‘You have to take action’: one hospital cleaner’s journey through the pandemic | Society


On 9 February, a cold, damp Sunday, an Uber pulled up to University Hospital Lewisham in south-east London and dropped off a woman who had recently returned from China. The woman walked up to the reception desk and outlined her symptoms. She was given a mask, taken to a designated area outside the A&E building and tested for coronavirus. When, three days later, the test came back positive, it confirmed what medical authorities had already suspected: this was London’s first case.

That day, Ernesta Nat Cote, a cleaner at Lewisham hospital, heard the news from a nurse in her department. The nurses, Ernesta told me, are always the best source of information: “They tell me everything.” Ernesta has been cleaning the hospital for 11 years, ever since she first came to London. She arrives just before the start of her shift at 6.30am, clocks in and goes to clean the paediatric operating theatres, changing rooms and corridors. Over the years, she has come to know these rooms intimately: every corner, every surface, every tap.

Ernesta has a certain status in the hospital. At 57, she’s is older than many of her colleagues, a grandmother and an old-timer in a workforce where people tend to come and go. But she’s also the representative for the cleaners’ union, GMB, one of the largest British general trade unions. Ernesta helps her colleagues if they are in trouble or there’s a problem with their pay. “People come up to me in the hospital and they want advice. It’s a lot, but I’m very pleased to tell them,” she told me. “And if someone follows my instructions, they come back and say: ‘God bless you, God bless you!’” Everyone knows Ernesta. Walk down the road with her at the end of a shift and you have to stop every few seconds as she greets colleagues: “Madam! You OK?!”

It wasn’t always like this. Not long ago, Ernesta hadn’t even heard of the union. She just knew, at £8.21 an hour, that she was being paid too little, and wanted to do something about it. She was tired, too, of being treated dismissively by successive managers from companies that turned up at the hospital and then disappeared again after a few years while she stayed and cleaned. In more than a decade of working at the hospital, Ernesta has been employed by four different private companies – PSR, then Initial, then Interserve (who acquired Initial) and now ISS, a Danish multinational. ISS is the largest cleaning company in the world, employing nearly 500,000 people globally, with a revenue, in 2019, of £9.4bn and profit of £395m.

Over the years, as the companies have swept in and out, Ernesta’s NHS colleagues have remained more consistent. She is deeply fond of the doctors and nurses she works with: they look out for her and appreciate her hard work. Ernesta lives alone, and the medics have become like family, she told me – the reason she likes her job. Her employers have never seemed to hold her in quite the same regard. “I’ve been here since 2009,” she said, “and they come, they leave me, they go.”

Two years ago, Ernesta decided she wanted to improve things for the cleaners at Lewisham hospital. She believed they deserved better pay and better treatment. She joined the union, persuaded her colleagues to join, too, and they began to organise themselves. In a long campaign to improve their working lives – a campaign that has persevered through a pandemic – the cleaners have won various battles, but they still have more to fight. In the past three months, their vulnerability has also been made distressingly clear. Cleaners from all over the country have died from Covid-19 – two of those who died worked down the road from Lewisham at St George’s hospital in Tooting. The pandemic has revealed what was always obvious to Ernesta: a hospital can’t function without its cleaners. They are as vital to its purpose as any of the other frontline staff, and equally at risk.


The Lewisham cleaners are like many parts of the NHS that, over the past 30 years, have been sold off. In the windows of St Mary’s primary school, opposite the hospital, there are rainbows thanking the NHS – in our minds a single, cohesive institution that protects the nation’s health. But in the hospital grounds, staff walk around wearing lanyards of multiple private companies, the colours equally various: sky-blue ISS, a red-and-black G4S logo on the side of an ambulance, a navy sign for the onsite pharmacy now run by Boots. These days, the NHS remains beloved, but in a quasi-fantasy form – a story we like to tell ourselves about an organisation that is still pure, free and public.

The outsourcing experiment began in earnest after the 1983 election, won by Margaret Thatcher’s Conservative party with a huge majority for their second term in government. As part of a wider privatisation agenda, sections of the NHS were identified as candidates to be taken over by private-sector companies. The policy was continued by every subsequent government, both Conservative and Labour, taking place alongside multiple NHS reorganisations intended to promote an ever-expanding internal market and greater competition between hospital trusts (formed under the National Health Service and Community Care Act in 1990). Competition, it was thought, would help to improve standards, drive down costs and save the taxpayer money.

