They diagnose a blind pursuit of political and managerial targets as the root cause of a string of hospital scandals that have cost thousands of lives.

The harsh verdict on the state of the NHS, after a spending splurge under Labour between 2000 and 2008, raises worrying questions about the future quality of the health service as budgets are squeezed.

One report, based on the advice of almost 200 top managers and doctors, says hospitals ignored basic hygiene to cram in patients to meet waiting time targets.

It says “several interviewees” cited the Maidstone and Tunbridge Wells [NHS Trust in Kent where 269 deaths during 2005-6 were caused by infection with Clostridium difficile bacteria].

“Managers crowded in patients in order to meet waiting-time targets and, in the process, lost sight of the fundamental hygiene requirements for infection prevention,” the report stated.

There were subsequent failings at health trusts in Basildon in Essex, and Mid Staffordshire. Filthy wards and nurse shortages led to up to 1,200 deaths at Stafford hospital.

Lord Darzi, the former health minister, commissioned the three reports from international consultancies to assess the progress of the NHS as it approached its 60th anniversary in 2008. They have come to light after a freedom of information request.

The first report, by the Massachusetts-based Institute for Healthcare Improvements (IHI), identified the neglect of patients as a serious obstacle to improving the NHS. “The lack of a prominent focus on patients’ interests and needs … represents a significant barrier to shifting the trajectory of quality improvement in the NHS.”

One heading in the report says: “The patient doesn’t seem to be in the picture.” It adds: “We were struck by the virtual absence of mention of patients and families … whether we were discussing aims and ambition for improvement, measurement of progress or any other topic relevant to quality.

“Most targets and standards appear to be defined in professional, organisational and political terms, not in terms of patients’ experience of care.”

This weekend it emerged the recommendations of the reports, intended to help the NHS improve, have not even been circulated.

The stark assessments, collected from leading NHS clinicians and managers, include:

A damaging rift between doctors and managers: “The GP and consultant contracts are de-professionalising, and have had the peculiar effect of simultaneously demoralising and enriching doctors. We’ve lost the volitional work of the doctors and far too many of us are now just working to rule.”

Pointless new structures. “Stop the restructurings. The only thing they generate is redundancy payments.” One body responsible for improving standards reported to five different ministers and had three different names in the space of 30 months.

A culture of fear and slavish compliance. “The risk of consequences to managers is much greater for not meeting expectations from above than for not meeting expectations of patients and families.”

The IHI report, whose interviewees included Lord Crisp, chief executive of the NHS between 2000 and 2006, also described a system of self-assessment where only 4% of trusts are externally inspected.

A similar picture emerges in the second report, by the US-based Joint Commission International. It says the “quality and integrity of [NHS]performance data is suspect”.

Dennis O’Leary, its lead author and an international expert on patient safety and improvement, said it was not intended as an exposé but as a series of useful suggestions for change.

“Our instructions were to pull no punches and tell it like it was, but the report wasn’t overstated,” he said. “It was how we saw things based on interviews with more than 50 people.”

The third report, by the US-based Rand Corporation, expresses surprise at the lack of a requirement to identify the specific drug involved when patient accidents are reported.

In 2008 Darzi issued his own blueprint for the future of the NHS, High Quality Care for All, but resigned from the government last July to return to his surgical commitments.

Last week he said: “The NHS is continuing a journey of improvements, moving from a service that has rightly focused on increasing the quantity of care to one that focuses on improving the quality of care.

However, Brian Jarman, emeritus professor at Imperial College London and an expert in hospital standards, said the findings should have been made available to Robert Francis QC, who led the inquiry into the Mid Staffordshire NHS Foundation Trust.

He said: “These reports have never seen the light of day. We desperately need a better monitoring system for the NHS which actually works.”

From:

In the UK, hospital acquired infections (HAI) such as MRSA and clostridium difficile affect 300,000 patients each year and cause about 5,000 deaths- nearly double the number of people killed in road accidents.

The problem is worse in the US, where HAIs are estimated to be one of the top 10 causes of death, claiming close to 100,000 lives every year.

And the costs are mounting. In the US, government studies estimate that the extra cost of treating a patient with HAI averages almost $9,000 (£5,600).

UK companies are among the leaders in the fight against superbugs but they say that they are encountering problems in getting their products adopted by UK hospitals. They complain that hospital managers lack accountability for deaths relating to HAIs.

