Select Committee on Public Accounts Forty-Second Report


FORTY-SECOND REPORT

The Committee of Public Accounts has agreed to the following Report:—

THE MANAGEMENT AND CONTROL OF HOSPITAL ACQUIRED INFECTION IN ACUTE NHS TRUSTS IN ENGLAND

INTRODUCTION AND SUMMARY OF CONCLUSIONS AND RECOMMENDATIONS

1. Hospital acquired infections are those that are neither present nor incubating when a patient enters hospital. Their effects vary from discomfort for the patient, to prolonged or permanent disability and even death.[1] This is a very serious subject in terms of the impact on patients and costs to the National Health Service. The best estimates we have suggest that each year there are at least 100,000 cases of hospital acquired infection in England causing around 5,000 deaths, and the cost to the NHS may be as much as £1 billion a year.

2. Not all hospital acquired infection is preventable, since the very old, the very young, those undergoing invasive procedures and those with suppressed immune systems are particularly susceptible.[2] In his report the Comptroller and Auditor General estimated, from information provided by infection control teams in hospitals, that across all NHS Trusts infection rates could be reduced by 15 per cent by better application of existing knowledge and realistic infection control practices. Attributing costs to hospital acquired infection is complex and uncertain but the potentially avoidable cost is around £150 million a year.[3] On the basis of his report we took evidence from the NHS Executive and the Chief Medical Officer on what was known about the extent, cost and effects of hospital acquired infection and how infection control could be improved.

3. Two overall points emerge from our investigation:

  • The NHS do not have a grip on the extent of hospital acquired infection and the costs involved and are unlikely to have the information they need for a further 3 to 4 years. Without robust, up to date, data it is difficult to see how the Department of Health, the NHS Executive, health authorities and NHS Trusts can target activity and resources to best effect. This lack of data mirrors our concerns about significant weaknesses in NHS information and systems that have arisen in our recent hearings on medical equipment; inpatient admissions, bed management and patient discharge; and hip replacements. Effective information is essential for good management and effective health care, and central to NHS modernisation.

  • A root and branch shift towards prevention will be needed at all levels of the NHS if hospital acquired infection is to be kept under control. That will require commitment from everyone involved, and a philosophy that prevention is everybody's business, not just the specialists. Leadership and accountability, through the new controls assurance process, is crucial, as is education and training, and monitoring of performance and progress. New investment is also needed. The NHS Executive have launched an array of initiatives to help make this happen, but the results have yet to work through, and we are not convinced that the Executive have given these initiatives sufficient priority when allocating resources.

4. Our more detailed conclusions and recommendations are as follows

On improving understanding of the extent, cost and effects of hospital acquired infection

      (i)  Research indicates that between 50 per cent and 70 per cent of surgical wound infections occur post-discharge, but these infections are not monitored. The NHS Executive are undertaking research into post-discharge infection, and we look forward to seeing the outcome later this year. We recommend that post-discharge infections are monitored in future through the national surveillance scheme (paragraph 16).

      (ii)  The NHS Executive have now taken action to improve surveillance, including researching the links between antimicrobial resistance and prescribing, measuring infections that occur after patients have been discharged from hospital, and doubling their investment in the Nosocomial Infection National Surveillance Scheme. But by December 1999, only 139 self-selecting Acute NHS Trusts in England were participating in the surveillance scheme. We recognise that the Executive are expanding the Scheme, but we believe that they should go further and make it mandatory (paragraph 17).

On improving infection control

      (iii)  The NHS Executive acknowledge that it should be possible to reduce the incidence of hospital acquired infection by 15 per or more, avoiding costs of some £150 million and saving lives. Since 1996, and particularly since 1998, the NHS Executive have taken a series of actions and initiatives to address this issue, but do not expect to see tangible, measurable progress until 2003. Such progress will be essential for the NHS to meet their duty and commitment to patients (paragraph 45).

      (iv)  Key to achieving progress will be the effective implementation of the new Controls Assurance System, which builds on the statutory duty of chief executives for quality of care. This will raise the profile of hospital acquired infection, especially in the 20 per cent of Acute NHS Trusts that do not have a strategy for dealing with it. Every Trust has to have a plan in place by July 2000 setting out priorities for action and produce an annual report on progress. We look to the NHS Executive to let us have an initial summary report of progress, priorities and key issues by the end of April 2003 (paragraph 46).

      (v)  Complacency, poor prescribing practice and misuse of antibiotics has led to the emergence of drug resistant infections. As the Chief Medical Officer told us, there are no simple solutions any more. The NHS Executive have now launched initiatives to look at the more prudent use of antibiotics, and to monitor and control prescribing including the new Government strategy to tackle antibiotic resistant infections announced in June 2000. We expect this work to lead to evidence-based guidance on effective prescribing strategies (paragraph 47).

