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Clostridium Difficile

Volume 455: debated on Tuesday 16 January 2007

Motion made, and Question proposed, That this House do now adjourn.—[Huw Irranca-Davies.]

It is a pleasure to have secured, for the first time, a debate on clostridium difficile. The subject is important, and merits not merely a short Adjournment debate but a longer debate, perhaps in Government time. Clostridium difficile infection is recognised by the Health Protection Agency as the most important cause of hospital-acquired diarrhoea. The purpose of this debate is to challenge the Government on whether C. difficile—as I shall refer to it from now on—is given the importance that it deserves in action as well as words.

The debate is timely, given that last week a Department of Health memorandum warned that C. difficile was now

“endemic throughout the health service, with virtually all trusts reporting cases”.

The official statistics paint only a partial picture. In 2005 there were 51,690 reports of C. difficile among people aged 65 and over; in 2004 an estimated 1,300 deaths were attributed to it. There are clearly at least seven times more cases of C. difficile than of MRSA—methicillin-resistant Staphylococcus aureus—and at least four times more deaths from C. difficile than from MRSA. But is C. difficile receiving the attention that it deserves? Many would describe it as the Cinderella of hospital-acquired infections, but it deserves to be at the centre of everyone’s attention, given its prevalence and the risks of fatality.

The purpose of the debate is also to highlight the tireless efforts of my constituent Graziella Kontkowski, who, with her brother Mark—both are here in the House tonight—set up a website and forum, There are literally thousands of hits per day from the many people who wish to receive support and advice, and to give their stories. That highlights the profound concern about C. difficile throughout the country.

My constituent was motivated by her and her family’s experience with her grandmother, who sadly and tragically died on 26 September 2005 as a result of contracting C. difficile at North Middlesex hospital. Graziella tells me that half the ward became infected with the deadly bacteria, all due to lack of hygiene. Measures were not taken to prevent the spread of the bug, and patients and their relatives were not given information about the severity of C. difficile. Graziella’s efforts to get to the truth and to secure improvements at North Middlesex university hospital and the other local hospital, Chase Farm, spurred her to set up the website and to help others in a similar situation to that of her family.

C. difficile is an appalling infection, attacking particularly the elderly on prescribed antibiotics. The symptoms of severe diarrhoea, stomach cramps and fever, often followed by dehydration, take their toll on the vulnerable. Loss of pride and self-esteem is great, and extremely sad for relatives as they watch the deterioration happen before their eyes. That is particularly aggravated by the lack of information about what is happening. That is why the C. difficile support group was set up, and that is also why the Government must take urgent action.

Many sad cases could be recounted, such as those of elderly patients who have fought successfully for years against cancer only suddenly to be struck down by C. difficile, and to die in a matter of weeks. Such tragic circumstances were highlighted in the outbreaks of C. difficile at Stoke Mandeville hospital that ended in 2005 and that led to at least 33 deaths. A Healthcare Commission report challenged the Government approach, not just to isolated incidents of infection control, but to the whole policy on health care.

The report stated:

“The achievement of the Government’s targets was seen as more important than the management of the clinical risk inherent in the outbreaks of C. difficile.”

Have the lessons from that report been learned? Let me give another quote that highlights the lessons that need to be learned nationwide by all trusts:

“operational problems arose out of the need to juggle a number of ‘must do’ objectives, including the control of finance, the reconfiguration of services, and meeting targets for waiting times.”

The juggling of those targets and reconfigurations is a reality across the country. In the Enfield area, Chase Farm hospital is facing the prospect of cuts to its accident and emergency services and doctor-led maternity services, and North Middlesex university hospital is debt-ridden. The risk is that as they juggle their priorities, they will drop the ball of infection control, particularly in respect of the care of the most vulnerable—the elderly. That is the Government’s responsibility. As Graziella has said:

“The government has set hospital trusts targets, in the process of trying to achieve these targets patient care has been compromised and standards have dropped drastically now making hospitals a dangerous place to be in. People are no longer afraid of going in to have treatment but what infections they might catch. Does the Minister not feel that is unacceptable”?

The key question is: have lessons been learned? However, perhaps that could be prefaced by another question: do the Government know the extent of the problem, so that they can tackle properly the C. difficile problem? There is evidence of under-reporting; there is mandatory surveillance only of over-65s, so there is no obligation to report on under-65s.

Let me refer the Minister to three examples on the C. difficile support website this week. There is an example of poor hygiene not from someone older than 65, but from a 23-year-old young man. He said that he suffered from ill health; he had suffered from Crohn’s disease. He entered hospital and thought he

“was in a clean environment … I was suffering intense diarrhoea and reported it to the doctors and nurses that were looking after me. They told me it was nothing to worry about. A day or so later, when going to the toilet, I noticed excrement on the floor leading up to the toilets themselves. When I went into the toilet, there was…fecal matter all round the bowl and over the floor. I said to the staff about this, but it wasn’t cleared up for a good few hours after I reported it. The following day I was feeling a lot worse. Nausea and severe stomach cramps along with dizzy spells made me realise that there was something seriously wrong.

