NHS: Why can't we keep our hospitals clean and protect patients from infection?

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The Big Question: Why can't we keep our hospitals clean and protect patients from infection? By Jeremy Laurance, Health Editor Published: 12 October 2007

Why are we asking this now?
- Yesterday an investigation by the Healthcare Commission revealed an astonishing litany of failings at three hospitals in Kent run by the Maidstone and Tunbridge Wells NHS Trust which allowed the lethal bug Clostridium Difficile to spread unchecked. Between 2004 and 2006 it infected more than 1,100 patients, directly causing the deaths of 90 and contributing to the deaths of 345. The commission found appalling standards, akin to a Third World health service, including beds crammed together, wards dirty and understaffed, and patients with urgent diarrhoea told to "go in the bed" because nurses were too busy to take them to the lavatory.
Is this just an isolated case?
Sadly not – though it is the worst to have come to light. Last year an investigation into a similar outbreak at Stoke Mandeville hospital, where 334 patients were infected and 33 died from C Difficile between 2003 and 2005, painted a very similar picture of a poorly run hospital operating under extreme pressure where doctors and managers had failed to heed warnings about the threat from the bug. Last July, the 900-bed Barnet and Chase Farm Hospitals NHS trust in north London became the first in the country to receive an official warning from the commission for putting patients at risk of infection. Serious breaches of the Hygiene Code, introduced in October 2006, which sets minimum standards for all trusts were found at the hospital.

But can we assume that hospitals are generally clean?
No. In June the Healthcare Commission reported that 99 NHS trusts admitted failing to meet minimum hygiene standards. That is one in four of the total in England. Worryingly, Barnet and Chase Farm was not among the 99. It had claimed it was meeting minimum standards but a spot check revealed poor provision of gels for cleaning hands, inconsistent and confusing messages to staff and inadequate isolation facilities. If other trusts are similarly deceived about their performance then hygiene problems may be even more widespread than the one in four figure suggests.

Will Gordon Brown's 'deep-clean' directive make any difference?
It depends whether we are talking politically or scientifically. Scientifically, it will make little difference unless it is done on a regular basis. Patients and visitors are constantly bringing new bugs such as MRSA and C Difficile into hospitals. It may also mean wards being closed while they are cleaned. However, the battle against hospital infections is as much political as medical – raising its profile and getting the NHS to take it seriously. One of the key defences against hospital infection is to get staff to wash their hands between patients - but they don't. On that score measures such as this can help.

Have doctors ignored the problem?
This goes to the crux of the issue. Doctors have regarded their main task as treating patients, and seen hospital infections as an unfortunate but inevitable complication of medical care. The bugs thrive in people whose immune systems are weak – and advances in medicine and the ageing of the population mean that older and sicker patients are being treated. Managers have gone along with this view because their interest is in getting patients through the hospital rapidly and cutting waiting lists. The result has been a fatalistic attitude to the occurrence of infections and an over-reliance on antibiotics to deal with them when they happen. In the case of MRSA, more and more powerful antibiotics have been required to shift it. In the case of C Difficile, antibiotics are themselves a key cause of the infection. They knock out "healthy" bacteria in the gut, allowing the C Difficile bacteria, which are normally held in check, to gain the upper hand.

Is the threat growing?
Yes. According to the OECD, hospital acquired infections now account for more days spent in hospitals in Europe than all other causes of infectious disease – flu, pneumonia, tuberculosis, Aids - combined. In the UK, the National Audit Office estimates they cost the NHS over £1 billion a year to treat. Cases of MRSA have grown from less than 100 a year in the early 1990s to 6,378 cases in 2006-7. The infection is linked with more than 1,000 deaths a year. C Difficile case have grown from a few hundred in the early 1990s to 55,681 in 2006-7 and causes around 4,000 deaths a year. Much of the rise in recent years has been because of greater awareness rather than hospitals getting dirtier. In the last couple of years, cases of MRSA have begun to fall, as tighter infection control procedures have taken effect, having peaked at 7,684 cases in 2003-4. Cases of C Difficile are still rising, but the rate of growth has slowed.

Are targets to blame?
Yes – at least in part – despite health secretary Alan Johnson's denials on BBC Radio 4s Today programme yesterday. His own department produced a report by its chief economist, Professor Barry McCormick, which blamed Government targets for increasing the risk. That found that the most crowded hospitals, with bed occupancy rates over 90 per cent, had MRSA rates 42 per cent higher than average. The report, obtained by The Independent last year, has never been published. The Healthcare commission said managers at both Maidstone and Stoke Mandeville were unduly fixated on hitting their targets, under pressure from their ministerial overlords, to the exclusion of considerations about patient safety.

Isn't proper cleaning the answer?
It is not that simple. Proper cleaning is essential, and there should be a bottle of alcohol gel beside every hospital bed for doctors and nurses to use. Screening of all patients for MRSA, announced by the health department last week, will allow those carrying the bug to be isolated on admission. Such measures can reduce infections, but they will not eliminate them. In the case of C Difficile, the main problem is over use of antibiotics. C Difficile also creates spores which are difficult to destroy and require soap and water to shift them. Alcohol gels are not up to job.

What will it take to reduce infections?
A change in the culture of medicine. Cleaning up diarrhoea, washing down wards and monitoring antibiotic prescribing are not glamorous activities. They will not yield breakthroughs, claim headlines or win Nobel prizes. But they will save more lives than a clutch of miracle cures.
Can hospital infections be beaten and patients protected?
Yes...
* Some hospitals have infection rates that are up to six times lower than others
* Consistent handwashing and proper standards of hygiene can reduce the bugs
* Spot-checks of hygiene standards are raising awareness and concentrating minds
No...
* Patients are older and sicker and infections thrive where immune systems are weak
* Hygiene is not the only answer to C Difficile, which is caused by overuse of antibiotics
* Doctors and nurses believe they are there to treat patients and regard washing their hands as an irritating distraction
© 2007 Independent News and Media Limited
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