Dysfunctional governance and concentration on target-hitting rather than patient safety contributed to two infection outbreaks at Stoke Mandeville, says a damning Healthcare Commission report. Alexis Nolan reports on the problem that's bigger than MRSA

It is not really a sentiment that anyone involved can express, but Stoke Mandeville Hospital was, arguably, unlucky.

This may seem an unpalatable or heartless sentiment to express when one considers that 33 people died in two outbreaks of Clostridium difficileat the hospital between October 2003 and June 2005, but the trust's rate of healthcare-acquired infection is nowhere near the worst in the NHS.

Nonetheless, the organisation has received intense attention both before and after the Healthcare Commission was asked to investigate by the health secretary.

The commission's report in July was extremely critical and makes uncomfortable reading for senior managers at the trust. They had failed to learn the lessons from a first outbreak, had 'dysfunctional' governance and 'mistakenly' prioritised objectives such as achievement of government targets, control of finances and reconfiguration of services above patient safety. Senior staff were unresponsive and feared by other staff.

Even before the commission report was published, the hospital's chief executive and director of nursing had quit. It has been left to trust acting chief executive Alan Bedford to steer Stoke Mandeville on its recovery path.

'The report came out on my eighth working day and almost the entire period up to that was about how we were going to handle publication and talking to the Healthcare Commission and preparing our staff for a very heavy-hitting report and the messages we would give to staff, the public and patients,' he says.

An unconditional apology was top of the list, with an acceptance of the commission's report, its conclusions and recommendations and a top-level commitment to doing everything possible to fulfil them. Management would have to be more responsive and open, the governance structure would give staff the best opportunity to do things to the best of their abilities and follow good practice to a high level of compliance. Basic standards of care would be in place and bed management would be tightened up.

The response pointed out that levels of infection in the trust are not exceptional. Outbreak peaks may have been handled badly but the rates of infection were not that high.

Comparison with other trusts

Figures released by the Health Protection Agency in July show there were 61 trusts with a worse C difficilerate per 1,000 bed-days for patients aged 65 or over than Buckinghamshire Hospitals trust in 2004. In 2005, the figure was 62. Buckinghamshire's C difficilerate in 2005 was 12 per cent higher than in 2004 and the total number of C difficilereports rose from 307 to 344.

'It's a difficult message,' says Mr Bedford. 'You tell patients that yes, you accept all this [the commission report], things could have been better and we will do better. But you're not at any greater risk here than anywhere else.'

Where the trust got it wrong was to put other targets first - and this was damned in the Healthcare Commission report. 'Targets are not to blame for the trust's leaders taking their eye off the ball,' said commission chief executive Anna Walker. 'Managers always have to deal with conflicting priorities and plenty of organisations do it successfully.'

Commission chair Professor Sir Ian Kennedy said: 'Safety can never be allowed to play second fiddle to other objectives that may emerge from time to time. It is the first objective.'

Mr Bedford agrees. He is a self-confessed 'believer' in targets driving improvement in the NHS (he previously worked on a part-time basis as a targets troubleshooter at the Department of Health) but recognises that patient safety cannot be compromised.

'We've told staff that with an individual patient in front of you patient safety always comes first - but we expect targets to be hit as well.

'It's not acceptable to say you can't put someone in a bed because it will break a target. But, on the other hand, you have to do everything possible to hit targets.'

'We can't afford to put one before another. The top five or six targets you just have to do - and MRSA has been one of the top group for quite a long time now.'

The only target for HAI is indeed around methicillin-resistant Staphylococcus aureus. Data on MRSA levels has been collected for longer than C difficile.And in the run-up to the last general election, former health secretary John Reid made a rash promise that the NHS would halve MRSA rates between this year and 2008-09.

The spectre of MRSA spreads fear - it kills one third of all those who contract it - and demanded action. Last year's DoH Saving Livesreport aimed to help acute trusts attack MRSA and other HAIs. An improvement team was set up at the beginning of this year to troubleshoot those trusts in need of help to reduce their MRSA rates. Pilot projects at three trusts took place in the spring.

The roll-out of the programme began in earnest in the summer. So by the end of the year 20 trusts will have received help. The government is in talks with the HPA to increase MRSA monitoring and reporting to quarterly updates rather than the current half-yearly.

But what about C difficile, which is a bigger infection control problem for the NHS than MRSA?

Death rates soar

Mentions of MRSA on death certificates in England and Wales rose by 75 per cent from 669 in 2000 to 1,168 in 2004. It was the underlying cause for 360 of those deaths in 2004 - at 31 per cent, just slightly more than in 2000.

But C difficilewas mentioned on death certificates in England and Wales 975 times in 1999 and 2,247 times in 2004, an increase of 130 per cent. It was identified as the underlying cause for 1,245 of those deaths in 2004, roughly the same percentage - 55 per cent - as in 1999.

What about frequency of infection in hospital? MRSA had an average bacteraemia rate per 10,000 bed-days in the last financial year of 1.60, according to the HPA. This is dwarfed by C difficile. Other figures from the agency show that, in the 2005 calendar year, the rate per 10,000 bed-days for patients aged 65 or over for C difficilewas 22.2. Reports of MRSA infection fell by 0.56 per cent last financial year - reports of C difficilerose by 17 per cent in the last calendar year. So, in the drive against HAIs, is the focus on MRSA too narrow? Not according to Healthcare Commission safety strategy lead Murray Devine.

'When mandatory surveillance for MRSA began in 2001, it was a perfectly laudable thing to start doing as was the move to make the measurement of it mandatory so it was clear how many cases were happening in the country,' he says. 'It's absolutely right to have a strong focus on MRSA.'

