Infection Prevention and Control

Philippa Whitford Excerpts

Tuesday 15th May 2018 Westminster Hall

[Nigel Mills (Amber Valley) (Con)]

I congratulate the hon. Member for Strangford (Jim Shannon) on securing this debate. It reminds me of a debate on much the same topic that we had a few months ago. Its aim was to find out from the then Minister when the Government might enforce the strategy they had announced. It is a pity that we are repeating that debate a few months later and we still do not have the answers. The case has been set out very clearly by the previous speakers. There is not much advantage in repeating it, but, just to reinforce the point, we are talking about 5,000 deaths annually. The World Health Organisation estimates that half of those are preventable through effective hand hygiene. I do not know of other situations in UK life where we could have 2,500 people die each year unnecessarily and that would not be a national scandal. We would do anything we possibly could to fix it. There are things we can do to save a large proportion of those lives that are not very difficult or expensive. Our strong message today is: let us get on and do them.

I accept it will not be easy. We are not talking about finding the number of people who do not practise any hand hygiene and making them practise it; we are talking about making sure that as many health staff as possible get up to the very high levels of compliance with hand hygiene rules, rather than being in the middle. I suspect that no health service staff are deliberately not cleaning their hands as often as they ought to. We know they work in high-pressure situations. They do their very best for patients, and occasionally some behaviours creep in that perhaps should not. The important thing is to have processes in place that can identify when performance is perhaps slipping and then remind people, gently and constructively, how important hand hygiene is. That is why we need accurate and sensible monitoring.

We all know what happens when a colleague in a team says, “We have got to do one of these audits today. I’ll go round and watch to make sure you are all practising the right hand hygiene.” We all know what will happen. We have all been in those situations. We are all very careful to make sure we wash our hands as best as we possibly can. We all think we know the same rules, so we all comply with the same things. The person observing probably does not know the rules any better than those being observed. It is no surprise, therefore, that we end up with near 100% compliance. In fact, it is a surprise that we do not end up with 100% compliance in that situation. It is like the driving test. I have never looked in my mirror as much in my life as on my driving test, because I knew I was being checked on that.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

Is there not a simpler approach? Should not the audit be unannounced and carried out by people like secret shoppers, which is a technique that we use in Scotland?

[Nigel Mills]

Yes, that would be clear progress. However, I sense that we would notice an unknown person walking round the ward with a clipboard, which might make someone behave more carefully. I am not sure how easy it is to stop the word going round the hospital that such work is being done, but I accept that that is better than one member of the existing team doing it. The question is: can we find a better way of monitoring compliance and getting the data we need, so that we can work out what is happening, see what the trends are, and see whether they are reflected in infection rates? As hon. Members have pointed out, there are various techniques on the market to do that electronically.

Simply counting how many times the ward dispensers are squeezed will not work because we need to know the type of ward, how many patients there are and how sensitive the work is to know how many times people need to squeeze the dispensers. We need a system that says, “On a ward carrying out this sort of activity with this number of patients, we would have expected this level of hand hygiene-compliant moments, and we actually got this many squeezes on the dispenser. That is only a quarter of what it ought to have been. That tells us there is a big problem on this ward.” Or it might tell us that we got 80%, which is probably a sensible level to get.

In my constituency is the Deb Group, a large employer that produces hand hygiene gel and monitoring techniques. I accept there are many rivals on the market and many different ways of monitoring. Some people prefer to have each member of staff wear a badge with a sensor that can tell how often that member of staff approaches a hand hygiene gel dispenser, so that we can monitor at an individual level rather than a ward level.

All those ideas are out there. We need the Government, and presumably the Care Quality Commission or NHS Improvement, to say to hospitals, “We want you to collect real data. We don’t want you to do stupid observations that give you 99% compliance, which we know is meaningless, just so that you can tick a box to say that you’re compliant. We want you to collect real data. We don’t mind how you do it, and we’re not going to punish you, take money off you, or put you in special measures if that data shows that you’re at 25% or 35% compliance, and all your rivals are at 97% because they’re doing it wrongly. We want you to do it properly, get the data, use the data, and improve your performance where you can see that it is linked to infections being too high.”

When the CQC reviews hospitals and other health environments, it should check that hospitals are collecting that data sensibly and using it to improve performance. The CQC should be very serious about that when it assesses a hospital. Can we see that hospitals know what their performance is, have a plan in place to improve it, and are improving it, and that infection rates are falling? It would be a serious matter if hospitals were not doing that work properly—if they were just having a quick half-hour assessment now and again, and producing data that they must know is complete rubbish.