I tried telling the doctors about my concerns, but I felt as though they just guffawed at it …The diarrhoea and vomiting had severely disrupted the electrolytes…in my blood, putting my heart under intense strain. My heart stopped and I had to be resuscitated.

The doctors concluded that this was all due to an infection with a highly virulent strain of C.Diff.

The ward I was on was closed as another 13 patients were affected by the bug”.

That is just one example among many of poor hygiene.

I turn to an example of a lack of infection control, given by a 20-year old:

“I was diagnosed with C.diff following a course of antibiotics that I took for an infected scar after a laparoscopy operation. I had a really dodgy tummy, then was admitted to hospital with life-threatening temperature, low blood pressure and high pulse. 24 hours later I was diagnosed with C.diff … They got my temperature back up, and sent me home. Waiting at home for me was my Mum—she had just finished chemotherapy and was still susceptible to illness—so should they have sent me home? They kept me on a general ward”—

not an isolated unit, a general ward—

“whilst in hospital, and made no effort to stop the infection spreading to other patients.”

Here is an example of a lack of accurate information, which was posted on the website as recently as 10 January:

“Brought my dad home from hospital yesterday … Just looking through the copy of the discharge notes sent to the GP:

‘Mr. X has been well throughout his stay’.

I can’t believe there is no mention of catching C.diff, treatment given etc. The GP now has no idea that my dad has this bacterium.”

There are reports of patients being discharged from hospital before they are fit and ready to go home. This debate was also prompted by my experience over Christmas when visiting various residential homes. Sadly, I saw time and again residents who had recently been discharged from hospital who were malnourished and dehydrated; indeed, some were infected by the bug. Does the Minister therefore agree that all health care professionals, including those working in long-term care facilities, need to be made aware of the emergence of a stronger strain of C. difficile? Why are basic hygiene and the soap and water scrubbing that are so essential in tackling C. difficile not commonplace in hospitals?

Dr. Stephen Fowlie, medical director of Nottingham University Hospitals NHS Trust, said the following of the recent outbreak at Nottingham City hospital:

“Staff have to go back to the rather old-fashioned method of soap and water and that is a rather difficult message to get through”.

Why is this basic element of hygiene such a difficult message to get through?

Have the Government taken heed of the recent outbreak at Nottingham’s Queen’s Medical Centre and joined in the good practice of setting up isolation wards away from short-stay surgical wards? Why, contrary to advice from the chief medical officer, is there inadequate control over the prescribing of high-risk broad-spectrum antibiotics to over-65s? Why do we not in this instance—perhaps uniquely—learn a lesson from Europe and industrially launder nurses’ uniforms, instead of continuing with our unique British practice of laundering uniforms at home?

Will the Government, who are so intent on a target culture—national targets, combined targets and now local targets—agree with the memo from their own Department, which said that this is basically a cop-out? Will the Minister condemn trusts that, according to the memo, simply see C. difficile as an unavoidable fact of hospital life? What will be done to tackle the lack of information for patients and relatives once patients are infected? What precautions are communicated to discharged patients when they go home, in order to stop C. difficile spreading in the community, as it can do? It is not just a hospital problem—it is out there in the community. Will the Minister therefore agree that C. difficile is indeed endemic and needs to be tackled as an urgent priority, rather than by simply trying to handle targets better?

I congratulate the hon. Member for Enfield, Southgate (Mr. Burrowes) on securing the debate. He began by saying that this is an important subject, and he is absolutely right. I also pay tribute to the constituents he mentioned for the work that they have done in setting up the website. It is important that people have sources of information to which they can turn to find out more. I pay tribute to his constituents for using their personal tragedy to help others who may be affected by the condition.

I also welcome the opportunity to put on the public record some information about Clostridium difficile that will help to aid our understanding of it. While I appreciate much of what the hon. Gentleman said and I do not wish to inject a note of party political knockabout into the debate, it is important to understand that the vast majority of health service staff take these issues extremely seriously. They work to provide high standards of hygiene and a high quality of health care. They take concerns about C. difficile very seriously. That said, there is always more that can be done and I hope that in the course of this debate we can allude to some of those things and address this problem of concern to us all.

Clostridium difficile infection is a hazardous complication of modern medical care. It usually affects vulnerable patients, particularly elderly patients with underlying illness for which they have been treated with antibiotics. Antibiotics are often life-saving, but a side effect of antibiotic treatment on the intestine can be to allow the C. difficile organism to grow and produce toxins that cause diarrhoea, which can be very severe.

This is not a new disease. It was identified as a complication of antibiotic treatment in the late 1970s. A major outbreak in Manchester in 1991-92 caused questions to be raised in this House and publication in 1994 of national guidance that is still appropriate.

