A Health economy wide approach to quality care
- Published on Friday, 11 June 2010 01:00
- Written by Karen Taylor OBE
In an exclusive interview with GovToday, Karen Taylor OBE, Head of Value for Money at the National Audit Office discusses the management and control of hospital acquired infections.
As one of two directors of health and value for money audit at the National Audit Office, we present to Parliament around 7-8 national reports each year on the way the Department of Health and the NHS are spending public money.
These reports cover issues as far ranging as the pay modernisation programme, end of life care, dementia, clinical governance, use of temporary staff and the health and safety risk to staff - so we cover the whole gamut of issues that affect both staff and patients in the NHS.
The first report on the management and control of hospital acquired infection was published in 2000, when the issue of hospital acquired infection was poorly understood and had a very low profile within the Department of Health and the NHS and indeed the public more generally. There had been a voluntary surveillance system in place since 1996, and national guidelines, known as the Cook Report, was published in 1996, highlighting the extent of the problem and what the NHS should be doing to reduce the risks of infections.
In designing the first report, we started looking at the issue of hospital cleaning but during our preliminary fieldwork various stakeholders raised concerns about the increase in infection rates within their hospitals. We, therefore, pursued this angle further and this became the basis of the study.
Interestingly, as our focus was on the role of the infection control team and the views of the hospital Chief Executive, cleaning became a very subsidiary issue as infection control teams, did not have responsibility for cleaning. Consequently, in the first report the issue of cleaning was not raised other than to comment on whether the infection control team was involved in advising on cleaning contracts, which many weren't.
As most people know, since then cleaning has become intrinsically linked with infection control and despite the lack of a statistically significant link, eventually accepted as something that needs to be addressed.
In our first report, we analysed the responsibilities of the infection control team, the available data on infection rates and what was being done to reduce infection. There was a prevailing view that because of the ‘irreducible minimum', there was little that could be done, and that antibiotics would target the problem. So actually, the awareness of clinicians, in particular, as to the impact of their behaviour in relation to causing infections was low or even not accepted.
As a result of that first report, we recommended that surveillance should be made mandatory, and the Government's response was to introduce mandatory reporting of MRSA bloodstream infections.
Over the next few years, we monitored this reporting and the implementation of our other recommendations and noticed that despite successive reports on MRSA infections showing year-on-year increases, there was no evidence that anything was being done to stop it and the MRSA issue continued to attract intense media coverage.
Consequently, in 2003, the Committee of Public Accounts (PAC), Parliament's senior select committee who take evidence on our reports, asked us to revisit the issue and our 2004 Report, which incidentally included more about cleaning, highlighted the lack of progress in addressing this important issue. In clearing the report, the Department of Health still insisted that there was no link between cleaning and infection rates, but we nevertheless noted that there certainly was a link in the eyes of the public.
The response to the second Report was that the Secretary of State for Health at the time, John Reid MP, established the Towards Cleaning Hospitals and Lower Infection Rates Programme Board and introduced both the MRSA reduction targets.
Subsequently and following the problems at Maidstone and Tunbridge Wells and Stoke Mandeville, mandatory C. Difficile reporting was introduced. In establishing the Programme board and subsequently the 2006 Health Act - cleaning and infection rates became inextricably linked; echoing the public response and the wider perception that if a hospital is not clean, if it is not well maintained, then the risk of infection is much higher.
In compiling our 2004 report, we surveyed Chief Executives who stressed that the reason they were not really prioritising infection control was because it was not a national priority - like waiting times and A&E targets etc. So reflecting the old adage - be careful what you wish for - it was then made a national priority with a reduction target in the NHS Operating Framework and has continued as a level 1, top tier, vital signs priority since then.
The Department of Health as part of the Towards Cleaner Hospitals initiative under the leadership of the Chief Nursing Officer established a support unit and allocated central resources towards driving improvement. The well regarded Saving Lives initiative also brought together the evidence base as to what worked and what didn't, and established the Care Bundle approach to improving infections.