Cleaning was an obvious service to outsource: a low-paid part of the hospital workforce and a sector that doesn’t have the specialist requirements or public profile of, say, cardiology. According to John Lister, the author of multiple books on the NHS and founder of campaigning group London Health Emergency, the competition created between companies to win contracts meant they had to cut costs to make a profit. Cleaning is a labour-intensive service – there aren’t many ways to mechanise it or speed it up. To make it more efficient, cleaners would have to do more work in less time. “I remember one contract,” Lister told me, “that involved a cleaner having to clean a bath in 29 seconds.”

The effects of austerity, from 2010 onwards, meant hospitals across the country were being pushed to find further savings. Lewisham hospital – a mix of Victorian red-brick and glassy new wings built on the site of a former workhouse – first outsourced its “soft facilities management services”, including cleaning, portering, catering, pest control, switchboard and laundry services, in February 2012. In October of that year, the government intensified the pressure on the hospital when the NHS Trust Development Authority (now part of NHS Improvement) recommended closing some of its major services, including A&E and maternity. Activists – led by the former clinical director of children’s services at Lewisham and current co-chair of Keep Our NHS Public, Tony O’Sullivan, and his wife, Olivia – launched a vociferous campaign, organising public meetings, large protests and a judicial review into the decision. A judge found in favour of the hospital, the government then appealed but the appeal was thrown out.





Lewisham Hospital in 2017.



Lewisham Hospital in 2017. Photograph: Dan Kitwood/Getty Images

The hospital was saved, but it remained under pressure. When Lewisham was merged with Queen Elizabeth Hospital in Woolwich into the new Lewisham and Greenwich NHS trust on 1 October 2013, it was forced to take on a large private finance initiative (PFI) debt from the building of Queen Elizabeth Hospital in 2001. The debt cost the new trust £30m a year to repay, and the Treasury had to step in to subsidise the repayments. (This wasn’t unusual. Seven PFI-funded hospital trusts around the country had already been bailed out by the taxpayer after the payments to private funds or companies as a result ofthe PFI – an initiative that was supposed to harness the power of private investment to build new hospitals – became too onerous.) The financial strain had inevitable effects. O’Sullivan said he was told, not long after the new trust was formed, that “the biggest motivator towards outsourcing was the trust being ordered to cut costs, and the only significant way was to cut non-clinical wages”. And the only way to do that was to let a private company pay “non-clinical” workers the minimum wage.

Last year, when the soft-facilities contract became available again, O’Sullivan suggested to the trust’s board that this might be an ideal moment to take the contract back in house, and make the staff NHS employees once again. They would then qualify for NHS benefits: better pay, access to the NHS pension scheme and a vastly improved sick-pay arrangement. An NHS employee is entitled to one month full pay and two months’ half pay for sickness in their first year of service, and these allowances increase year on year. Under ISS, the cleaners receive full sick pay from the third day of illness, and it lasts for as many days as the number of credits they have built up. They receive a single credit for every month in which they haven’t taken time off work, and if their credits run out, their pay reverts to the statutory rate of £96 a week. (An ISS spokesperson said the policy was “in line with industry and government standards and has been fully accepted for many years”.)

O’Sullivan was told that the trust didn’t have the “internal resources” to take the soft facilities back. When I asked Ben Travis, the trust’s CEO since 2018, why it continued to outsource the contract, he told me that the trust didn’t feel it had either the expertise or management capacity to look after hundreds of extra staff. When he joined the trust, there were far too many unfilled posts among doctors, nurses and therapists (the vacancy rate among medical staff was 17.5%). “I suppose it was a bit of a choice,” said Travis. “Where we wanted to prioritise was absolutely around making sure that we had a really sustainable clinical workforce.”

That distinction – between the soft facilities and the “clinical workforce” – never used to exist. Before the routine outsourcing of such contracts, cleaners and porters were part of the NHS team, managed on the ward, overseen by clinical staff. Ernesta and many of her colleagues still see themselves as NHS workers, and in their view, their role is clinical. Good cleaning stops infection. It prevents someone from coming into hospital with one illness and leaving with another. “If it wasn’t for them,” a consultant doctor at Lewisham told me, “the rest of us would be entirely unable to do our jobs.” Ernesta once pointed out to me that on the cleaners’ uniform it says “ISS in partnership with the Lewisham and Greenwich NHS Trust”. There it is: the hallowed acronym stitched on to their shirts as proof. They do work for the NHS – they just don’t receive its benefits.