We have the right plan; we know what we want hospitals to start doing. Let us get it in force, and task the CQC to ensure that hospitals are doing it. Let us set out clearly what we want hospitals to do and ensure that they are not too scared to go down that line, thinking that their data will suddenly get worse and they will be punished for it. Let us do what we know we need to do, and hope that we do not have to come back in another couple of years to talk about the fact that 2,500 people have died because we have not managed to put something in place that is easy and relatively cheap, and that we know works.

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[Dr Philippa Whitford (Central Ayrshire) (SNP)]

I pay tribute to the hon. Member for Strangford (Jim Shannon) for securing this important debate. As he said, it is only a few weeks since the World Health Organisation’s “Save Lives: Clean Your Hands” campaign and we are talking about how to reduce healthcare-associated infections. Most hon. Members have rightly focused on hand-washing and hand hygiene, because it is crucial, but that alone will not tackle hospital infection. It is not just about hand-washing; it is about the cleaning of wards.

We started to see the rise in MRSA, MSSA and so on after we started to outsource cleaning. I remember watching a young man cleaning with a machine in the Royal in Glasgow. He looked about 20, and if anyone who has a 20-year-old son can tell me that he knows that there is such a thing as corners, I would be delighted to admit defeat. We need people who are committed to the space. I was very glad that my hospital in Ayrshire never outsourced. We kept ward maids who had their own patch, in which they took pride, and there were supervisors who came along—a bit like someone’s mum-in-law with a white cloth—checking under the beds and the trolleys and on top of the curtain rails. It is really important that the environment is clean.

Bed occupancy is another issue. We know that the NHS in England has been under pressure for quite a long time, because the number of beds has halved over the past 30 years. England has one of the lowest bed ratios in Europe, at 2.4 per 1,000. Bed occupancy has been more than 95% and the recommendation for a safe level is 85%. The average in Scotland in 83%. That will vary between rural and urban areas, but if there is no time to clean the bed between patients, the risk increases. If the hospital is under pressure with a queue down in A&E, people are going to cut corners.

As the hon. Member for Moray (Douglas Ross) mentioned, the fabric of the building is crucial. If something is cracked or broken or old or wooden, it is not possible to clean it properly. That is why we have the Healthcare Environment Inspectorate in Scotland, which—believe me—turns up unannounced, poking around in every nook and cranny, looking under trolleys and wheelchairs, in the toilets and the shower rooms. That also includes external unannounced observation of people washing their hands.

I will turn to staffing levels. Across the UK we face nursing workforce challenges. Although we are struggling with a 4.1% nursing vacancy rate in Scotland, in England at the moment it is more than 10%. That creates pressure on everyone else on the ward. As the hon. Member for Amber Valley (Nigel Mills) said, there is a temptation, if not to do no hand hygiene, perhaps not to spend long enough with the gel on the hands and not to take quite the same quantity.

It is important to remember that clostridium difficile is caused by the overuse of antibiotics. It may spread from patient to patient due to poor hand-washing, but the initial problem was overuse and prolonged use of broad-spectrum antibiotics. It is very important that that is controlled. We need to think about sources, such as pressure sores and intravenous access, whether it is a peripheral drip or a central line. An important one at the moment is the management of urinary catheters. How long is it left in place? Is it too long? If it needs to be in longer, is it being changed regularly?

We also need to monitor surgical site infections. In Scotland, two wounds are monitored so that we are aware of whether things are improving or worsening. Although the hon. Member for Moray complains about a 1.37% wound infection rate after C-section, that has actually decreased over many years, and for hip replacements the rate is 0.63%. Some of that is not due to hand-washing. I have been a surgeon for more than 30 years and have seen the change from big interrupted black silk sutures that allowed penetration points for infection, to subcuticular invisible mending that means that the wound seals very quickly, using better dressings and glue to seal the wound so that there is less risk of external ingress. There is also a plan to add bowel surgery and vascular surgery—a dirty operation and a clean operation—because that is how we can monitor if something more general is going wrong.

Like the rest of the UK, in Scotland since about 2000 we have been trying to tackle infections. We lost our white coats and had to wear short sleeves—I still do. We were not allowed watches—I still do not wear one—and hand-washing and hand gel were promoted. Nevertheless, in 2007-08 an appalling outbreak of clostridium difficile in the Vale of Leven Hospital affected more than 150 people and caused 34 deaths. That wake-up call made us realise that tackling healthcare-acquired infections cannot be done in isolation; it must be part of a quality improvement and safety drive.