Following the publicity given to Stoke Mandeville and Maidstone Tunbridge Wells which kept the issues of infection control in the public eye, once again the PAC asked us to return to the issue to analyse why the problems were still reoccurring. The second follow-up Report was published in 2009.
This time we found that the reduction targets for MRSA and C. Difficile have now been met and there have been visible improvements in hospital cleanliness, but our concern remains - and it comes back to our recommendation in 2000 and again in 2004 - that they are only managing what they were measuring and that is only around 7-8 per cent of healthcare associated infections acquired in hospitals.
This was based on the fact that we asked the Health Protection Agency (HPA) to analyse all the available data from their voluntary reporting scheme and other sources in order to evaluate the prevalence of other infections. Especially as the 2008 National Prevalence Study confirmed our view that MRSA and C. Difficile accounted for a very small proportion of what we now name healthcare associated infections acquired in hospitals (HCAIs).
We published that analysis as a separate Report on our website, but also used the findings as part of our main Report, highlighting concerns that these other infections were increasing and certainly were not improving like MRSA bloodstream infections and C Difficile infections. So our recommendations stressed the need for better information on these other infections and the need for a strategy that addressed all HCAIs.
Although the Health Act and others did concentrate on reducing all avoidable infections, the Care Quality Commission and its predecessor the Healthcare Commission focused on MRSA - MRSA bloodstream infections not all MRSA infections - and C. Difficile, so there was not the attention given to the other infections.
During our visits to Trusts, we often saw that Chief Executives knew exactly how many MRSA bloodstream infections and C. Difficile infections they had had, but had no idea about any other type of infection or indeed patient falls for example. So the Reports have had the desired effect in raising the profile of the issue, but have also had the unintended consequences of making hospitals and policy makers believe that the issue is mostly just about MRSA bloodstream infections and C. Difficile.
Our overall conclusion in 2009, was that the money spent on trying to reduce MRSA and C. Difficile was commensurate with the benefits that they achieved, but that we remained concerned about other infection rates; and in the absence of an understanding on other infections, we had some concerns as to whether optimal value for money was being achieved.
Having said that, visiting hospitals in 2009, compared with visiting them in 2004, the difference in terms of cleanliness is very evident - hospitals are visibly much cleaner - and staff understands of infection prevention arrangements and hand hygiene issues, on line insertion, line management and on many of the risk factors for infection, are much higher. Moreover, compliance with the Care Bundle approach goes wider than just MRSA and C. Difficile.
Nevertheless, there are still a number of challenges highlighted in our 2009 Report with one of our biggest concerns still about antibiotic prescribing - the data is still very poor and understanding and compliance with protocols is still very varied.
Ultimately, the greatest risk to patients is antibiotic resistance with many Trusts concerned about the increase in various antibiotic resistant organisms, such as E Coli. Given bugs will always be evolving; the lack of priority that has been given to getting a better grip on antibiotic prescribing is a key challenge that still remains.
Overall to achieve sustained improvement requires a major culture change within organisations, which has to also be bottom up but also has to be consistent and measured.
There is a need for a balance between standardisation or industrialisation of processes and local freedom to decide based on local priorities, and a clear idea of the aspects that would be best achieved under central direction or standards and those best achieved by local determination. There also a needs for a clearer view of the cost benefits of changing processes and systems to show the benefits of investing in monitoring and good infection control measures.
Where does this leave us? The Department of Health did not agree with some of the PAC recommendations and, the then Chairman of the Committee has written to the Department requesting they provide further information about their plans on increasing surveillance to the new PAC. We will no doubt have to advise the new Committee on this.
Similarly, there is also a need for us to be clearer as to the reasons for disagreeing with the other PAC recommendations. For example, the PAC recommendation that there should be an analysis of the cost benefits of the last 12 months use of mandatory screening of all elective and non-elective patients, which we consider was introduced without having a robust evidence base of the cost benefits.
The 2009 report is, therefore, unlikely to be the end of the story!