Antibiotics have been around in medicine for 70 years and, although they have undoubtedly saved the lives of millions, they can cause havoc with the delicate balance of gut bacteria.
C difficile occurs naturally in over 60 per cent of children and 3 per cent of adults, and can spread very easily; it can also occur through the use of necessary antibiotics.
The Department of Health wants to maintain a zero-tolerance approach to all healthcare acquired infections, and has set trusts individual targets for reducing C difficile cases - and we understand why.
The problem is that the way the penalties for breaching these targets are administered would make the Financial Times’ Undercover Economist weep in frustration - they are not even “more or less” fair. The targets are demanding. Four trusts have a target of zero and 22 (13 per cent) have a target of fewer than 10 cases of C difficile per year. The pressure is on for large, high performing trusts with low C difficile rates in particular; they will have quite low targets already so it will be tough to drive down the number of cases further. But if they breach targets by only a few cases, under the NHS standard contract they could suffer an exorbitant fine of up to 2 per cent of turnover. For a large trust that could run to more than £10m in a single year.
It would be much fairer if any fines recognised the genuine performance of a trust by looking at the ratio of cases to patient bed days so all trusts are judged by the same standards and those with large turnover and low rates of infection do not face disproportionate penalties.
Using absolute numbers and a margin before fines are levied inevitably leads to a somewhat uneven - and hence unfair - system. For example, a trust with 1,000 beds might have a C difficile target of 80 cases per year and could face a fine of 2 per cent of income if cases rose to 88, amounting to say, £8m; a trust half the size, however, might have a target of 40 but would typically have a similar “margin for error” - taking no account of its smaller size. This is clunky maths and penalises the good large trusts. Trusts with targets below 35 cases would be shielded by the de minimus practice, but those with targets just above 35 - many of them excellent - need to worry.
The Department of Health has exacerbated the problem by giving out mixed messages. A letter to the Foundation Trust Network from the DH said: “We do not expect commissioners to act in a punitive or disproportionate way when applying contract consequences, but even the best performers are expected to improve.” It also stated that: “There needs to be a mature debate about the application of any sanction and it is clearly not the expectation that sanctions are imposed in a mechanistic way.”
Although the DH clearly expects local discussions between providers and commissioners, there is little evidence this is taking place. Our members tell us strategic health authorities are determined to make commissioners enforce fines, even though they recognise they are unfair.
The DH is not doing anything different this year on C difficile penalties in spite of the growing grumbling about the unfairness of the system. But the Foundation Trust Network has won a small victory. The DH has agreed to monitor C difficile fines this year, and to introduce a contract variation if the “consequences are shown to have disproportionate and unintended impact on some organisations that breach their objective by a small number”.
But this is not enough. We would like to see clearly worded guidance from the DH stating that commissioners must take into account individual circumstances. This would go some way to making local conditions more flexible and could mitigate the most glaring iniquities.
But it is worth considering whether a system of fines or penalties is the best way to incentivise health service managers and clinicians to work as hard as they can to reach the laudable - but unquestionably complex and challenging - goal of eliminating C difficile from hospitals.
If the DH decided to tackle C difficile in a different way, then this should not be equated with rolling back on the commitment to fight against this blight on hospital care.
We should never forget that in the end it is patient care that will suffer when funds are withheld from frontline care. That doesn’t help anyone.
Saffron Cordery is director of strategy at the Foundation Trust Network.