Outsourcing cleaning services increases MRSA incidence: Evidence from 126 english acute trusts

There has been extensive outsourcing of hospital cleaning services in the NHS in England, in part because of the potential to reduce costs. Yet some argue that this leads to lower hygiene standards and more infections, such as MRSA and, perhaps because of this, the Scottish, Welsh, and Northern Irish health services have rejected outsourcing. This study evaluates whether contracting out cleaning services in English acute hospital Trusts (legal authorities that run one or more hospitals) is associated with risks of hospital-borne MRSA infection and lower economic costs.

By linking data on MRSA incidence per 100,000 hospital bed-days with surveys of cleanliness among patient and staff in 126 English acute hospital Trusts during 2010–2014, we find that outsourcing cleaning services was associated with greater incidence of MRSA, fewer cleaning staff per hospital bed, worse patient perceptions of cleanliness and staff perceptions of availability of handwashing facilities. However, outsourcing was also associated with lower economic costs (without accounting for additional costs associated with treatment of hospital acquired infections).

Keywords: Outsourcing, Hospital acquired infections, Hospital cleaning, Contracting-out
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1. Introduction
There is a long-standing debate in the United Kingdom about the impact of outsourcing of hospital cleaning services to private sector contractors. Beginning in 1983, cleaning services were one of the first parts of the NHS to be contracted to private providers under HC(8318) “Competitive tendering in the provision of domestic, catering and laundry services”. The then Department of Health and Social Security wanted hospitals to save money and argued that they would “make the maximum possible savings by putting services like laundry, catering and hospital cleaning out to competitive tender. We are tightening up, too, on management costs, and getting much firmer control of staff numbers”(Conservative Party, 1983)._ENREF_1_ENREF_1.

Always controversial, in the 1990s critics linked outsourcing to growing concerns about hospital acquired infections, and in particular, methicillin-resistant Staphylococcus aureus (MRSA), which was felt to be especially frequent in the UK (Johnson, 2011, Washer and Joffe, 2006). Media coverage emphasised the role played by “dirty” hospitals (Chan et al., 2010), drawing on evidence of the importance of hospital cleanliness (Dancer, 2009, Dancer, 2008, Davies, 2009, Davies, 2010), patients’ perception of cleanliness (Greaves et al., 2012, Trucano and Kaldenberg, 2007) and frequency of handwashing to preventing infections (Sroka et al., 2010, Stone et al., 2012). There was speculation, and extensive anecdotal evidence, that contractors were seeking to save money, for example by employing fewer staff, with poorer working conditions and hence lower motivation, and were as a result achieving lower levels of cleanliness than the in-house NHS staff they replaced (Davies, 2010). In addition, contracted-out services were considered too inflexible to deal with changing circumstances, including problems with unscheduled cleaning out-of-hours, which might have increased risks of outbreaks (Davies, 2010). Because of these concerns, the Royal College of Nursing called for hospital cleaning to be brought in-house in 2008 (BBC News, 2008) and, later that year, Nicola Sturgeon, then Scottish Health Minister, instructed that this be done in all Scottish hospitals to reduce risks of infection (European Federation of Public Service Unions, 2011)_ENREF_11_ENREF_1, later linking this move with the subsequent fall in cases of C. difficile infection (Daily Record, 2011), although this view was not universally accepted, with others linking it to improved antimicrobial stewardship (Nathwani et al., 2012). Outsourcing has also ceased in Wales and Northern Ireland (European Federation of Public Service Unions, 2011). However, these fears were dismissed by others, with the Business Services Association, representing outsourcing companies, arguing that “There is no evidence to suggest that outsourcing cleaning services causes increased rates of infection” (BBC News, 2008)_ENREF_11.

This debate has been handicapped by the scarcity of robust empirical evidence on the impact of outsourcing per se. A few descriptive studies from the 1990s, which compared the crude NHS Audit scores across hospitals, suggested potentially worse performance among hospitals outsourcing cleaning services (Davies, 2010). These studies argued that outsourcing to private contractors led to poorer coordination between nursing staff and independent cleaners, especially as previous lines of accountability had been broken. However, the ability to evaluate these claims was limited by _ENREF_9a lack of data on rates of hospital-acquired infection. This has now changed, with the NHS’s mandatory surveillance of MRSA, implemented in 2005 (Johnson et al., 2012), creating a set of comparative data over time. Under the new system, the MRSA rate is calculated as the number of MRSA bacteraemia reports from that Hospital Trust per 100,000 bed days (in the UK a Hospital Trust is a public entity that hospital operates facilities on one or more sites). Starting from October 2005, all Trusts in England were asked to submit data electronically, and in 2006 this system was further enhanced to provide data on possible sources of the MRSA bacteraemia, although this was only on voluntary basis. Until 2009 reports on MRSA bacteraemia rates in each acute Trust were published at six or 12 months interval; afterwards the reports were published on a monthly, quarterly and annual basis.

Here, for the first time to our knowledge, we test the hypothesis that outsourcing cleaning facilities is associated with greater incidence of MRSA, by linking newly available comparative data on its incidence with data on the provision of cleaning across English Acute Hospital Trusts.