Given the increased focus on NHS targets, especially those process targets that appear to be increasingly difficult to achieve, this blog focusses on two high profile healthcare associated infections (HCAIs) reduction targets . These targets, like many other targets, have consistently polarised views. With many believing that they were the best way to ensure that hospitals gave this significant patient safety issue the highest priority and others questioning the evidence for, and clinical validity, of the targets.
The HCAI targets, like most of the current NHS targets, were introduced by the Labour government of the 2000s. HCAIs develop either as a direct result of healthcare interventions, such as medical or surgical treatment, or from being in contact with a healthcare setting. The two most well-known HCAIs, largely because they are the subject of NHS targets, are meticillin-resistant Staphylococcus aureus bloodstream infections (MRSA) and Clostridium difficile (C. difficile).
At the start of 2000, HCAIs had a very low profile, and infection control was seen as the ‘Cinderella service’ of the NHS. Two National Audit Office (NAO) reports in 2000i and 2004ii changed that. They demonstrated that HCAIs were, in fact, a huge problem for the NHS. That at any one time around one in eleven hospital patients had an HCAI which not only prolonged patients’ hospital stay but, in the worst cases, caused permanent disability and even death. The NAO identified a lack of robust aggregate data on the total number of HCAIs in England but estimated that there were at least 300,000 HCAIs a year and that they were costing the NHS over £1 billion.
The 2004 report concluded that progress in reducing healthcare associated infection had been patchy, and that there was a distinct lack of urgency on issues such as cleanliness and compliance with good hand hygiene; limited progress in improving isolation facilities or reducing bed occupancy rates; and that progress continued to be constrained by a lack of robust data other than on MRSA bloodstream infections and a lack of evidence of the impact of different intervention strategies.
Following these NAO reports, the Department of Health introduced a range of policies and measures designed to reduce rates of infection. For example:
- Mandatory surveillance for MRSA was introduced in 2001 (accounting for some five – ten per cent of all infections)
- In 2004, a target to reduce MRSA bloodstream infections by 50 per cent by 2008 in all NHS acute and foundation trusts
- The introduction of the Health Act in 2006, made it a legal requirement for chief executives to put systems in place to minimise the risk of HCAIs
- In 2007, following mandatory surveillance of C. difficile introduced in 2004, a target was introduced for a 30 per cent reduction in the number of cases of C. difficile (2007-08 to 2011-12).
While these targets were welcomed by many there were just as many cynics who questioned the scientific or other evidence for the targets. The NAO’s third report in 2009 provided evidence that the targets were having a measurable impact. It found that the Department’s hands-on approach to what had seemed an intractable problem had been successful, as both the MRSA bloodstream and C. difficile infection reduction targets had been exceeded. The numbers of MRSA bloodstream infections fell from 7,700 in 2003-04 to an estimated 2,984 in 2008-09 (a 61 per cent reduction) and the numbers of C. difficile reported in patients aged 65 and over reduced from the peak of 55,635 in 2006 to 32,628 in 2008 (a 41 per cent reduction)iii The NAO concluded that this was a clear example of what could be achieved by concerted effort and centrally managed targets, not to mention close performance monitoring and imposition of financial and other penalties. However it also noted that with a focused and centrally driven initiative, improvements were not uniform across the NHS nor was there any meaningful data on other healthcare associated infections, which according to available data, continued to increase. It consequently identified a number of other problems that needed to be addressed such as collecting robust comparable data on other infection risks; tackling increases in antibiotic resistance and improving data on hospital prescribing and compliance with good practice.
The principle of accountability and performance management through targets was continued by the Coalition Government in the form of the NHS Mandate and the NHS Outcomes Framework. New trust specific targets were set for both MRSA bloodstream infections and C. difficile. For example, the NHS was asked to collectively reduce the numbers of infections in 2012-13 on MRSA by a further 29 per cent and C. difficile by 17 per cent.
Over the last few years, the Department has continued to raise its expectations and local commissioners have set stretching targets for each trust, which includes zero MRSA bloodstream infections and stretching C difficile targets.iv The latest figures published by Public Health England show that between 2013-14 – 2014-15 recorded cases of MRSA declined by 23 per cent (373 vs. 287) whilst C. difficile, increased by two per cent (4,610 vs. 4,724).v
Two important factors appear to be associated with success in meeting the HCAI targets, namely the significant financial and leadership support provided and the pressure and penalties issued centrally. This support helped ensure HCAI targets were seen as everyone's responsibility, with improvement programmes especially in relation to cleanliness, hand hygiene, antibiotic prescribing and other evidence-based infection control interventions implemented system wide. Indeed, infection control became and remains a Board agenda item in most trusts. But much of the original achievements and the resultant change in culture was against a background of significant funding increases for the NHS which arguably made the improvement easier to achieve.
In recent years, we are seeing that most trusts are continuing to meet their very challenging stretch targets, beyond what experts originally believed was possible, leading to better patient outcomes and in turn reduced costs of treating those patients who might otherwise have acquired an infection. However maintaining these targets requires a great deal of management attention on process and administration, at a time when other challenges may deflecting attention elsewhere. Yet for HCAIs there remains a lot to do, not only in sustaining the progress made but in considering the importance of other infections, a risk highlighted by the NAO in 2009. Indeed two bloodstream infections, which do not have targets associated with them, have increased between 2013-14 and 2014-15; cases of meticillin Staphylococcus aureus (MSSA) increased by three per cent (2,458 vs. 2,534) and Escherichia coli (E-coli,) increased by four per cent (31,398 vs. 32,740).vi
This story illustrates what can be done by centrally managed or monitored targets, but in the absence of such an approach, patients everywhere require assurance that the culture changes and performance achieved to date, will be sustained and not sacrificed to satisfy new efficiency ’targets’.
iThe management and control of hospital acquired infection in acute NHS trusts in England National Audit Office. 2000. See also: http://www.nao.org.uk/report/the-management-and-control-of-hospital-acquired-infection-in-acute-nhs-trusts-in-england/
iiImproving patient care by reducing the risk of hospital acquired infection: a progress report. National Audit Office 2004. See also: http://www.nao.org.uk/report/improving-patient-care-by-reducing-the-risk-of-hospital-acquired-infection-a-progress-report/d/
iiiReducing healthcare associated infections in hospitals in England. National Audit Office 2009 http://www.nao.org.uk/report/reducing-healthcare-associated-infections-in-hospitals-in-england/
vDeloitte analysis of Public Health England dataset for 11 month period from April – February. Source: https://www.gov.uk/government/statistics