In November, a report by the Department of Health criticised the NHS for not achieving “measurable reductions” in HAIs outside of MRSA and C.difficile.

“The heart of the problem is that whatever DoH says or decrees, it doesn’t necessarily impact hospitals,” says Nick Adams, chief executive of Bioquell, the decontamination technology provider. “In the US, a hospital can be sued and that’s a big deal because they’re desperate to keep it out of the press, so they’ll settle. In the UK, hospitals pass the issue very quickly on to the NHS litigation board, so it’s not the hospital’s problem.”

Synergy Health is another company that produces decontamination technology. It has concentrated its sales efforts in Asia and Europe.

One of Synergy’s decontamination products uses a disinfectant technology produced by another company, Byotrol, that has been tested by the NHS in an 11-month study. The Byotrol technology was deployed against a bleach-based product currently used by the NHS.

Despite positive results showing superior effectiveness and lower side effects, the product has not been taken up, even by the Manchester Royal Infirmary where it was tested.

Richard Steeves, Synergy’s chief executive, says that his group is making more sales to countries where hospitals are encouraged to innovate, such as in the Netherlands, where “hospitals are competing for patients”.

Although there is state-funded national insurance for health care in the Netherlands, hospitals compete with each other to provide services for a number of private insurers.

Most UK hospitals are run by the NHS, and Dr Steeves points out that many of the UK’s private hospitals are owned by private equity, and that there is financial pressure to reduce costs.

However, there are those in the sector that say that innovation by UK companies is a direct result of the “laissez faire” environment.

Paul Swinney is chief executive of Tristel, which produces a chlorine dioxide-based disinfectant that treats everything from salads in supermarkets to surgical instruments and surfaces.

Its product is used throughout the UK, which Mr Swinney says is “de facto approval”. Moreover, he says, companies here do not have to pass the expensive regulatory procedure of the US Food and Drugs Administration or the Environmental Protection Agency.

From:
http://www.ft.com/cms/s/0/f989ee86-f405-11de-ac55-00144feab49a.html?nclick_check=1

The Public Accounts Committee said setting targets in England for the two infections had led to a fall in cases.

But they warned there were signs other bugs, such as E. coli, were becoming more common and they called for better surveillance to curb the problem.

In England, MRSA rates are now a quarter of what they were at their peak in 2004, while C. difficile rates have fallen by nearly a third in the past year, following the introduction of targets.
   
THE OTHER THREATS
E. coli
Pneumonia
Surgical site infections
Urinary tract infections
Gastrointestinal infections
Skin infections

But the MPs said these only accounted for about a fifth of the total number of all infections seen in hospital.

While MRSA is the most high-profile bloodstream infection, E. coli is much more common and has actually increased by a third in the past four years, the report said.

It also highlighted surgical site infections, which were twice as common as bloodstream infections, and respiratory and urinary tract infections, which were three times as common.

MPs warned there was still no robust data on the extent and risks of at least 80% of bugs linked to hospital care.

Committee chairman Edward Leigh said this report was the third time the committee had warned about the threat of other infections, adding it was “disappointing” the issue had yet to be addressed.

“The government has taken its eye off the ball regarding all other healthcare associated infections – which actually constitute most by far of all infections.”

The report suggested hospitals start reporting all types of infection and that they look to curb the use of antibiotics.

Professor Mark Enright, an infections expert at Imperial College London, said: “I can understand why the government focused on the infections it has, but now we are getting to grips with those it is time to look elsewhere.

“There are some strains of infections, such as E. coli, where we are seeing increasing levels of antibiotic resistance and that is concerning.”

Nigel Edwards, of the NHS Confederation, which represents trusts, agreed it was time to review other infections.

But he added: “We would want to know the balance of costs and benefits from additional surveillance.”

Katherine Murphy, director of the Patients Association, said: “This target culture is just like squeezing a balloon – if you squeeze one end it will bulge out at the other.

“But the problem for patients is that the balloon stays the same size. The problem of patient safety will stay the same huge size as long as it is regarded as an optional extra by some.”

From:
http://news.bbc.co.uk/1/hi/health/8351269.stm

All of those affected had been in the hospital’s ward 31, which generally cares for geriatric patients.

Seven of the patients had contracted the more dangerous 027 strain.

NHS Tayside said it carried out regular testing in order to detect C. diff outbreaks early.