      (vi)  Hospital hygiene is crucial in preventing hospital acquired infection, including basic practice such as handwashing. We find it inexcusable that compliance with guidance on handwashing is so poor. We note the steps the Executive have now taken to improve awareness and education, but look to them to audit progress and report back to us by the end of 2001 (paragraph 48).

      (vii)  The increased priority and attention that is rightly now being given to hospital acquired infection has not been matched by resources. Some new money, £5 million over two years, has been allocated, some extra infection control nurses have been appointed, and the Executive accept the case for investment in smaller wards and isolation facilities. The scale of hospital acquired infection calls for sufficient funding to ensure that hospitals can tackle the problem effectively, and so reduce the impact on patients and NHS costs (paragraph 49).

      (viii)  The NHS Executive recognise that more effective bed management can help reduce hospital acquired infection. Greater use of smaller rooms and single bed rooms is now part of health service planning, and the Executive accept that increased investment in isolation facilities is a priority. But high throughput of patients is also a factor. As we noted in our report on Inpatient Admissions, bed management and patient discharge, some hospitals are operating at very high levels of bed occupancy. Wider application of best practice will help Acute Trusts manage beds better. Trusts also need to ensure that infection control is an integral part of their bed management policies (paragraph 50).

      (ix)  The Chief Medical Officer accepts that in staffing infection control teams, a ratio of one nurse to 250 beds is a good benchmark for NHS Trusts. But many Trusts have much larger numbers of beds per nurse. While local variations in circumstances and practice may account for some of these variations, we expect the NHS Executive to carry out further research, in conjunction with the Infection Control Nurses Association, with the aim of developing staffing guidelines for Trusts (paragraph 51).

IMPROVING UNDERSTANDING OF THE EXTENT, COST AND EFFECTS OF HOSPITAL ACQUIRED INFECTION

5. There is no requirement for NHS Trusts to publish data on rates of hospital acquired infection and such data that have been published are limited and not comparable. While most Trusts undertake some surveillance there are wide variations in the criteria used for defining infections, types of infection monitored, methods used, and ways infection rates are measured.[4]

6. Various estimates of the size, cost and impact of the problem were presented to the Committee. Figure 1 summarises the key figures, their bases and their reliability. [5] Though not necessarily consistent with each other,[6] they suggested that:

  • At any one time around 9 per cent of patients had a hospital acquired infection;

  • There are at least 100,000 hospital acquired infections in England and Wales each year, and possibly many more;[7]

  • Around 5,000 patients die each year in the United Kingdom as a direct result of acquiring an infection;[8]

  • These infections may be costing the NHS around £1 billion a year;[9]

  • While few Trusts monitor infections that develop after a patient leaves hospital, several studies have indicated that between 50 and 70 per cent of surgical wound infections occur post-discharge.[10]

7. The NHS Executive acknowledged that hospital acquired infection was a very serious issue but that the information available was limited. The estimate that there were at least 100,000 cases of hospital acquired infection a year made a number of assumptions, excluded key areas such as teaching hospitals and intensive care units, and did not include infections that present post discharge. These could be significant and the 100,000 is likely to be an underestimate.[11] Research was continuing into post-discharge infection, and the Executive hoped to have the results in the summer, and promised to share it with us.[12]

8. The Executive did not have data on the incidence of hospital acquired infection by NHS region or Trust, nor comparative data between England, Northern Ireland, Scotland and Wales. In particular, they could not identify the worst performing hospitals.[13] They noted that hospital acquired infection was a world wide problem, but here too the information was sketchy. Any international information that was available was really just a composite of country-wide studies and it was very difficult to make judgements about international comparisons. But in the Executive's view, England was doing better generally than most Scandinavian countries, did roughly as well as the USA in relation to MRSA (methicillin resistant Staphylococcus aureus), but did not do as well as some other European countries such as France and the Netherlands. Overall, they saw England as in the middle of the league rather than at the top.[14]

9. The estimate of £1 billion for the cost of treating hospital acquired infection was based on a study that was thought to be one of the most comprehensive undertaken in the developed world. However, it was still shaky in some respects, being based on one hospital, and then extrapolated across the NHS. There were many variables, for example in terms of the pattern of disease and in understanding the relationship between hospital acquired infection and length of stay. Moreover, there was no consistent basis for costing the work that went on in hospitals in relation to the control of infection, and the NHS Executive did not know in total how much the NHS spent on this issue.[15]

10. As regards the estimate of 5000 for the number of deaths directly resulting from hospital acquired, the Executive accepted that this could be on the low side, but the reality was that they did not know. Getting accurate figures was difficult, because in complex cases the causes of death were multiple. For example, someone undergoing cancer treatment with their immune system suppressed might be susceptible to secondary infection.[16]

