Wednesday, January 30, 2008

Hospital deep cleaning

Devils Kitchen has a post on MRSA and the Government's attempts to meet its targets through "deep cleaning" and the way that awful woman from Kent who was responsible for about 90 deaths has cleaned up, as it were, at our expense. As always it is rather a good read and it refers back to an excellent post on BOM.

I am more concerned by why need a deep clean in the first place. When the Tories first started insisting of competitive tendering for cleaning Labour was apoplectic, claiming that it would lead to dirty hospitals. Well if they were right why didn't they do something 10 years ago? Surely all those contracts will have been up for renewal by now?

I suspect that the real problem isn't that cleaning was outsourced, but the way it was done. To understand the problem you first have to understand the reasons why any company* would outsource any function in the first place. There are 2 reasons: reduce costs and/or remove a none core function which is a distraction to management.

In the first case cost should never be the driving force unless the function is easily removed to other suppliers who can extract economies of scale. Lets say its the manufacturing of a widget in the car industry that all cars need. It makes sense to buy this in rather than having the costs of tooling up and managing a production line. It is hard to see, though, how this can be extrapolated to hospital cleaning. The function cannot be removed to a central point to get economies of scale so the only savings are going to be minor, through process improvements and pooling of staff across many contracts to cover holidays and work peaks. Any savings here are only going to be minor and at the margins.

This leaves removing a none core competence. I can see this being a good reason; should nurses and doctors be worrying about treating patients not managing cleaners? Yes, they need to make sure that hospitals are clean, but you don't need to be micro managing cleaners to get that done. On the face of it then this looks like a good idea.

But as always the the problem lies in the implementation**. The real driving force was the need to get NHS costs down (not a bad reason in itself) so contracts went out and were let on a cost basis. Having been involved with government and private industry tendering I am sure that the real problem lies in the contract process. Sloppy contracts that don't clearly define the service and then a need to select the cheapest tender.

The next problem is contract management. Having been squeezed until the pips squeak the contract winner will now look to make their margin. This will be done by reducing staff and speeding up cleaning. They will endeavour to do this within the contract and will push the terms to the limit. Any variation to the contract required by the hospital will be negotiated to the nth degree as there will be no good will left. I will go a step further and speculate that NHS contract management is quite weak and that they have rings run round them.

So why not bring it back in house? Well, as I said it isn't a core competence and why lumber nurses and doctors with the problem of managing cleaners? Furthermore I don't think they are capable. I have recently watched hospitals as a visitor and patient and what surprised me was how poor senior nurses are at management. You see groups of nurses milling around a central station chatting. Occasionally one will wander off to do something and then return. It all seems quite random with nobody in control giving instructions to junior staff; but that's a general problem in society anyway and may be the subject of another blog someday.

So, in conclusion, cleaning isn't the problem, its contract management and the desire of politicians to make savings where they can't be made.

*For the sake of this argument lets assume that the NHS and indeed other Government controlled organisations are companies

**In a past life I have made a bit of money sorting out poor implementation of outsourcing in the mobile telecoms industry

1 comment:

Mark Wadsworth said...

You have guessed right, it's the contract management. One of my clients runs a hospital cleaning business, he is constantly being undercut by fly-by-night operators who take the money, make a total mess of things and disappear again, so he gets the contracts back. Also, he reckoned that the actual amount of cleaning that is done is half what it was ten or twenty years ago. All very worrying.