Every morning when she arrives for work, Ernesta gets changed in the locker room. As a cleaner of operating theatres, she is obliged to wear scrubs, and her cleaning has to be at the highest, most intensive level of all. “Not everyone can do theatres,” she told me. She applies an obsessive rigour. “You have to think of yourself, you have to think of your family who come in the hospital.” Once dressed, Ernesta goes to the cleaning cupboard in her department and finds what she needs: gloves, a mask, an apron, a cap and utensils that are colour-coded according to the area being cleaned. For theatres, it’s yellow: a yellow mop, a yellow bucket, a packet of single-use cloths for surfaces. To deep clean the floors, she uses a bleach tablet in 1 litre of water. Cleaning the whole theatre takes her 30-35 minutes if she’s quick, or 45 minutes if it needs extra work. “I make sure there is no dust,” she told me. “The floor is supposed to be shining.”

Ernesta was born in Equatorial Guinea in 1962, the third of 12 children, her father a prosperous farmer. She was always buoyant with confidence: while at convent school she told her father she would like to eat the proper food that the nuns were eating, not the stuff they palmed off on the kids. (I asked her where her confidence came from. “It’s inside me,” she replied frankly, amused by the question. “Maybe I was born with it.”) In her early 30s, she moved to Spain, got married and had three children. Ernesta didn’t work while she was married, but when she left her husband she had to support herself. Unemployment was high in Spain after the financial crash in 2008, so she decided to move to London and start again. When she arrived, she couldn’t speak English – “not even ‘Good morning!’” – but found people to help her. A friend told her to go to the council for help with housing, another suggested she visit the Jobcentre down the road from Lewisham hospital. Ernesta decided she wanted to work at the hospital – she felt it would be more permanent than the other work on offer in restaurants or hotels. She got a job there quickly, the first paid job she’d ever had.





Ernesta Nat Cote, a hospital cleaner protesting for better pay and conditions at Lewisham hospital during the coronavirus pandemic.



Ernesta Nat Cote outside Lewisham hospital. Photograph: Jill Mead/The Guardian

Moving to a new country by herself, finding a job, learning a new language – none of it struck Ernesta as particularly arduous. “Some people struggle a lot in the world,” she told me. “No, I’m very blessed. God is good for me.” Even so, while working at the hospital, Ernesta said there were times, earning £8.21 an hour, when she struggled to pay her bills. She would take on more hours, often working, as she still does now, from 6.30am to 2.30pm, and then another shift from 4pm until 8.30pm. She remembers under the last contract, run by Interserve, how some of her colleagues worked 12 hours a day, 6 days a week. Those who were renting privately often couldn’t make it work: “If the money is too low, how do you pay rent? A lot of my colleagues were having a hard time.”

It wasn’t just the pay: there were reports of poor treatment, the kind of petty bullying that, over time, makes a workplace unbearable and a workforce despairing. Ernesta recalled being shouted out by a manager for sitting down while on her shift. Another cleaner, William, told me about how he’d had his overtime taken away for not emptying the bins, even though he’d been told he was only supposed to empty them if the bags were more than half full (so they didn’t use too many bags). The sick-pay arrangements caused problems, too: Ernesta recalled how a colleague came to work with an injury because he couldn’t afford not to work. (Interserve paid statutory sick pay of £96 a week, kicking in after three days of sickness.)

Ava, another cleaner, told me she had been unwell once, with vomiting and diarrhoea, had a telephone consultation with her GP and sent a doctor’s certificate to her manager to explain her absence. She was told a telephone consultation wasn’t sufficient and was called in for a disciplinary meeting. (In response to these claims, a spokesperson for Interserve told me: “We strongly refute unsubstantiated allegations of bullying on this contract. Over the seven-year period delivering services to Lewisham and Greenwich NHS Trust at University Hospital Lewisham, not a single formal allegation of bullying was made to our management team. We have a robust, independent complaints process and where issues of any nature are raised, they are properly investigated. None were raised.” The spokesperson added: “We enjoyed a good working relationship with the hospital. During the period we delivered the contract, there were only two instances when two members of staff took breaks outside of permitted hours and sat in the corridor. Following an investigation, we took swift action as obviously this presented a serious health and safety risk and was a breach of discipline by the two staff members.”)

Tired of feeling ground down, Ernesta decided to call a lawyer. She thought that going alone to the management office to complain wouldn’t have much effect: she needed backup. Ernesta imagined going to court, explaining how badly they were being treated and justice being served. She suggested to some of her colleagues that they all pitch in £100 and hire someone, but no one was keen. They didn’t have the money, but they also didn’t want to get in trouble or risk losing their jobs.

