Abstract
Much has been written on the outsourcing of public services, including its impact on the workforce. Dan Zuberi presents a compelling case that there is ‘a relationship between work conditions and work quality’ (p. 18) and, specifically, between the poor treatment of outsourced cleaners and the incidence of hospital acquired infections (HAIs), with all that means in terms of patient suffering and sometimes death.
Under financial pressure, health authorities look for ‘savings’ in ‘non-core’ areas such as cleaning, often by contracting out to private sector companies. The problem is that cleaning in a hospital presents a range of different challenges to office or hotel cleaning.
Zuberi’s study involved 96 interviews with staff at Vancouver area hospitals, which contracted out their support workers in 2003 and 2004. The sample consisted of 70 hospital support workers, such as cleaners, and 26 physicians, nurses and infection control professionals, augmented by ‘observations at hospitals and in neighborhoods from 2007 to 2011’ (p. 9). It would have been useful to know a little more about the sample and the hospitals from which it came. Although the data gathered comes from Canada, the author convincingly shows that the USA and Europe face similar problems.
Cleaners are an ‘invisible workforce’ and one of the great strengths of Zuberi’s book is how he brings their lives into focus through his series of interviews. His field work reveals that contract cleaning staff are often over-worked, under-valued, lower paid than when in the public sector, have inadequate training, poor equipment and conflicting managerial demands – working in the hospital but not working for the hospital. He sets out to show that outsourcing may cut costs but also cuts corners and, in doing so, not only damages the working lives of cleaners but also contributes to the crisis of HAIs.
Chapter 1 reviews the scale of the crisis. In Chapter 2, Zuberi explains how hospitals organize cleaning and examines some of the problems that cleaners face. Chapters 3 and 4 look at how outsourcing exacerbates the difficulties in dealing with the challenges of HAIs. Chapter 5 examines how outsourcing fragments the healthcare team, creates problems of communication and damages teamwork. It also questions the utility of inspections and audits as a replacement for coordinated in-house management. Chapter 6 uses the experiences of five interviewees to illustrate the personal impact of outsourcing. In Chapter 7, Zuberi reviews the data and suggests a way forward because ‘in retrospect, support services were too important – too critical to the hospital’s core mission – to be outsourced’ (p. 106). He illustrates very clearly that the whole notion of ‘core’ and ‘non-core’ functions when applied to hospital cleaning is not only mistaken but potentially dangerous. As Zuberi says: ‘Hotels can lose a star from their rating if their cleanliness suffers. Hospitals can lose patients’ (p. 105).
Zuberi supplies a great deal of circumstantial evidence in support of his proposition that there is a causal relationship between the outsourcing of hospital cleaning and an increase in HAIs. Critics may argue that this is never conclusively proven. That is true but misplaced. A causal relationship is virtually impossible to prove given the multi-causal nature of the problem. Zuberi recognizes that hospital cleanliness and the outsourcing of cleaning are not the only factors, and he reviews some of the different elements of the problem, such as hand hygiene, anti-biotic misuse, poor hospital design, overcrowding and inappropriate hospitalization of vulnerable groups.
He might have located his study more firmly within the theoretical debates about public service organization. In the 1990s the mainstream saw the disaggregation of services; contracting and markets were seen as the solution to proclaimed problems of hierarchy and bureaucracy. When this failed, networks were put forward as the answer to continuing problems in marketized public services. Zuberi’s work shows that serious problems remain.
What is not in doubt is that good quality cleaning is an effective tool in controlling HAIs, as has been shown in the work of many scholars, including the pioneering British microbiologist, Stephanie Dancer. What is also not in doubt is that outsourcing separates cleaners from the rest of the healthcare team and militates against the integration of cleaning as a function within the work of the hospital. Thirdly, it is something that can be controlled. The dynamic nature of hospitals as shifting communities of patients, visitors, staff and contractors means that a simple and effective measure such as hand hygiene is actually very difficult to enforce. It is easier to ensure that the hospital has a well-resourced and high quality cleaning service. It simply requires the will to do it and the foresight to recognize that it is not a cost but an investment in the health of patients that will, in any event, pay for itself many times over, given the cost of treating infections.