Hand Hygiene: NHS

Alan Meale Excerpts

Wednesday 13th January 2016 Westminster Hall

[Nigel Mills (Amber Valley) (Con)]

I beg to move,

That this House has considered hand hygiene in the NHS.

I am grateful for the chance to raise these concerns. It is a pleasure to serve under your chairmanship, Sir Alan. I secured this debate to highlight some important issues. The germs that cause infections are spread to patients primarily on the hands of healthcare workers, so cleaning hands is the No. 1 way of reducing the spread of infection. Guidelines and rules are already in place, but they are not followed closely enough and the inspection regimes do not do their job and do not produce meaningful data about hand hygiene compliance levels. This serious issue has a dramatic effect on the health of many thousands of patients a year. For many of them, it could be avoided. There is a way of dramatically improving this issue for patients.

The data on this issue are scary. The 2011 prevalence survey showed that 6.4% of hospital patients—one in every 16—contracted an infection while in hospital. Imagine going to a restaurant where one in 16 customers was made ill by the food. No one would go back again; we would not allow it to stay open. But that is what the data showed for our hospitals five years ago. We should not be willing to accept that.

Infections contracted in hospitals affect 300,000 patients every year and cause 5,000 deaths. They have a dramatic impact on those individuals and a significant impact on the NHS, because patients who contract such infections remain in hospital on average two and a half times longer than patients who do not. They spend an average of 11, and a maximum of 25, extra days in hospital at an estimated cost of about £1 billion a year. It is estimated that 30% of such infections can be avoided simply by better applying the existing rules and practices.

The NHS must improve its performance on this fundamental issue. We should not be willing to accept that level of unnecessary infection. I am not saying that such infections are caused by people deliberately not washing their hands enough. They probably do not realise what they are doing, and their behaviour is not corrected. I suspect that most people in the NHS do not realise how many times they should wash their hands when they see a patient and do not know that they are not doing all they can. I am sure most people are extremely keen to do everything they can to fix this problem and prevent such infections. We must look at what more we can do to put systems in place and enforce them. We should give people support, training, peer pressure and peer reviews to ensure it is happening, rather than blame individuals. This issue will become increasingly important as the problem of antimicrobial resistance grows. We cannot rely on antibiotics to fix such infections and tackle the problem, so it is important that we stop the infections in the first place and prevent the situation from getting worse.

I want to talk about the existing hand-washing rules, the systems for monitoring them and why they do not work. I will look at some things that can be done to improve the situation. I hope the Minister will accept that I do not intend these ideas to be controversial or costly; they are ways of enforcing the rules that are already in place and of using the existing systems.

There is a generally accepted international standard for the number of hand-washing moments when nurses and doctors treat patients. It is not controversial; all nurses and doctors are taught it as part of their training. It is an accepted standard in the NHS and most hospitals around the world. I am not asking for a super gold standard for the UK. I do not want to create anything new, different or complicated. That set of moments when hand-washing is needed is accepted by everybody; it is just a question of how many of them are acted upon.

The National Institute for Health and Care Excellence put in place rules for hospitals to assess compliance with that number of hand-washing moments, so we do not need a new framework or a new duty on hospitals. Hospitals already have a duty to assess how well their staff comply with the rules for the five hand-washing moments when they deal with patients. When the Care Quality Commission audits hospitals, it checks how well those rules are enforced, so the systems are there but they are not working and we are not getting the outcomes we ought to have.

One of the problems is that hospitals check the compliance of their staff mainly through observations carried out by a member of staff on the ward or a member of the team. Normally, a nurse who happens to have half an hour spare one day is asked to review how well her colleagues are performing the five hand-washing moments. If I am doing a job and someone tells me, “Right, today you’re being observed on these criteria,” my performance goes up a bit because I know I am being observed and I do everything I can to comply—far in excess of my normal behaviour.

Another issue is that the staff members conducting the review are not trained in how to do it. They may not be entirely familiar with how many hand-washing moments there are or how many arise in the care of patients, so there is a combination of effects. If the people reviewing their colleagues, perhaps their friends, have not been trained to do so—they are not specialists—and are not fully familiar with the rules, it is not surprising that we do not end up with the most reliable data.

The vast majority of the observations show that the nurses and doctors observed are somewhere in the high 90s for compliance, which means they clean their hands more than 96% of the time, as they are meant to. The problem is that independent assessments carried out by people in a more reliable way suggest that compliance is significantly lower. Those data suggest that the actual compliance levels are somewhere between 18% and 40%. There is a set of rules and a system for checking compliance, but it is producing a dramatic false positive. It suggests that we are in the very high 90s for compliance, when we are nearer 20% compliant. It overstates the results by a factor of nearly five, with the terrible effect that there are more infections than there need to be and patients are suffering.

The NHS and other international health bodies accept that the levels of compliance with the hand-washing rules in the high 90s cannot possibly be right. Everybody knows they are false positives, but they give excessive reassurance to the boards of trusts that their staff are compliant, so further action is not taken. Everybody accepts that there has been progress in recent years in tackling infections, which have been reduced from even higher levels. The measures that were adopted to tackle infections had an effect on clostridium difficile and MRSA, but the problem is that we do not track instances of other infections, so it is hard to get data on how many are being tackled.