Dr Gabby Phillips, lead infection control doctor for Ninewells Hospital, said the ward remained closed to new admissions.

The hospital has been dealing with the outbreak since September, over a 10 week period.

The deaths occurred between 19 October and 6 November.

‘Appropriate measures’

Dr Phillips added: “We have comprehensive infection monitoring procedures throughout our hospitals and these are able to rapidly identify any emerging trends of infection which then trigger a rapid response from our infection control teams.

“These cases of C. diff infection were detected very early which meant we were then able to identify the 027 strain rapidly and reinforce all appropriate infection control measures.

She added that the hospital had sought external advice over its policies and procedures, and had been “reassured that our surveillance systems are robust”.

The MRSA Working Group, together with National Concern for Healthcare Infection and the Patients Association, is calling for the early discharge of patients from hospital to try and prevent a rise in the killer superbug.

They said when hospital bed occupancy rates were high, MRSA infection rates increased.

The group has written to all NHS hospital staff, reminding them to review their policy for the early discharge of MRSA patients.

The also urge hospitals not to let increasing pressure on staff and rising bed occupancy rates during winter to reverse the good work they have done to date to reduce MRSA rates.

Department of Health research has shown that when a hospital’s bed occupancy rate exceeds 90%, MRSA rates can be as much as 40% above average.

Dr Matthew Dryden, consultant microbiologist at the Royal Hampshire County Hospital and General Secretary of the British Society of Antimicrobial Chemotherapy, said: ”The NHS has been working really hard to plan for swine flu and ensure there will be enough hospital beds available for patients who need to be admitted.

”What we don’t want to see is an increase in infections such as MRSA, which have been linked to high bed occupancy rates.

”A way to get around this is to support patients with infections to get out of hospital earlier with outpatient and home care and good antibiotic stewardship.”

The letter to hospitals outlines methods to help ensure sufficient critical care beds are available this winter through identifying MRSA patients and discharging them early. Studies have shown that providing IV treatment at home or switching eligible patients to oral antibiotics could free-up scarce hospital beds by enabling patients who are well enough to go home earlier.

”When faced with a difficult winter, it is vital that hospitals ensure sufficient beds are available,” said Dr Dryden.

”Treating patients with infections such as MRSA at home can help by reducing their length of stay in hospital, freeing up much-needed beds and easing pressure on staff and resources.

”It also helps to improve a patient’s quality of life.”

Katherine Murphy of The Patients Association, who co-signed the letter, said: ”There is a real risk that swine flu patients may block isolation beds resulting in patients with healthcare infections such as MRSA being treated on general wards.

”This coupled with a highly pressured and reduced workforce, could increase the risk of infections such as MRSA spreading to other vulnerable patients and throughout the hospital.”

Neil Manser, of the NCHI, added: ”Where possible and when it is clinically prudent, patients who have been infected or colonised with infections such as MRSA should be treated in the safety and comfort of their own homes.

”Only then can we be sure we are doing our best to effectively contain the spread of infectious diseases such as MRSA and prevent further infection of hospital patients during any winter bed crisis period.”

The Care Quality Commission found nearly a fifth of homes were not being told if patients discharged from hospitals are or had been infected.

Even when they were told, the data was sometimes incomplete or illegible, the survey of more than 1,000 homes showed.

Latest figures show that MRSA levels in hospitals – they are not measured in care homes – have fallen in the past year.

C difficile figures have also been falling. But the CQC report said the progress being made could be compromised by communication problems.

Hospitals are meant to include infection history on discharge summaries.

However, the survey revealed 17% of care homes said they did not receive information from hospitals, while another 28% complained of incomplete and ineligible data.

The regulator also highlighted poor practice by care homes – a quarter were not following guidelines covering issues such as isolating residents with infections and antibiotic management.

It said care homes had until next year to follow the guidelines or face being refused registration.

CQC chief executive Cynthia Bower said: “Infection prevention and control is not simply an issue for hospitals – care needs to be clean and safe wherever it is provided.

“If we are to tackle infections effectively we need to check that all providers of care are talking to each other.”

Health minister Mike O’Brien said while there had been good progress on infections, he agreed closer working was needed.

“People have the right to the same standards of clean, safe care whether in health or social care.”

A separate CQC report also criticised the way patient information was being used.

The regulator said it had concerns about privacy – a third of staff said they had not been given training on confidentiality – while delays in hospitals sending GPs information after discharge were also noted.