We created Healthcare Improvement Scotland, and in 2008 we established the Scottish patient safety programme, which was based on principles from Boston but was the first national patient safety programme. It is a structure on which we can hang evidence-based practice about many of the challenges that put patients at risk. It involves not the great and the good sitting in an office, but frontline champions from all health boards and all areas. It is driven by outcome data, which is shared, published, peer reviewed and actioned. We have to make hand-washing, like patient safety, part of daily practice; it must not sit on a shelf in a folder.

The Scottish patient safety programme was started to tackle all risks. I came across it as a surgeon, because it was used to tackle surgical errors such as wrong-site surgery and drug errors—patients being given the wrong drug—but it also addressed healthcare-acquired infections and hand hygiene. We had ward champions and unannounced audits carried out by people from other wards. I agree that, unfortunately, the worst performers in every audit were the doctors. That is why we had to publish the results, put them on the doors of the ward and literally name and shame. We also did a lot of education with relatives, because they come in from outside. In recent years we have made our hospital grounds smoke-free to try to tackle the issue of staff and patients forming a mug of smoke that people have to walk through to get to the door.

All infection-control measures are brought together in one manual, the “National Infection Prevention and Control Manual”, which means that everything is in one place. If there are five or six different initiatives and guidelines, they can sometimes be slightly different and can end up causing confusion.

The hon. Member for Filton and Bradley Stoke (Jack Lopresti), who is no longer in his place, mentioned the important issue of antimicrobial resistance, which will make it harder to tackle infection. Our behaviour in healthcare is helping to drive it. We are threatened by a post-antibiotic era. Alexander Fleming came from Ayrshire, and it would be horrific to think that the antibiotic era might last less than 100 years. Antibiotic stewardship is critical, and it is part of our patient safety programme. The Scottish Government are now also working with vets, because part of the issue is the use of antibiotics in animal husbandry. It therefore comes under the title of the “one health” programme.

The purpose of the Scottish patient safety programme was to reduce deaths, and within just three years there was a 9.3% drop in hospital standardised mortality rates and a 24% drop in deaths in intensive care. The hon. Member for Moray said that there is an infection rate of 2.7% in intensive care, but we have to remember that those are the sickest, most complex patients, and they are therefore most at risk of having or bringing in an infection. There was a 90% drop in ward clostridium difficile rates within three years. Deaths from C. diff dropped by 79% between 2007 and 2015, and those from MRSA dropped by 87%.

Many hon. Members mentioned sepsis. We have all seen the horrific cases in the media, and 40,000 deaths is more than many cancers, which get a lot more attention. In Scotland we established the Sepsis Collaborative, which ran from 2012 to 2014. It focused on just one measure: the national early warning system, which was about delivering antibiotics intravenously to the patient within an hour. Every hour’s delay increases the death rate by more than 7.5%. In 2010 an audit showed that fewer than 25% of patients were getting an IV antibiotic within an hour, but by 2014 it was more than 80%. The aim was to reduce deaths by 10%, but during the time of the programme there was an almost 20% reduction.

All parts of the UK have seen a dramatic fall in C. diff and MRSA, but all have seen a rise in E. coli, which is a bug that lives in the bowel. It is largely driven by catheter infections and it concerns older patients. It is one of the challenges we face, because many of these bugs will be resistant. There is actually a higher mortality rate from E. coli than from MRSA.

One of the differences in approach is to look at healthcare-acquired infections not by themselves, but as part of patient safety. In Scotland there are no financial incentives to meet standards, either for the hospital or for the staff; it is just pure clinical competitiveness. Nurses and doctors go to work to do a good job, and if we give them the tools, the education and the training, they will do that. We also have to give them time and support. Having a more complex quality improvement structure makes it easier to share good practice. That is what we are talking about today. We want to see a change in approach, not in a protocol folder on a shelf, but in the DNA of staff.

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[The Minister for Health (Stephen Barclay)]

As always, Mr Howarth, it is a pleasure to serve under your chairmanship.

I join the shadow Minister, the hon. Member for Ellesmere Port and Neston (Justin Madders), in congratulating the hon. Member for Strangford (Jim Shannon) on securing the debate, which provides an opportunity for the House to emphasise the importance of raising standards of infection prevention and control in the NHS. He was kind to pay tribute to the Secretary of State for his work on patient safety, and on putting that front and centre in his priorities. As the hon. Members for Ellesmere Port and Neston and for Central Ayrshire (Dr Whitford) acknowledged, that is a point on which the House is united in a common cause. How we reduce infections is of real importance to our constituents, as my hon. Friend the Member for North East Derbyshire (Lee Rowley) said, and that is reflected in our surgeries, because it impacts on the lives of those we represent. There is therefore a great deal of common cause.

