Andy Burnham is expected to tell the prime minister that hospital cleaners should be part of the 'NHS family', but the companies providing services complain that poor trust management and contracting are to blame for low standards. Alison Moore digs the dirt

When health minister Andy Burnham suggested to HSJ that hospitals might think about bringing cleaning services back in-house, he entered a long-running row.

Since Margaret Thatcher first introduced compulsory competitive tendering in the 1980s, unions have argued that bringing in external contractors and creating a cost-driven cleaning service have damaged standards. But is there evidence to support this?

Historically, there may well have been a problem with some contracts, especially when cost was king. Unison points out that the 10 most dirty hospitals highlighted in the first round of PEAT (patient environment action teams) inspections in 2001 were disproportionately cleaned by the private sector.

But it is less clear that this is the case today. The Business Services Association (BSA), which represents many of the cleaning services companies, argues that in the last three rounds of PEAT inspections there has been little difference between trusts that have outsourced their cleaning and those doing it themselves. 'There's not a whisker between them,' says director general Norman Rose.

National Patient Safety Agency head of cleaning Graham Jacob says that although there may have been some evidence that trusts outsourcing cleaning were not achieving so well in early PEAT inspections, there has been no significant difference since 2004.

He suggests that in the early days of contracted-out cleaning, companies may not have realised how difficult hospitals were to clean and that trusts were under pressure always to take the lowest bid.

While there has been criticism of the cleanliness of some hospitals with outsourced cleaners, the same is true of some who have returned to in-house cleaning.

For example, Maidstone and Tunbridge Wells trust returned to in-house cleaning after poor PEAT reports but has been criticised for low standards of cleanliness since then and has also had a serious Clostridium difficile outbreak at one of its hospitals.

The Scottish Audit Commission looked at hospital cleanliness in 2003 and said: 'We found high levels of cleanliness at many hospitals with external providers-however, a number of other hospitals had problems associated with poorly defined or managed contracts.' NHS Confederation policy director Nigel Edwards comments: 'It is not about whether it is in or out of house - it is about how well you specify the contract and what your relationship is like.'

The contractors agree. Steven Cenci, operations director for hotel services provider Medirest, says: 'The issue is not who does your cleaning. The issue is about management and resources. The NHS is trying to undo the damage of 20 years of downward pressure on facilities budgets.'

Unison says the number of cleaners in the NHS has almost halved in the past 20 years.

Family values

Mr Burnham has said his NHS engagement and communications plan report, commissioned by the prime minister and due to go to him any day now, will set out the need to ensure that all domestics are working as part of the 'NHS family'.

Those in favour of in-house services argue that having a company involved makes services less responsive and distances cleaning from other hospital functions: ward staff faced with a spillage or an unclean area can no longer get it cleaned up instantly; the system is clogged up by 'service agreements' and specifications that militate against the smooth running of the service.

But could many of these problems be overcome by better contract negotiation?

Mr Edwards points out that a trust could specify numbers of hours of cleaner time and then leave how they are deployed to senior ward staff. Issues such as 24-hour access to cleaners could be dealt with in the same way. However, convenience costs: Maidstone and Tunbridge Wells has recently introduced 24-hour cleaners but has had to find£300,000 a year to do so.

Cleaning contracts can also set standards and have penalty clauses if they are not met. Mr Rose suggests this gives trusts 'the greatest control imaginable', potentially more than they would have with an in-house team. Contracts can have both a regular maintenance aspect and an 'ad hoc' element to allow for the unexpected.

Another question is whether external contracting aims for cleaning on the cheap, which affects standards. Unison says the process of considering contracting out led to an overall focus on cost, even within in-house teams, that has been detrimental to cleaning standards.

The Royal College of Nursing says that when nurses are involved in drawing up cleaning specifications, they find it difficult to get included the frequency and flexibility of cleaning services they need. 'Cost is an absolutely critical factor,' says head of policy Howard Catton.

The BSA says that trusts are simply not willing to pay for hospitals to be cleaned in line with the 2004 cleaning standards, formulated by the industry and government. As many as 90 per cent of contracts on offer are not in line with these standards, says Mr Rose.

Anecdotally, trusts have come under pressure to cut their cleaning budgets from turnaround teams in the past year - a point made in a Commons debate last week.

Sodexho Healthcare managing director Iain Anderson says the company is not often asked to bid on the basis of the 2004 standards. Sometimes this is because trusts are already achieving well on PEAT scores, but it may also be linked to financial constraints.

Wage war

But the standards - which have recently been updated - are likely to become more important for trusts as they have to affirm to the Healthcare Commission that they are being cleaned to national specifications.

External companies have limited ability to undercut the NHS on price - doing the work more efficiently (and this can mean less time spent cleaning each ward but could also include economies of scale through providing services to a large number of hospitals) and paying their workers less. Typically, staff costs are more than 90 per cent of the cost of cleaning.

Back in 2004, then health secretary John Reid announced that contracted staff would move to equivalent pay to NHS workers - which would limit the ability of contractors to undercut in-house teams by paying new workers less (workers who transferred got some pay protection).

But according to the BSA this has not happened - even though it claims the government has included additional money in the tariff to cover the costs to the NHS.

Mr Rose says around half of trusts have simply not paid up and, although the BSA has pressurised the government on this, trusts cannot be obliged to do so.

Low wages may encourage a culture where workers clean hospitals until they find something better paid. That can mean extra costs in training staff who will swiftly disappear and less continuity in cleaning teams - which may itself be seen as symbolic of a lower standard of service by hospital staff.

Many NHS organisations point to an indefinable sense of belonging as crucial in motivating staff. NHS staff work hard - often for relatively low wages - because they feel part of a team on a ward or unit. It may be harder to establish this feeling with cleaners if they are employed by an outside body and reporting to a different structure but it should not be impossible, argues Mr Edwards.

A report commissioned by Unison says: 'The contract culture atomises functions within a hospital and contributes to a breakdown of a team-based approach that unifies clinical and non-clinical staff.' Author Professor Steve Davies says cleaners are often 'itinerant workers', moving around the hospital. 'If there were cleaners attached to wards and seen as part of the team, then integration would be easier,' he says.

Mr Catton says: 'Nurses often talk about the time when cleaning, ancillary and housekeeping staff felt part of the ward team. They clearly knew that matron or sister was in charge. Being part of a team breeds flexibility. If people feel part of the team they might go that extra mile.'

Many companies try to foster a sense of partnership, of shared goals and of being in it together: Sodexho had had several of its staff nominated as 'Employee of the Month' in their host trusts, and sees some of its key relationships as being with senior nurses and infection control specialists within trusts. It also encourages joint training with the trust.

But where things can go wrong may be where there is hostility from staff ('some of our people are treated appallingly by the clinical staff,' says Mr Cenci) or a lack of commitment to contracting out - or where the NHS is trying to contract out a problem. Mr Anderson says he will walk away from a tender if he feels the trust team does not really want to contract out and has been pushed into it. Mr Cenci points out firms have a reputation and a brand to protect. They do not want to do a cheap job or bad job.

In the 1980s contracted out cleaning was seen as the flagship policy for involving the private sector in the NHS. Twenty years on it is still not accepted and arouses fierce passions. As the government increases private involvement in the NHS, it may well ponder that public and staff acceptance of change takes a long time.