Then, early last year, Helen O’Connor, an officer from the GMB union, turned up in the hospital canteen. O’Connor had been a nurse in the NHS for 28 years, moving from Limerick to London to start her training when she was 18. Over the years, she went from not even knowing what a union was to organising her fellow nurses and preventing a pay reduction in the community mental health service where she worked. O’Connor became a GMB officer in 2018, and was tasked to work with a handful of hospitals in the south-east, recruiting members and organising for better pay and conditions.

O’Connor is the kind of person who has no qualms about striding into a hospital and chatting to anyone, nor is she afraid of becoming an irritant to the management of a private company. “I’m not shy,” she told me. She quickly bonded with the Lewisham cleaners – she knew the terrain, understood how hospitals worked. More than that, she kept coming to see them, week after week, asking them what they wanted to change, listening to their answers.

At first, the cleaners were nervous. O’Connor recalls how it took months to gain their confidence, and even longer to build up the strength to act. After a while, they would confide in her about the problems they were having, but there was still hesitation. “If you do it together, they can’t sack you,” she told them. She noticed Ernesta early on: “I could tell she was serious,” she recalled. She encouraged Ernesta to join the GMB, and then to become a rep, liaising between the union and the staff. Ernesta worried that her English wasn’t good enough – she is a native French speaker and can speak and write fluently in Spanish, but her English, she felt, was still a work in progress. But she knew O’Connor represented a chance to change their situation. “When I have Helen,” Ernesta told me, “I have support.”

Ernesta began persuading her colleagues to join the union, too. She carried around membership papers stuffed inside her uniform, and during her breaks she would ask every colleague she met how they were, if they were happy with their pay, their work, their hours. She assured them joining the union was legal. “A lot of the cleaners have just arrived in this country,” Ernesta told me. “They don’t know their rights.” Soon she was no longer just recruiting, but helping colleagues who were in trouble. The next time Ava was sick and was asked, again, to attend a disciplinary meeting, she asked for a letter up front, with a date and time, so she could inform her union rep – Ernesta – who would accompany her. This time, she didn’t even get the letter. The management backed off and there was no meeting. Working together seemed to have worked. “The word ‘union’”, Ava told me, “is like the magic word.”

In early 2019, the cleaners and O’Connor became aware that the cleaning contract was to be put out for tender. O’Connor had already lobbied the trust to raise the cleaners’ wages, but now began campaigning harder, telling the trust it would be unacceptable for the cleaners to stay on such a low wage. The trust also consulted the local authority, local MPs and its NHS staff, all of whom agreed that raising the pay was a priority. “We recognised that we were discharging our responsibilities around the ‘national living wage’, but little more,” said Ben Travis, the trust’s CEO. “We were clear we wanted to increase people’s pay.” As part of the tendering process, the trust asked companies to prepare two bids, one paying the national living wage and one paying the London living wage of £10.55 an hour (now £10.75).





Cleaning staff organised by the GMB union protesting for better pay and conditions at Lewisham Hospital in November 2019.



Cleaning staff organised by the GMB union protesting for better pay and conditions at Lewisham Hospital in November 2019. Photograph: Helen O’Connor

On 24 October 2019, outside the hospital in the pouring rain, many of the 100-odd cleaners who were now GMB members held their first protest for better pay. A few weeks later, on 18 November, it was announced that ISS had been chosen as the provider and awarded a seven-year contract. On 24 November, O’Connor was invited to a meeting with ISS and the trust, and told that the London living wage would be paid after a three-month delay, during which the staff would need to complete “revitalisation training”, a sort of cleaning refresher course. It was a victory of sorts, but O’Connor was worried about the delay – it didn’t seem necessary. On 27 November, the cleaners held another protest.

When ISS finally took over the contract on 1 February 2020, the atmosphere was initially positive. The cleaners had been desperate for their new wage for so long, and it wasn’t long to wait now. They were told in an early briefing by ISS that their conditions would improve: the company was investing £4m in new training and new equipment, including, ISS told me, “Bioquell technology, a hydrogen peroxide vapour machine that decontaminates full rooms including the ceiling” and “UVC Moonbeam, a machine that uses a UV light to provide targeted equipment decontamination”. It all sounded so promising. Then, nine days later, the pandemic hit.