The debate is timely because it was World Hand Hygiene Day on 5 May, which is an initiative that the World Health Organisation started in 2010 to remind us all, including patients and family members, to practise good hand hygiene, to help reduce the spread of infections. The hon. Member for Strangford was right to challenge the Government to reinvigorate our approach to hand hygiene. A number of initiatives are under way in Government to address exactly the points that he raised. Public Health England has been raising awareness, and NHS Improvement has begun a number of initiatives, such as its NHS provider bulletin and a hand hygiene theme in its executive masterclass. Other ways of raising awareness include the Royal College of Nursing’s glove awareness week. As the hon. Member for Central Ayrshire said, that it is all about taking practice from guidance or files and embedding that into the DNA, the culture and the way people operate, who include visiting relatives and staff at all levels, including doctors as well as nursing staff.

A number of hon. Members, including my hon. Friend the Member for Amber Valley (Nigel Mills), raised technology and what more we can do. One theme of the debate was whether the Government are doing enough to drive forward the use of technology. I recognise the limits of direct observation and how behavioural change may respond to those. That is why the Government are actively looking at the extent to which technology can facilitate this area.

We have carried out an initial assessment; indeed, the NHS Improvement director of infection prevention and control, Dr Ruth May, and her team recently visited the Royal Wolverhampton NHS Trust, which has been trialling an electronic monitoring system to make an initial assessment of that. Their feedback is that the system is reliant on existing technology, and that many IT systems would not be able to support that. A number of practical issues need to be addressed before one would have a roll-out of technology. I reassure the House that Dr May and her team are actively looking at that issue. We all recognise the impact, not just on patient safety, but on the cost of infections and unnecessary deaths. We are actively looking at the issue of technology.

The hon. Member for Strangford also asked if we could publish more. To pick up on the remarks of the hon. Member for Central Ayrshire on the way information is published in NHS Scotland, dialogues are already taking place. I am happy to ask officials to ensure that, as part of the collaboration that is already under way in NHS Improvement with colleagues in the Scotland and England NHS, we look at best practice to ensure that we are working with and maximising the learning from both sets of NHS.

Public Health England has carried out some initial analysis of the available data to determine the suitability of the data available for publishing. Currently, the data is incomplete and will not truly reflect the usage of hand gel. We are exploring how to improve that data. The hon. Member for Central Ayrshire commented that transparency on what is being done and on variance in performance around infection rates is a key driver of prevention.

[Dr Whitford]

The Minister may know that as a breast cancer surgeon, I was involved in developing the breast cancer standards for Scotland. The only action was peer review—putting everyone’s performance up at an annual conference. No one wants to be at the back of the class; in actual fact, seeing genuine performance drives up quality.

[Stephen Barclay]

The hon. Lady is right that peer review is always a powerful motivator. That sort of transparency drives behaviour, so we need to ensure that we do that in an effective way that does not alarm patient families, because of the publication of data that could be misrepresented by those who have different objectives. The need to get more publication of data is an important point, which the hon. Member for Strangford and others raised, on which we need to do further work.

The hon. Member for Upper Bann (David Simpson) asked in his intervention about the specific issue of patients going outside to smoke, and whether there was an associated infection risk, for example through drips. I am advised that there is no additional risk of infection, as long as the drip is well managed. If colleagues have specific issues about the infection risk associated with that, that is the nature of the debate and helpful to know.

My hon. Friend the Member for Moray (Douglas Ross) spoke of the pain and distress to patients caused by infections, and the important link to buildings. Although that is relevant in Scotland, to which he referred, I accept that the point would also apply to the England NHS. The state of the buildings and the maintenance programme have a part to play, not just in the Scottish NHS, but in the England NHS as well.

The hon. Member for Strangford asked whether hand hygiene could be a national marker of care quality. The Department is considering how we could do that effectively. The points he raised were heard and I will ensure that they are addressed. As and when we have any update, I will be very happy to share that with him.

Overall, a great deal of progress has been made. We are committed to reducing the number of infections. Since 2010 we have made excellent progress on MRSA and C. difficile. In the 12 months ending March 2018, MRSA cases were down 54% on the 12 months ending May 2010, and C.diff infections were down 47%. Considerable progress has been made, but as the hon. Member for Central Ayrshire mentioned, although we have made progress in slowing the rate of increase of E. coli infections, there is more to be done to bring that rate down. NHS England has the challenging objective to bring that down by 20% as part of its mandate. As a result of slowing that down, there were 2,400 fewer cases of infections than there would have been with the previous trend.

