Kevin Lewis column

Kevin Lewis questions whether infection control standards are as widespread as they should be.


Talking dirty


There was a time when you went into hospital in order to get rid of a nasty infection. These days you go into hospital if you want to acquire one.

The Healthcare Commission has recently published its annual health check on NHS Trusts, and it makes you start scratching just reading about it. More than 25% of all Trusts are apparently failing to meet the three infection control standards that were introduced by the Department of Health in order to focus energy and attention on dealing with MRSA, C.diff and other nasties.

The place to go if you fancy cosying up to these and other fashionable organisms is clearly the West Country, with the Royal Cornwall Hospital NHS Trust top of the pops and the Northern Devon Healthcare NHS Trust not far behind. These are two of the four Trusts (out of almost 400) with the worst overall record in terms of both quality of services, and the effective management of resources. The chief executive of the Royal Cornwall was surprisingly upbeat at the news – presumably he had no immediate plans to become an in-patient himself. Although disappointed to be named in dispatches, he wanted the world to know that they had done wonderfully well in terms of ‘patient experience’, with 95% of patients rating their care between ‘good’ and ‘excellent’. Presumably the other 5% weren’t prepared to comment until they finished their course of antibiotics?

Around the same time as the Healthcare Commission report was published, the media latched on to the case of the former chief executive of the Buckinghamshire Hospitals NHS Trust, Ruth Harrison, who has was said to have presided over what appeared to have been a shocking series of failures, despite repeated warnings from staff. Over a three-year period, 65 elderly patients had died at Stoke Mandeville Hospital as a ‘definite, probable or possible’ consequence of C.diff infections. But as she passed through the departure lounge, Ruth Harrison received such a huge payout when finally moving on (in the region of £140,000) that one wonders if the lunatics had moved back in to run the asylum.

Everyone has their theories as to how and why UK hospitals have slumped back to standards of infection control that would have had Florence Nightingale and Edith Cavell reaching nervously for the carbolic. Is it the indirect effect of waiting list targets, creating pressure on beds which in turn leads to overcrowded wards, stretched staffing and excessively quick turnaround between patients? Even Easyjet would be proud of the minimal ‘downtime’ between discharges and admissions in the Stelios ward. But the prevalence of these hospital ‘superbugs’ has given a whole new meaning to the term ‘discharge’ – the order of play is now an admission, an infection, a nasty discharge, and then the treatment (if you’re lucky).

Is there a lack of financial investment? One of life’s mysteries in recent years is why the massive additional funding of the NHS has produced so little in terms of tangible results. The government released a white paper back in 2004, Choosing Health, which led to significant sums of money being ring-fenced for the treatment of obesity, sexually transmitted diseases and alcohol abuse (presumably, not all at the same time?).

Yet a recent survey has revealed that two thirds of the money had been spent instead on reducing deficits. Dentistry knows all about ring-fencing, of course. When everything else is fully resourced, ring-fencing works very nicely and chicken wire will do. When it isn’t, the fence needs to be on the scale of the Berlin Wall – including the border guards and gun turrets.

Is it something more fundamental? A deep cultural change or a progressive erosion of standards? Nurses didn’t wake up one morning and suddenly decide to travel to and from work on public transport in their uniforms, and yet it happens every day, all over the country.

Someone, way back in time, decided to close the hospital laundry and put away the starch. Uniforms can’t be sterilised, of course, but they can and do become contaminated – which is why today’s guidelines are an eclectic mix of bare arms but a plethora of barriers everywhere else. The logic is unarguable, but perhaps the real difference is that in Florence’s day awareness was sky high and hospital hygiene was top of the leader board. And now it isn’t. In the Buckinghamshire case, the Healthcare Commission report spoke of the Trust’s leadership being preoccupied with finance, reorganisation of the Trust, new buildings and achieving targets. The managers had ‘taken their eye off the patient safety ball’. Commission inspectors found that hospital workers did not clean equipment between patients and staff were poorly trained in hygiene. Even after the first criticisms had been made, an unannounced spot-check re-inspection found dirty wards and toilets, bedding and equipment lying on floors, faeces on bed rails, pubic hair in the bath, soiled commodes, and mould and cobwebs in shower areas. It is enough to make you feel sick, so to speak.

The paradox is that employees (of organisations both large and small) who fail to follow infection control policies face disciplinary procedures and often summary dismissal for gross misconduct. The reason given is that employers have no alternative because of their overriding duty of care to the patients for whom they are responsible. Precisely. That is the reason given in the Healthcare Commission report for its recommendation that Ruth Harrison and Maureen Davies (former Director of Nursing at the Buckinghamshire Hospitals NHS Trust) should hand over the leadership to others. The worrying difference is that if you are in the front line, junior and expendable, you are out on your ear pour encourager les autres. If you are sufficiently senior you get a payoff and move on to another job – often in another Trust. (No performers list for NHS managers, obviously). But the culture and the priorities come from the leadership, not from the poor bloody infantry, and surely it is only a matter of time before somebody is convicted of corporate manslaughter or criminal negligence – and the sooner the better.

Universal standards
One of the quickest ways to get an invitation to spend time at a prestigious London venue (the GDC at Wimpole Street) is to find yourself on the wrong end of a complaint that contains some kind of allegation that your infection control is inadequate. But in reality, a GDC ‘Fitness to Practise’ investigation is much more likely to happen if you are working in general practice, as opposed to working in the salaried services. There are internal, less public processes for dealing with such matters in the CDS or in the hospital service.

Infection control is probably the most important aspect of patient safety and the quality of care. An optimal ‘clinical outcome’ or ‘patient experience’ is no use to you in the cemetery. How inappropriate, therefore, that the term ‘universal standards’ has become associated with the subject of infection control – because that is one thing that we haven’t got. NHS Trust CEOs are not accountable to the GDC, but we are. There is no £140,000 payoff following erasure. Healthcare professionals are therefore much more accountable than healthcare managers. General dental practitioners are more accountable and more exposed than any other group in dentistry. Universal standards? I don’t think so.

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