11. We asked about the costs arising from clinical negligence claims from hospital acquired infection. The Department again told us that they did not know. Historically, information on clinical negligence costs had not been collected consistently, and although improvements had been made there was no centrally held data on how many compensation claims the NHS has had where hospital acquired infection was cited as a main or contributory cause. It was unlikely that robust information could be obtained even from a separate survey of NHS Trusts. Hospital acquired infection was often a contributory, but not necessarily the primary, cause of mortality and morbidity, so it was not uncommon for claims to cite infection as only one of a number of factors that contributed to the harm caused. That said, the NHS Litigation Authority was aware that a small but growing number of clinical negligence claims cited hospital acquired infection as a component of the circumstances resulting in a claim being made. In the Executive's view, this appeared to reflect the growing incidence of hospital acquired infection in clinical settings generally.[17]

12. Overall, the NHS Executive shared our frustration about the lack of authoritative information. The Chief Medical Officer added that there had been a tendency in the Health Service over the years not to invest as much money in information and to regard money not directly spent on patient care as money wasted. It was now obvious that the service had to spend money on information if it was going to improve the quality of service.[18]

13. Since 1996, the Department and Public Health Laboratory Service have been working together to develop a national surveillance scheme, the Nosocomial (meaning hospital acquired) Infection National Surveillance Scheme. The aim of the scheme is to improve patient care by providing information to assist NHS Trusts to reduce rates and risk of hospital acquired infection and to provide national statistics on specific types of infection for comparison with local results. Surveillance is an essential component of the prevention and control of infection in hospitals. The main objectives are the prevention and early detection of outbreaks and the assessment of infection levels over time in order to determine the need for, and measure the effect of, preventative or control measures.[19]

14. The Comptroller and Auditor General reported that there were some limitations in the way the scheme was operated, including the fact that it comprised only self-selecting hospitals. And while most infection control teams in hospitals carried out some form of surveillance to detect infections, there were wide variations in the methods used, types of infection monitored, ways infection rates were measured and criteria used for evaluation. Nevertheless, he concluded that the scheme's first year results showed considerable scope for NHS Trusts to reduce rates through better practice.[20]

15. The Department told us that they were doubling their investment in surveillance to £1 million a year. They were extending coverage to obtain data for more clinical areas such as intensive care settings and on links between antimicrobial resistance and prescribing. This work was being developed in a systematic way with the commitment of everyone in the health service and the Public Health Laboratory Service. The new system should throw up data more systematically and in three to four years they should have very good data. And as a result of this work, the Executive's aim was to develop measures, targets and benchmarks that will allow people to know whether their practice was getting better.[21]

Conclusions

16. Research indicates that between 50 per cent and 70 per cent of surgical wound infections occur post-discharge, but these infections are not monitored. The NHS Executive are undertaking research into post-discharge infection, and we look forward to seeing the outcome later this year. We recommend that post-discharge infections are monitored in future through the national surveillance scheme.

17. The NHS Executive have now taken action to improve surveillance, including researching the links between antimicrobial resistance and prescribing, measuring infections that occur after patients have been discharged from hospital, and doubling their investment in the Nosocomial Infection National Surveillance Scheme. But by December 1999, only 139 self-selecting Acute NHS Trusts in England were participating in the surveillance scheme. We recognise that the Executive are expanding the Scheme, but we believe that they should go further and make it mandatory.


1  C&AG's Report (HC 230, session 1999-00) para 1 Back

2  ibid, para 2 Back

3  ibid, paras 15-16 Back

4  C&AG's Report (HC 230, session 1999-00) para 1.3 Back

5  Evidence, Qs 190, 210 Back

6  Evidence, Appendix 2, p25 Back

7  C&AG's Report (HC 230, session 1999-00) para 1.5 Back

8  ibid, para 1.7 Back

9  ibid, para 1.13 Back

10  ibid, para 1.6 Back

11  Evidence, Qs 1-2, 10-17 and Evidence, Appendix 1, pp 22-25 Back

12  Evidence, Qs 12, 20, 24-25, 162-163 Back

13  Evidence, Qs 21-22 and Evidence, Appendix 1, pp 22-25, and C&AG's Report (HC 230, session 1999-00) paras 3.21-3.22, Figures 19 and 20 Back

14  Evidence, Qs 1, 21, 50-51, 95-96 Back

15  C&AG's Report (HC 230, session 1999-00) paras 1.10-1.13 and Evidence, Qs 2, 33, 95-103, 179, 190  Back

16  Evidence, Q5 Back

17  Evidence, Q209 and Evidence, Appendix 1, pp 22-25 Back

18  Evidence, Qs 116-117, 190 Back

19  C&AG's Report (HC 230, session 1999-00) paras 17-18, 1.3, 3.6-3.14 Back

20  C&AG's Report (HC 230, session 1999-00) paras19 and 3.15-3. 22 Back

21  Evidence, Qs 2-3; 51-53; 103-104, 107, 153-156 Back


 
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Prepared 23 November 2000