Clearly, there is more to be done on E. coli and it is an area of considerable focus in the team. Those cases also have a fiscal cost of between £3,000 and £7,000 per infection, but the much more material cost is the patient safety issue and the harm that accrues as a result. NHS Improvement is leading this programme, aimed at a 20% reduction in E. coli bloodstream infections in 2018-19. It is an ambitious but important target. NHS Improvement has begun working with the medical director of NHS England, Steve Powis, on setting up pilots with local health economies across England to engage and assist in the reduction. That may be an issue that my hon. Friend the Member for Morley and Outwood (Andrea Jenkyns) wishes to pick up with me after the debate—how we can work together, given her powerful but extremely sad experience of the events that befell her father.

Colleagues recognised the considerable amount of work on antimicrobial resistance, which is an important factor in treating infections. Our latest estimate is that over five years, there could be an extra 6,000 deaths attributable to pan-antibiotic resistance. Lord O’Neill’s review on AMR said that drug-resistant infections will cost the world 10 million extra deaths a year and $100 trillion by 2050. Those are pretty scary figures, but they underline the importance of preventing infections occurring in the first place.

That brings me on to patient safety. Following the tragic events at Mid Staffordshire and the subsequent public inquiry led by Sir Robert Francis, the NHS embarked on a journey of improvement based upon three strands: better regulation, greater transparency and a culture of learning. Assessing the risk of, and preventing, detecting and controlling the spread of, infections, including those that are healthcare associated, is addressed by the fundamental standards of care, enshrined in regulations, that all Care Quality Commission registered providers are expected to meet. A number of colleagues mentioned the role of the CQC as part of the checks and balances that need to be in place.

In November 2016, the Secretary of State launched new plans to reduce infections in the NHS, including the sepsis commissioning for quality and innovation. Through that, we have incentivised hospitals to improve their sepsis care. Independent CQC inspections have focused on E. coli rates in hospitals and in the community. In addition, we have appointed a national infection prevention lead to ensure a sustained focus at national level, improved training and information sharing, so that NHS staff can cut infection rates and, through the National Institute for Health and Care Excellence’s 2017 guidelines, highlight standard principles and advice on good hygiene.

Considerable progress is being made. Data published in 2017 suggests that four in 10 of all E. coli blood infections cannot be treated with commonly used antibiotics. Infection prevention and control is a key element of tackling antimicrobial resistance, and hand hygiene plays an important part in that. We are working extensively with stakeholders, including the royal colleges, academia and the research community, industry and our expert advisory groups, to inform our next steps.

Several colleagues, including the hon. Member for Ellesmere Port and Neston, mentioned sepsis. We have made significant progress since our focus to improve sepsis practices increased in January 2015. There is new NICE guidance and a new national CQUIN measure to incentivise providers to improve the identification and timely treatment of sepsis. The hon. Member for Central Ayrshire was absolutely right about the time-critical nature of that treatment. That work is already delivering change. The most recent data, which is for the third quarter of 2017-18, shows that emergency department assessment for sepsis has increased from 52% to 92%, and in-patient assessment has increased from 62% to 84% since April 2016.

Considerable progress has been made, which reflects the renewed focus across the NHS, in England and Scotland, on the time-critical nature of sepsis treatment, but we know there is more to do, which is why a new cross-system action plan was launched in September 2017. That plan outlines a range of activities to ensure that the NHS is on the highest possible alert to tackle that devastating condition. Indeed, just recently, on 25 April, NHS Improvement issued a national early warning score 2 patient safety alert to support providers to adopt the revised NEWS2 to detect deterioration in adult patients, including better identification of patients likely to have sepsis.

My colleague the Minister for Care, my hon. Friend the Member for Gosport (Caroline Dinenage), hosted and gave a speech at the launch of Health Education England’s paediatric sepsis e-learning package, which, again, is about raising awareness at an early stage. That training package was informed by clinicians and by parents whose children sadly passed away from sepsis, so we can learn from those tragic events and ensure that warning signs are better picked up at an earlier stage.

As several Members recognised, hand hygiene plays a key role in infection prevention and control, in supporting patient safety and in our efforts to address antimicrobial resistance. Considerable progress has been made—MRSA has more than halved and C. difficile has reduced by just under half since 2010—but, as the hon. Member for Central Ayrshire rightly said, E. coli remains a key area for renewed focus. We have successfully slowed its growth, but we now need to reduce it significantly. Part of the challenge is that a lot of it occurs outside the hospital setting, in the community.

I look forward to working with colleagues from across the House on this shared objective in an area where shared practice, from both England and Scotland, can help. We can learn from each other and from Members’ experiences in their constituencies. We will continue to embed hand hygiene practice and promote awareness of it in the NHS, not just through World Hand Hygiene Day but through debates such as this one.