After the first coronavirus case was confirmed on 12 February, concerns began to work their way round the cleaners. ISS gave the staff another briefing. The cleaners were told they had to wear personal protective equipment (PPE) and tape was put on the floor at 2-metre intervals in the room where they clock in and out. The cleaners typically had access to basic PPE – gloves, an apron and a cloth mask – but if a cleaner was on a Covid-19 ward and additional PPE was needed, it would, in agreement with the trust, be provided by the NHS ward manager.

As cases of coronavirus rose in the hospital, some of Ernesta’s colleagues started to go off sick. Across the country, it was quickly becoming obvious that black, Asian and minority ethnic communities were disproportionately affected by the disease. In Lewisham hospital, the majority of the cleaning staff is black. ISS declared that anyone with Covid-19 symptoms could self-isolate for two weeks on full pay. The service became short-staffed, and so Ernesta, despite the risks, took on extra shifts, once working 13 days straight. “The whole pandemic,” she told me, “I was never off sick for one day.”

During the pandemic, many of the cleaners, like Ernesta, have worked longer hours. Ava told me that on one of the May bank holidays, she had come to work, although her normal department was closed, and was sent to clean a different ward to cover a cleaner who was off. It was only when she finished that she realised it was a ward with Covid patients. “I left the ward and I saw it on the lift – ‘This lift only for coronavirus patients’.” She was amazed, and frightened. “They just sent me, they didn’t tell me: ‘Be careful this is a coronavirus ward.’” She should have been wearing full PPE – a medical-grade mask, proper gloves, a gown.

The trust’s spokesperson told me that staff had been advised to ask the NHS ward manager for appropriate PPE. In other words, it was Ava’s responsibility to find the right protection. But Ava had never been to that ward before, and didn’t know who was being treated there. Her case struck me as typical of an outsourced worker’s predicament – floating between two organisations, employed by one yet working for another, neither quite covering the gap between the two where her own safety seemed to lie.

PPE wasn’t the only problem. The cleaners were due their first payday under the ISS contract on 27 February. But when the cleaners checked their accounts that day, many had received the wrong pay, and some had received nothing at all. In a written statement, ISS said there had been administrative issues transferring some of the staff from their old employer, and that a new ISS payroll system had experienced technical problems. They sought to correct the errors quickly, but when Ernesta arrived at the hospital on 12 March, the next payday, she found the corridor outside the clock-in room packed with her colleagues. “Everybody was saying: ‘My pay’s short!’” Ernesta told me. Some, once again, had no money in their account.

A hospital manager asked why they weren’t coming up to work, and Ernesta recalled the cleaners saying: “No, we don’t have the money!” They were furious, refusing to go to work. Some were crying and unable, after two missed paydays, to buy their bus pass, Ernesta said. O’Connor arrived and the cleaners assembled in the canteen, where ISS managers began talking to them individually to work out what they were owed. She asked ISS to get any missing money transferred by the following morning, otherwise they would hold another protest. She was worried. “We knew the pandemic was coming, and I thought: ‘Oh my God, the cleaning isn’t going to be done in a hospital.’”

The next morning, the cleaners came into work to find that the errors in their pay had still not been corrected. Instead of walking out there and then, they decided to go to work and protest at 3pm, after the first shift, and before the later shift clocked on at 4pm. That way, more people could join and the hospital would still be cleaned. In the afternoon, they gathered outside, mostly women wearing their winter coats over their uniforms, now on their third protest in six months. Before all this, most had never protested in their lives. Some still didn’t look wholly at ease. Ernesta was fairly relaxed about the situation. “In Spain,” she told me, “people like to riot a lot.”

Word started to creep out: local media reported on the protest, then the national papers picked up the story. Later that day, ISS issued a statement through the trust. Chris Ash, ISS’s managing director of healthcare, said that it had apologised to the staff affected and taken urgent steps to resolve the issue, “making immediate additional emergency payments where there were shortfalls”. They emphasised, too, that the cleaning had never stopped: “It is important to note that the issue has not affected the service we provide.” The public needed reassurance that, in the midst of a pandemic, the hospital they might need to save their lives was still being cleaned. Apart from on one day – 12 March, the second missed payday – it was. Despite everything, the cleaners carried on doing their work.


When, on 23 April, the cleaners received the missing back pay of their promised higher wage, the relief was intense. “You can see it hanging in my closet,” joked Ava, referring to the new clothes she had bought with the extra cash. Ernesta acknowledged the company’s efforts. When she goes to the office now, the ISS managers will often ask if she’s OK, as if they know it’s important that she’s happy. The past few weeks have revealed what Ernesta has built in the past two years: the organisation of her colleagues, a group of more than 100 people who are brave enough to stand outside their hospital and demand better. Ernesta, in the process, has earned her due: not just money, but power.

