1 billion next year. Other benefits include better training and a regrading exercise to match pay to responsibilities.
Under the deal, the NHS minimum pay rate will rise from £4.85 to £5.69 an hour with immediate effect – 17 per cent above the national minimum wage. It will go up further to £5.88 from April. The question is whether contractors’ employees with TUPE protection will be entitled to a rise to stay on a par with staff still working for the NHS.
The unions think it is only fair they should. After all, TUPE was introduced so employees would not be disadvantaged by moving into the private sector. But abolition of the two-tier workforce implies that new staff taken on by contractors should not be paid less than their TUPE-protected colleagues. So if the TUPE group get the Agenda for Change deal, all contractors staff should end up at the same level.
The contractors took legal advice through their umbrella group, the Business Services Association, and found the picture even more complex than they first thought. For some NHS trusts, Agenda for Change could be regarded as a national settlement replacing the old Whitley arrangements – and for them the TUPE rules would apply. But others, which had local deals varying the Whitley terms, would be outside TUPE’s protective umbrella.
Unless the government takes a grip on this, a nightmare beckons. Instead of a two-tier workforce, we could have a four-tier bear garden. Contracts might expire at different times in different places. Agenda for Change might apply in different trusts in different ways. The muddle needs sorting.
And then there is MRSA. The government’s drive to improve cleanliness may require another set of contract renegotiations to offer a higher price for a higher specification of services. That work is even more urgent for patients than the pay renegotiation is for Unison.
Health ministers could avoid a headache after Christmas by drawing the obvious conclusion: synchronise the renegotiations, achieving better cleaning standards and abolishing two-tier working at a single stroke. That will not come cheap, but better patient safety and avoidance of strikes in election year may be worth the price.