There have been various studies to try to assess levels of hand hygiene compliance to see what can be done to improve it. I am grateful to the Deb Group, one of the large employers in my constituency, which has an interest in this issue because it makes hand hygiene gel. It has some innovative ideas about how we can monitor hand hygiene compliance. I am grateful for the information it gave me for this debate. I should be clear that I am not advocating any one solution or product; we need a greater recognition in the NHS that this is an issue, and that there are better ways of assessing compliance. We need to encourage greater compliance.

As for recognition of the issue, Sir Mike Richards, the chief inspector of hospitals at the CQC, has highlighted the inaccuracy of local hand hygiene audits, so one would think that action is required. If we recognise that hand hygiene is important and if we recognise that we are nowhere near as compliant as we ought to be, one would think that many hospital trusts would be taking action to try to improve the situation. Sadly, that is not the case. Trusts have a lot on their plates and there are many issues, financial and others, to deal with, so they may decide that an area with compliance levels in the high 90s is not a stone that they want to turn over. They may fear that some proper audits might lead to the discovery that they are only 25% compliant and thus incur some unnecessary wrath.

However, the experience is that hospitals that take the matter seriously do get positive feedback. The CQC report on Burton Hospitals NHS Foundation Trust, which was in special measures until last year and is not too far from my constituency, highlights its use of a method to count the number of hand hygiene moments and the number of times ward staff were complying with the rules. It received some positive feedback in the letter from the chief inspector of hospitals in the report, which states that the hospital was using

“innovative practice to increase hand hygiene, using the latest technology monitoring the use of alcohol in sanitising gel.”

They were not marked down for having discovered an issue; they were complimented. The report states:

“We saw innovation in practice on ward 11 (male surgical ward) where the infection control nurses had worked with staff to reduce infection control risks and increase hand hygiene. The team implemented technology which counted the use of alcohol sanitising gel and compared it against the target of how often it should be used. This was in response to hand hygiene audits which needed improvement.”

On action that the trust must take to improve, the report states:

“The trust must ensure that ward assurance targets, such as hand hygiene practice and recording of patient observations, is achieved at a consistent level in the emergency department.”

We can see from that that if hospitals take the matter seriously, recognise that they are not as compliant as they ought to be and take action, that helps them in these audits.

The big ask here is what more we can do to ensure that CQC reviews identify that hospitals are perhaps fooling themselves into thinking that they are compliant when they are not. Perhaps asking, “Are you really doing accurate and competent monitoring of whether your staff are complying with the hand hygiene rules? Do you have any independent assurance that that data is accurate or are you just relying on surveys done in an idle half an hour by a member of staff who is not really trained, which can produce false positives?” should be a regular feature of all inspections. Work done over a long period to improve levels of hand hygiene compliance in hospitals has produced data showing that when hospitals improve performance and increase the number of hand hygiene moments, infections decrease at a pretty similar rate to the increase in hand hygiene moments. Data exists in the public domain that shows that that is not just a coincidence. If a hospital can increase compliance, infection rates can come down, improving outcomes for patients and reducing costs to the NHS.

My suggestion is not particularly complicated or expensive. It would not lead to the creation of new rules or new burdens that people have not been trained for. I am simply asking that hospital trusts around the country comply with the rules that are already there and monitor whether their staff are complying with the standards that they have been trained in. The NICE guidelines could be tightened up so that hospitals must not only monitor whether staff are compliant, but do so in a competent, independent and impartial manner and not rely on the occasional untrained observation by members of the same team.

When the CQC goes around hospitals assessing cleanliness and patient safety, we should expect it to check whether competent work has been done. If it has not, it should encourage and instruct hospitals to take the matter seriously. When hospitals show higher than average instances of infections, it should check that they took this issue seriously and that the relatively simple and low-cost measures that can be taken to reduce infection were applied. When hospitals are not doing that, it should be regarded as a serious issue.

There are many things in health that we cannot control or fix or that are incredibly expensive, but what we have here is a set of rules that already exist. It is a simple thing that most people are trained in. By doing everything that we can to comply with it, we could save a lot of money and a lot of patient suffering. There is the potential for real improvement. I hope the Minister will accept that this is a serious situation, and that there is more that NICE and the CQC can do and more that hospital trusts can be expected to do, so that the prevalence of infections in the next report is at the lowest possible level.

[Sir Alan Meale (in the Chair)]

As the debate is only an hour long and we have three quarters of an hour remaining, I want to inform Members that I intend to call Back Benchers first, then the Front-Bench Spokespeople and then the Minister. I will call the Back Benchers who stand.

--- Later in debate ---

[Jim Shannon (Strangford) (DUP)]

It is always a pleasure to serve under your chairmanship, Sir Alan. It was especially nice to hear the hon. Member for Amber Valley (Nigel Mills) introduce the debate, and it is good to participate in it. I would like to give some personal knowledge and put forward some viewpoints.