The struggle isn’t over, though. One hot afternoon in late May, as we sat on a bench down the road from the hospital, many cleaners came to tell Ernesta how they were being given more areas to clean in the same shift time. (An ISS spokesperson told me there had been “no formal changes” to the staff’s workload, but the new technologies they’d introduced were speeding up the work. “Modern cleaning methods,” the spokesperson wrote, “allow for tasks to be undertaken more efficiently.”)

A fellow union rep passed by our bench, and Ernesta hailed him with the warmth of someone trying to convey the affection of three months’ worth of ungiven hugs. “Hello my darling!” she called out. They discussed their other campaign, which was to get full sick pay from day one of an illness. Were they hopeful they would win? The male rep smiled. “When we fight, we win,” he said. “We ain’t no losers.” Ernesta laughed loudly. “Trust me,” she said, nodding to her friend and smiling with pride, “this character is very, very strong.”

In late May, for the first time, Lewisham hospital began to record no new deaths from coronavirus on consecutive days. Like every hospital in the country during the pandemic, Lewisham had reorganised itself, created new wards, cared for hundreds of patients and kept going. By 17 June, 410 patients had died of Covid-19 at both Lewisham and QEH hospitals (the deaths are recorded for each trust, rather than by individual hospital). These deaths included two staff members – healthcare assistants Grace Kungwengwe and Esther Akinsanya. The trust has since been raising money for their families.

Recently, the trust began offering antibody tests to its 6,500 staff. There was confusion over who was able to take the test – the cleaners said they hadn’t been told about it and, according to a consultant at the hospital, a priority list had put frontline clinical staff first. (The trust told me that anyone working in frontline departments such as intensive care or A&E, no matter their employer or job, could take the test.) Many of the cleaners seemed to have slipped through the cracks, either not knowing about the test at all or not thinking it was for them.

When I asked Ernesta about the test, she said that one of her colleagues had been told by a clinician on her ward that the test wasn’t for the cleaners. Ernesta was outraged. “I said: ‘No.’ Go downstairs and you do it.” Ernesta herself hadn’t hesitated. When one of the doctors in her department mentioned it, she had joined the queue and taken the test in early June. Since then, she had been passing the message round the cleaners, but some still seemed worried about being turned away, uncertain of their status, or whether they were allowed.

Sometimes, when her colleagues are reticent, Ernesta lacks patience. It’s not her way. “Listen,” she told me, “I’m a cleaner, but I don’t put myself like a cleaner. The way you put yourself is the way they’re going to take you.” The way she sees it, she’s a human being as much as the consultant in her department is a human being. On a practical point, the two see each other every day, and are physically close enough, frequently enough, to infect each other. There was no logic to one of them taking an antibody test before the other. “You have to take action for yourself,” she said. “When you wait for things to happen, it’s no good. You have to go.”

Over the past three months, the pandemic has performed a stark, public dissection of our society. It has shown us who frontline workers really are, and the degree to which we depend on them. There have been advertising billboards expressing the government’s gratitude, millions of pounds donated to NHS charities, a Vogue cover given to key workers. But often, Ernesta has felt that all this public sentiment wasn’t meant for her. During the pandemic, as gifts came into the hospital for “NHS workers”, she was acutely aware of the cleaners not officially fitting into that category. The dividing line between them and the NHS exists not in the cleaners’ minds, or the day-to-day reality of their work, but in everything else: in their pay, their benefits, their uniforms, their professional status, their public recognition.

One day, the Lewisham cleaners would like to be NHS employees again. If the opportunity arose, Ernesta told me she would leap at it “straight away”. It’s not impossible. Earlier this year, after a campaign by the United Voices of the World union which represents migrant workers, the CEO of the Imperial College Healthcare Trust, Prof Tim Orchard, announced that the trust (which includes Charing Cross and St Mary’s hospitals) would be bringing 1,000 previously outsourced staff back in-house. “Each of you plays a vital role in caring for our patients,” Orchard wrote to the staff.

The patients themselves might not always notice the cleaners, porters, caterers, switchboard operators and laundry staff, but these are the people who keep the engine of the hospital going – the parts clean, the cogs turning – day after day after day. “You get up in the morning, you get dressed, you come to work,” Ernesta told me once. “If I do something, it’s because I want to do it. And I do it with all my heart.”

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