House of Commons - Public Accounts - Twenty-Fourth Report

Select Committee on Public Accounts Twenty-Fourth Report

3 Improving infection control systems and management processes

22. Infection control has been given a higher priority in many trusts, with trusts making improvements to their infection control management arrangements and increasing their trust boards' involvement, largely as a result of the infection controls assurance standard, the key elements of which have now been incorporated into the new national Standards for Better Health. Infection control team staffing levels have increased, although wide variations remain and a fifth of teams still have no clerical support. More teams have infection control budgets, but again the amounts vary and a quarter of teams claim that their budgets have decreased. Increased demands on infection control teams, with more surveillance and external inspections, have meant a continuing mismatch between expectations placed on the team and the resources allocated to them.[30]

23. In 2000 the Department acknowledged that attempts to prevent infections could be adversely affected by trust bed management policies, and that the drive to achieve higher bed occupancy was not always consistent with good isolation, hygiene and cleaning practices. Developments such as placing beds too close together and patients moving around the hospital more frequently could increase the risk of infection, as could staff shortages, together with reliance on agency nurses. The Department considered that high staff turnover rather than the fact that staff may be temporary was the thing that made the task of infection control harder.[31]

24. The Department told our predecessors in 2000 that by 2003-04 they expected to reduce bed occupancy to 82%, significantly improving bed availability and the management of elective and emergency patients. Yet in 2003-04, 71% of trusts were still operating at occupancy levels of more than 82%.[32] 50% of senior trust managers reported that waiting times for inpatient treatment had conflicted with infection control management. The introduction of day surgeries was originally expected to reduce the need for beds, but has not done so, and the development of separate treatment centres was expected to help by separating elective patients in the future.[33]

25. The need for improved clinical leadership led to the introduction of the new "modern matrons" who were to be accountable for a group of wards and would be "easily identifiable, visible, accessible and authoritative figures". A poll of 100 matrons in September 2003 identified preventing infection and improving hospital cleanliness as the most challenging of their responsibilities. Matrons had a large workload with many other priorities, and that there was a lack of clarity on their role as regards infection control. By 2004 there were some 500 modern matrons working in the NHS.[34]

26. In 12% of cases infection control teams have had their recommendation to close a ward for infection control reasons refused or discouraged by their Chief Executive. The Department highlighted the new post of Director of Infection, Prevention and Control, which all trusts are required to designate, who would now have the authority to influence such decisions and would be expected to advise the Chief Executive on whether a ward should be closed because of an infection problem. He or she would also be expected to inform the strategic health authority and include the details in an annual report.[35]

27. The Department accepted in 2000 that infection control teams should be consulted more widely on wider trust activities, such as new construction projects and the letting of cleaning contracts, yet in many trusts infection control teams are still not being consulted. The design of a hospital can help minimise infection problems, including patient flows, ventilation, accessibility of hygiene basins, and numbers and gaps between beds in wards. The Department have now made this consultation a requirement in the new Director of Infection, Prevention and Control's job description.[36]

28. It is difficult to test robustly whether new hospitals are cleaner or have lower infection rates than older hospitals, partly because of the relatively small number of new hospitals and because many schemes are phased over a number of years. There is however good evidence of a significant relationship between the age and quality of the physical hospital environment and MRSA. Other things being equal trusts with older poorer quality buildings have higher rates of MRSA. Reducing the age and improving the quality of hospital building is also likely to have a proportionately larger effect on all hospital acquired infections, many of which are airborne, rather than MRSA which is overwhelmingly spread through direct contact.[37]

29. It is the responsibility of trusts to ensure that contract specification, including those for PFI projects, comply with all the NHS standards for the design, construction and performance of facilities, as contained in comprehensive guidance produced by NHS Estates. The most recent policy on infection control is set out in Infection Control in the Built Environment (NHS Estates 2002). Individual Health Technical Memoranda (HTMs) contain detailed requirements such as the specification of clinical wash hand basins and the special type of taps and handles required. Bidders are now required to respond to the Trust's output specifications in a standard format. This states specifically that: "proposals of how decontamination and control of infection are to be achieved should be provided". To ensure compliance with the specifications Trusts are required to review and sign-off the clinical functionality of proposals before any contract is entered into.[38]