I congratulate the hon. Gentleman on so succinctly setting the scene for the rest of us to follow. To add a bit of background to the debate, patients in the NHS today have a 6.4% chance of catching an infection in UK hospitals. There are 300,000 healthcare-acquired infections annually, of which 5,000 result in mortality. We cannot ignore the mortality rate—5,000 people dying in our hospitals is 5,000 too many. If the figure was one, that would be one too many. If we can take steps to prevent those deaths, we should do so.

Although our figures are below the European average, many other developed countries perform better, including the United States at 4.5%, Italy at 4.6%, Slovenia at 4.6% and Norway at 5.1%. I know that the Minister will address that in his response, but if the States, Italy, Norway and Slovenia can do it better, I am sure that we can achieve their levels, which would be a two percentage point drop or thereabouts from our current figure.

Not all healthcare-acquired infections are preventable, but it is believed that approximately 30% of them could be avoided by better application of existing knowledge and realistic infection control practices. Hand hygiene is an essential component of that.

I remember when my brother was in an accident. He liked racing motorbikes, but unfortunately 11 years ago he had a very serious accident that resulted in him being in a coma and in intensive care for some 19 weeks, followed by 2 years of rehabilitation. Whenever we visited him in the Royal Victoria hospital in Belfast, we all had to wash our hands. He was not able to respond to us at that stage, but his family and other people who knew him wanted to go and see him because of the severity of his injury. The nurse was clear: she said, “You have to wash your hands every time you go to that bed, because the risk of infection for someone in that extreme circumstance is very real.” Every time we left the bed and went outside the ward, we had to wash our hands before we went back to the bed—that was clearly outlined.

To me it was clear: we do that because we want to visit the person in the bed, but we may unwittingly have infections on our hands. The hon. Member for Bridgend (Mrs Moon) spoke earlier about sneezing. Unwittingly, we cover our mouth with our hand and then rub our hands. Then we might stick our hands in our pockets and rub them on the pockets. Even when using a hanky, there will still be infection on the hands. That is the point I am trying to make. It is clear that we have to do something.

The infection prevention and control sector claims that basic hand hygiene standards are not being met on many NHS wards. If that is the case, a clear guide needs to be given to those on wards to ensure compliance. The Deb Group claims that although 90% to 100% compliance with hand hygiene standards was reported by UK hospitals—it is easy to say that—the true figures are between 18% and 40%.

As health is a devolved matter, I have asked the Minister responsible for health back home questions on MRSA infections in hospitals, because even though we have few infections, it is clear that something needs to be done. Back home—it is probably the same elsewhere—many would say, “If you’re ill, be careful in hospital, because you have people with open wounds and people whose immune systems are down. If you bring in your colds, flus and coughs, or whatever it may be, that can have an impact.”

Deb also argues that the data collection method is flawed and that direct observation artificially inflates compliance, as nurses observe colleagues meeting the requirements and undertake a tick-box exercise. There needs to be more than that. NICE issues guidance on hand-washing in hospitals and encourages strict hand-washing practices, but it does not include a demand that accurate data be recorded. We want to ensure that that happens. If we record the data, we are making an effort and, if we are doing that, we are washing our hands. There may be some weight to Deb’s concerns, and that should be extremely worrying for all of us.

Good hand hygiene practice in hospitals is the single most effective way to prevent the spread of infection, and we should take action to ensure that more effective records of hand-washing on NHS wards are made in future. That is a simple yet effective way of making our hospitals safer, and with the recent growth in antimicrobial resistance we need to act sooner rather than later to ensure that poor hand hygiene does not further increase the severity of HAIs.

We have had an extensive hand hygiene strategy in Northern Ireland since 2008, and although some problems persist—in all honesty, we cannot stop all infections—we have seen results from simply adopting a thorough hand hygiene regime in our hospitals, with education on the importance and effectiveness of hand hygiene being an essential part of the Department of Health, Social Services and Public Safety’s regional infection control strategy. Like in Scotland and in some individual trusts, we are taking action to address the issue.

Accurate records are the starting point for addressing the problem. There are many examples across the world, but a recent three-year pilot in a hospital in South Carolina in the United States of America found that once staff were trained in how to use electronic hand monitoring systems, compliance with best practice increased and MRSA rates dropped. That saved the hospital $433,644 from April 2014 to March 2015. There was therefore also a financial advantage, and although that is not the reason to do it, it is an example of what can be done to stop infections and address costs.

As we seek to have a more streamlined and cost-effective NHS, those are the sorts of approaches we need to look into. Indeed, the introduction of such a system at Burton Hospitals NHS Foundation Trust drove up hand hygiene compliance by up to 50% in just three months. That is an example from this country, which shows what we can do if we put in the effort.

With 5,000 people dying each year as a result of HAIs, it is clear that action must be taken. With resistance to antimicrobial treatment increasing, we need to get on top of the issue before it is too late. Hand hygiene is the simplest and most effective way to do that, so let us make sure hospitals are doing that right and doing it well.

[Sir Alan Meale (in the Chair)]

We now move to the Front-Bench Members, and we have only until 5.30 pm. I therefore ask Members to be succinct. Minister, if it is possible, could you give a minute or so at the end to the Member who moved the motion to allow him to wind up the debate?