Mr Devine says the 50 per cent improvement target serves two purposes: to deal with MRSA directly and to provide a 'slipstream' to improve emphasis on infection prevention control through the processes and procedures that should be common to all HAIs. But, if this was so, you would expect to see a correlation between organisations doing well - or badly - with their MRSA and C difficilerates.

Correlation on success - and failure

Certainly, there is some evidence to support this. Four trusts are among the worst 20 for both MRSA and C difficile- University Hospital of North Staffordshire (8th and 6th worst, respectively), Ashford and St Peter's Hospitals (13th and 17th), Bath Royal United Hospital (15th and 7th) and Hereford Hospitals (18th an 9th).

Similarly, the best 20 include eight trusts common to both bacteraemia. Although most are specialist trusts, where rates of HAI are generally lower due to the nature of their business, there are two general acute trusts: Harrogate and District foundation and St Helens and Knowsley Hospitals.

The latter has seen its rates for MRSA drop by 48 per cent in the last year and those for Cdifficileby 53 per cent.

But there are also examples that would suggest little correlation. KetteringGeneralHospital trust, the acute with the highest C difficilerate is in the top 50 best trusts for MRSA rates. The second worst for C difficile, George Eliot Hospitals trust, is the 33rd best trust for MRSA. And going back to Stoke Mandeville, there are 78 other trusts with worse MRSA rates than Buckinghamshire Hospitals trust.

Chief nursing officer Chris Beasley is right when she says it is difficult to gauge the correlation between the two. Case mix can have an impact. And there is scepticism about the C difficilefigures - in these early days it is hard to tell whether the apparent increase in incidence of infection is a real increase or just more reporting.

'What we are committed to is making sure all work on MRSA applies to C difficile,' says Ms Beasley. 'I want to see both rates coming down.'

The focus on MRSA is there because of the target she says, but she echoes Mr Devine's comments when she says that addressing MRSA will help organisations make progress on all HAIs. Should there be specific targets for C difficile? No, says Ms Beasley: 'Adding another one would be very difficult.'

The Healthcare Commission report on Stoke Mandeville had plenty of lessons for the trust, but also some for the DoH. It should 're-emphasise to all trusts, including those responsible for commissioning, the importance of controlling this [ C difficile] infection' and 're-emphasise to NHS managers that assuring the safety of patients is a responsibility that cannot be compromised', the report said.

The reaction from the government was immediate. To coincide with the commission report, the DoH announced a draft statutory code of practice for the prevention and control of HAIs for all trusts. The final version of the code will be published next month and trusts' performance against the code will be measured by the Healthcare Commission from next year's annual health check.

In May, the government published an HCAI (health care associated infection) productivity tool to estimate the costs of MRSA and other HAIs. On his second day in post as health minister, Andy Burnham told a conference that trusts achieving the MRSA target across the board for all HAIs will save on average£4m and 6 per cent of bed days.

While it appears there will be no targets around C difficile, the pressure to achieve the MRSA target - with its knock-on benefits for C difficileand other HAIs - is greater than ever. It is also clear that it must not be jeopardised by other targets or achieved at the expense of other targets.

And that is the biggest challenge for managers.

'I don't think it's simple,' says Ms Beasley. 'It's a complex business running a healthcare organisation, whether it's a hospital or a community units but it's the job.

'You have to produce the very best safety and quality of care you can at the right price. Many organisations do just that, but all have to recognise that the business we are in is providing better care for patients and doing it in a cost-effective way. In organisations where these two things drift apart, you get difficulties.'

'Nothing terribly exciting' - how St Helens and Knowsley found the answer

The need to address Clostridium difficile was on the horizon, but it was not until she received figures for January last year that St Helens and Knowsley Hospitals trust consultant microbiologist and director of infection control Dr Karen Allen was prompted to take urgent action.

'We were shocked with how bad it was,' she says. 'We were going to do something anyway about C difficile, but seeing figures that put us fourth worst in the [Mersey] region really brought it home to us. We hadn't thought we were that bad.'

By year's end, the trust was not only top in the region but also made the top 20 in England by cutting the incidence of C difficile by 53 per cent.The infection control team launched a series of audits, identifying patients with C difficile, where the high-risk areas were in the trust, whether staff were washing their hands correctly and cleaning standards were up to scratch.

The audits informed both trust action and separate action plans to target resources at high-risk areas. Specific action included infection-control nurses running educational sessions specifically on C difficile, the use of hydrochloride disinfectant for cleaning in high-risk areas and in-house testing of diarrhoea specimens to help quicker diagnosis and isolation of infected patients.

'Nothing terribly exciting I'm afraid,' says Dr Allen. 'It just heightened awareness among the staff, showed where there was a problem that we had to change and gave them the tools to do something about it.'

Within months, C difficile infection rates were falling and, with the odd blip, continued to do so through last year and into this one.

'There is no way we could achieve these results on our own,' she says.

'The whole trust is responsible for infection control. It's a credit for medical staff, nurses, cleaners, pharmacists and managers. It's really the entire trust pulling together.' What makes St Helens and Knowsley unusual is it is also one of only two general hospitals in the 20 best acute trusts for both C difficile and MRSA rates. Since the trust's first MRSA plan in 1987 and first C difficile plan in 1994 both have been regularly updated.

'They overlap really,' says Dr Allen. 'With C difficile you may be targeting slightly different areas, but it all comes down to the basics: hand hygiene, environmental hygiene and staff.

'You can't do it without the staff - there are five of us in infection control and we can wash our hands as much as we like but it won't make any difference if the entire trust doesn't take infection control on board.'