Published: 30/06/2005, Volume II5, No. 5962 Page 14 15

With the spotlight on healthcare-acquired infection showing no signs of fading, health secretary Patricia Hewitt is responding with a statutory hygiene code. But is legislation the answer to a seemingly intractable problem? Tash Shifrin reports

Is there any infection that spreads quite as quickly as bad news? The 'superbug' methicillin-resistant Staphylococcus aureus - and now the Clostridium difficile infection that hit Stoke Mandeville Hospital, killing 12 patients - are making headlines daily.

And with the media spotlight firmly fixed on healthcare-acquired infections, health secretary Patricia Hewitt began her new job last month by announcing a Health Improvement and Protection Bill.

The bill will introduce a statutory hygiene code for the NHS and private health services and give the Healthcare Commission powers to slap 'improvement notices' on bodies that fail to comply and, should hospitals fail to mend their ways, impose sanctions.

Perhaps unsurprisingly, the media latched onto the sanctions. Could NHS trusts be hit with fines, an idea floated by former health secretary John Reid in March? Could chief executives be jailed?

The Department of Health is staying tight-lipped until it launches consultation on the code later in the summer, although the announcement noted ominously that this would include 'the issue of statutory powers of criminal prosecution, for which provision already exists in the Care Standards Act 2000'.

NHS Confederation chief executive Dr Gill Morgan is unfazed, . 'We recognise There is an issue of public confidence around MRSA and can see why it needs a political response, ' she says.

The NHS is used to similar regulations, she explains. Now that Crown immunity no longer applies to trusts, food standards laws mean inspectors can issue notices on their kitchens already.

Dr Morgan believes the code needs to be based on existing hospital cleaning standards. 'There is going to have to be an inspection component to it, ' she says. 'But I think the NHS will manage this perfectly well. We'll not be in a position where we have large numbers of trusts with enforcement notices on them.' Dr Morgan ridicules the idea of 'people being locked up'.

Commentators have 'conflated' the hygiene bill with the Corporate Manslaughter Bill announced at the same time, she argues. It would be hard to prove 'causality' - that a trust by its negligence caused a patient to die of MRSA - when so many people arrive in hospital carrying the bug, she says.

'It is a shame the rhetoric has focused on locking managers up.

That is not what the bill will be or should be about or what will actually happen, ' she says.

But she adds bluntly: 'Nor do I believe the Hygiene Bill will sort MRSA. It can only look at things you can inspect. But because MRSA exists in the community, you could have a very clean hospital that meets all hygiene standards and It is a patient admitted after an accident who brings in MRSA.' And that is one of the key problems any legislation would have to overcome: 40 per cent of MRSA comes in from the community or is transferred from other hospitals.

How can a chief executive be held accountable for an infection which came from outside?

The Department of Health is looking at how the bug is tackled in Sweden. Uppsala University Hospital is the pioneer of a new scheme which screens patients on arrival - including those who come in via accident and emergency - and treats the infected ones in isolation rooms.

Legal measures are not the key to solving the HAI problem, says Unison head of health Karen Jennings. 'It is vital that chief executives and non-executive directors see hygiene as key to their organisation, ' she says. 'To that extent It is welcomed.' But Ms Jennings believes the health secretary's announcement failed to touch on a crucial factor in hospital hygiene - the number of cleaners has nearly halved in the past two decades. 'We need a massive recruitment drive for cleaners, ' she urges.

'There is more to it than washing hands. There are two to three people in each bed each day. We need people to wash those beds between patients. They're not being washed down, ' she says.

John Lister, author of the Cleaners' Voices report published by Unison earlier this year, blames contracting out for the fall in numbers. 'Every time a contract tender comes up the pressure is on to reduce costs.' He interviewed groups of hospital cleaners to get their view of what they are up against. 'The key thing is how much time have they got to clean a ward, ' he says. Cleaners told him again and again of 'elementary things' that worked against good hygiene practice, such as lack of fresh uniforms and high-temperature laundry facilities, or poor cleaning materials, 'cheap and nasty bottom-of-the-range stuff', he adds.

Ms Jennings is cautious about the proposed sanctions regime. 'We have got to engage in dialogue around how we make trusts accountable, ' she says. 'Let's get the staffing right and agree in principle about what's causing cross-infections.' Lack of real evidence about those causes, and about the relationship between cleaning and MRSA, adds to the political controversy and frustrates those working to find a solution.

Dr Stephanie Dancer, consultant microbiologist at Southern General Hospital, Glasgow, and formerly of Health Protection Scotland, comments: 'There is a relation between visibly dirty hospitals and MRSA. But There is no scientifically proven link. No-one's ever investigated it.' Dr Dancer was not impressed by the hygiene bill announcement. 'For Patricia Hewitt to just blindly go ahead and say people are going to be prosecuted - how are you going to tell if It is clean or not?