30. Despite a significant number of Departmental initiatives launched following our predecessors' 2000 hearing, culminating in "Winning Ways" in December 2003, implementation and compliance have been patchy. At the same time as the Comptroller and Auditor General's follow-up report was published in July 2004, the Secretary of State announced "Towards cleaner hospitals and lower infection rates" with an emphasis on actions needed to cut levels of infection and improve hygiene. Since then a number of other developments suggest that actions are now being implemented on a number of fronts (Figure 4). The key impetus to this is the establishment of a Towards Cleaner Hospitals and Lower Rates of Infection Programme Board, and the involvement of the Prime Minister's Delivery Unit.[39] Figure 4: Recent actions and initiatives to improve prevention and control of hospital acquired infection

Action/Initiative Details including timetable for delivery

September 2004: Established Towards Cleaner Hospitals and Lower Rates of Infection Programme Board Chaired by the Chief Nursing Officer, the Board is expected to:

act as a strategic focal point for the Secretary of State and Ministers and perform an assurance role against the commitments in Winning Ways and Towards Cleaner Hospitals;
drive the delivery of change in the NHS to improve and provides strategic direction and ensure consistency in the delivery of the Department's work on cleanliness, lower healthcare acquired infection and lower MRSA rates in NHS hospitals.

September 2004 : National roll out of National Patient Safety Agency's cleanyourhands campaign Alcohol hand rubs to be placed next to all beds in acute hospitals from April 2005. In announcing the campaign Lord Warner noted that evidence shows that rates of infection can be reduced by 50% by providing disinfectant hand rubs and raising awareness.

Research project to evaluate compliance and sustainability.

November 2004: Announced new national performance target that MRSA bloodstream infection rates to be halved by 2008 Secretary of State announced a new initiative to dramatically reduce MRSA bloodstream infections by 50% by 2008 using the published rates for 2003-04 as the baseline. The Modernisation Agency is to provide advice and support, including expertise to develop "Care Bundles" of evidence based interventions.

December 2004: Published Revised Guidance on new Model Cleaning Contract to help improve standards Comprising a best practice guide on evaluating and awarding contracts so that quality is considered as well as price; revised national specifications for cleanliness which set clear minimum standards; recommended minimum cleaning frequencies; and a revised healthcare facilities cleaning manual to reflect changes in cleaning technologies and practice.

October 2004: Launched "A Matron's Charter; An action plan for cleaner hospitals". Also appointment of new Chief Nursing Officer Chief Nursing Officer Christine Beesley appointed, and part of her role is to drive through improvements in cleanliness and hygiene in every hospital.

The new Matron's charter sets out ten broad principles for delivering cleaner hospitals, aimed at all staff in the NHS, whatever their role. The intention is that it will also be shared with patients and visitors and that they will be involved in plans for improvement and in providing feedback.

October 2004: Held first national conferences for NHS Directors of Infection Prevention and Control Used conference to brief the directors on their new powers to ensure local action: challenge hygiene practice and prescribing decisions; increase training; enforce rigorous procedures for hand hygiene; and ensure the sterility of invasive equipment such as catheters.

December 2004: Announced first results of the Rapid Review panel in battle on MRSA Rapid review panel set up by the Health Protection Agency at request of Department. The panel does not conduct evaluations of products but reviews information and evidence provided in order to make recommendations to the Department. Products can then be fast-tracked into the future work plans of the NHS Purchasing and Supplies Agency and the National Institute for Clinical Excellence.

January 2005: Hosted Conference "MRSA- Learning from the Best at Home and Abroad" Hosted by the Chief Nursing Officer - the objective was to help share best practice on reducing MRSA, including improving surveillance, clinical protocols, aseptic techniques etc. Also issued ten actions for improvement under the three headings people, knowledge and practice.