'You're going to base it on aesthetic appearances. You still can't say that hospital is clean. They [the bugs] are microscopic organisms.

You can't tell by looking.

'All they're trying to do is quell the unease of the public. It is a political ploy, ' she says.

Dr Dancer wants more cleaners too, but has been campaigning for cleaning standards to be based on microbiological evidence.

Equipment near the patient's bedside is a likelier source of MRSA transmission than the floors and toilets highlighted in DoH cleaning guidance, she argues.

Jean Lawrence, chair of the Infection Control Nurses Association and director of infection prevention and control at Leeds Mental Health Teaching trust, also feels the new law might miss the point.

'The ICNA doesn't support the use of legislation against managers or nurses. It is just not the way forward. We cannot attack people.

Punishing people doesn't work, ' she says. 'What we need is proper monitoring: audit tools.' Ms Lawrence is concerned about a shortage of infection control specialists. Research suggests that hospitals should have an infection control nurse for every 100 beds, but in England there is an average of one per 347 beds, she says.

'The government is going to have to put its money where its mouth is.

We need a comprehensive national surveillance system, ' she says.

The HAI problem is, in Dr Morgan's phrase, 'multifactoral'. She too suggests solutions that lie outside a food industry-style code.

'One of the things we need to do is not run hospitals at over 82 per cent bed capacity; That is the critical figure. Under that, you have a lot less HAI, ' she says.

At the same time, she says, many trusts have adopted measures that have cut MRSA rates, such as University College London Hospitals foundation trust, where staff now wear alcohol gel dispensers on their belts (see box).

How - or whether - the hygiene code will take account of any of this is unclear. The DoH says there are no plans to reduce bed occupancy rates, or to launch recruitment drives for cleaners or infection control nurses. It will be up to trusts to determine what staff will be needed to comply with the code, a spokesperson says.

But one clue as to what Ms Hewitt's code might look like comes from Scotland - there are suggestions that it could be based on the Scottish code of practice for the local management of hygiene and HAIs, which came into force just over a year ago.

The Scottish code, drawn up by a multidisciplinary working group, is not statutory, but it carries a stern warning: 'While the code of practice did not develop from specific legislation, it may attract a legal effect through its definition of specific accepted professional practice in this sphere of healthcare provision, ' says Dr Morgan.

And she adds: 'Any radical departure from such accepted practice without clear justification might be regarded as a controversial decision within a legal setting.' A Scottish Executive spokesperson adds that NHS boards' prevention and control of HAIs will form part of their accountability reviews, which will be chaired by the Scottish health minister.

The Scottish code throws its net wide - this is no mere cleaning charter. Six chapters outline the issues and best practice on staff education, patient and public information, equipment, prevention and control of infection, cleaning services and compliance management - in that order.

It is frank about 'the lack of robust evidence underlying the practice of prevention and control of infection'. Its drafters could only ask for experts' opinions.

Education and training are emphasised: organisations must have 'an explicit strategy for mandatory induction training in relation to HAI' as well as integrating it into continuing professional development.

The code's measures have a practical feel to them - for example, urging clarity about who is responsible for cleaning particular items of equipment. There is a riskmanagement grid covering a long list of hospital kit, although the details of cleaning are left to local NHS bodies.

There is a strong stress on audit, and the code asks managers a key question that illustrates why a wordy document alone is not enough: 'Are there resources available to allow the code of practice to be followed?' Is the Scottish code working? A recent report paints a mixed picture: managers were praised for their efforts, but nearly two-thirds of NHS boards lacked a robust monitoring, review and audit regime for infections and only 28 per cent could show they monitored hand hygiene.

But with consultation on Ms Hewitt's code yet to begin, NHS managers in England may find a useful starting point - if not a glimpse of things to come - north of the border. .



University College London Hospitals foundation trust has reduced MRSA infections by 69 per cent since 2003.

The trust says the fall coincided with general acceptance of alcohol hand-gel dispensers at every bedside. Personal bottles carried on the belt have 'probably contributed to better compliance', the trust adds.

UCLH also uses an 'aseptic non-touch technique' for clinical procedures, developed by its haematology unit. This technique reduces accidental touching of areas likely to contaminate the patient by ensuring staff follow standardised ways of carrying out tasks.

Where possible, UCLH also screens patients for MRSA before admission so cutting someone with MRSA on their skin can be avoided. Patients are seen by wound surveillance staff in hospital and followed up after they go home. The results are reported back to surgeons.