We were the first country to introduce national surveillance. That was initially through the voluntary reporting system of the Public Health Laboratory Service, now the Health Protection Agency. That showed increasing numbers of cases during the 1990s and led the Department of Health steering group on health care-associated infections to recommend the introduction of mandatory surveillance. That was implemented in 2004 and all trusts in England are required to report their cases to the HPA. The surveillance is based on the most vulnerable group of patients, those over 65—who account for about three quarters of all cases.

From the following year, as part of this surveillance, all microbiology laboratories were asked to send isolates of the C. difficile bacteria via the HPA regional laboratories to the anaerobe reference laboratory in Cardiff for typing to identify the changing patterns of types circulating in England.

Clostridium difficile infection became prominent in the press and media, and of public and political concern, with several severe outbreaks in 2005 caused by a new type of C. difficile—type 027. The most prominent outbreak, as the hon. Gentleman mentioned, was at Stoke Mandeville hospital, and my right hon. Friend the Secretary of State for Health immediately asked the Healthcare Commission to investigate. Its report was published in July 2006 and made a number of recommendations, all of which were accepted by the Government and are being implemented in the NHS with support from the Department of Health.

The hon. Gentleman raised questions about the Stoke Mandeville case and, indeed, the report made appalling reading. There can be no justification for some of the responses to the outbreak in that hospital, but that is not common across the system and I am confident that measures have been put in place since then to aid our understanding further and to reinforce the message that the safety of patients comes before anything else in the hospital environment. I am happy to place that message again on the record this evening for the avoidance of any doubt.

I am grateful to the Minister for that assurance. In the executive summary on the national picture and lessons for other trusts, particular reference was made to the rapid isolation of patients with diarrhoea. That was not confined to those over 65, but was for patients in general. The experience reflected to the website and to me—and, I expect, to other hon. Members—is that that practice is not being followed by every trust or hospital. That provokes profound concern that lessons have not been learned.

Another recommendation concerned communication with patients, staff and outside agencies. There is a concern whether there is proper communication between the health service and long-term care facilities, and with patients and relatives on discharge. I would be grateful for the Minister’s comments on those points.

The hon. Gentleman will be aware that the Health Act 2006 introduced a new code of practice for cleanliness and hygiene. It requires acute trusts and PCTs to share information on infections when patients are transferred between health care settings. That should be the basic good practice to be followed by all the bodies involved, and he is right to raise the matter in this debate.

The hon. Gentleman also asked about isolation facilities. Obviously, hospital trusts have to manage on their existing resources, but the Government have made capital available to the NHS in this financial year for the purpose of making modest improvements to the ward environment. Those improvements may include the provision of extra isolation facilities, where they are deemed necessary for the control of infection.

Relatives of patients tell me that they are often not given adequate information, even though they are on the front line when it comes to providing care. In addition, as I mentioned earlier, patients’ records often contain no reference to C. difficile.

The hon. Gentleman raises an important point. It should be standard clinical practice to pass such information on to anyone who may find it useful and be able to act on it. I and my colleagues in the Department will reflect on what he says, but I repeat that passing on information should be simple good practice, and that getting people to follow what is no more than common sense should not require a departmental diktat.

My hon. Friend the Minister will recall that I said at Health questions last week that the Loughborough Echo was running a campaign on this very issue. The campaign has also touched on the reporting of C. difficile on the death certificate when it has contributed to a person’s death. Does the Department consider that such information should be included in death certificates? That does not happen in Leicestershire, although I know that it does elsewhere in the country. I am aware that he may not be able to answer this evening, but I should appreciate it if he would write to me. Inclusion of C. difficile as a contributory factor on a death certificate would not resolve the problem, but it would raise the infection’s profile and provide some closure for families who are affected.

My hon. Friend raises an important point. I pay tribute to him for the work that he is doing on this matter, which I know that he raised in the House last week. Where C. difficile is known to have contributed to a person’s death, that is indeed recorded, as it helps us to understand the extent of the problem caused by the infection. Over time, we can produce a pattern that will help us to understand the effects of the disease.

The House may be interested in some figures regarding cases of C. difficile. As I said, mandatory reporting was introduced in 2004. In 2005, 51,690 cases were reported, an increase of 17.2 per cent. on the previous year. In many ways, the problem has been exposed by the mandatory reporting system that we have put in place. The Department has responded quickly to those figures and taken a series of measures that will help in bearing down on the problem. Moreover, although I accept that the hon. Member for Enfield, Southgate may be able to give examples of failings in respect of C. difficile, in the vast majority of cases, the quality of care provided by staff, and the importance that they place on the matter, cannot be faulted.

I shall outline some of the actions the Government have taken. In response to the outbreak in 2005, a professional letter from the chief medical officer and the chief nursing officer was issued in December 2005 to all NHS trusts and foundation trusts in England. It reminded trusts of the surveillance requirements and of the key actions required for prevention and control of the C. difficile infection, and referred them to the existing 1994 guidance. The Department of Health has asked the Health Protection Agency to convene an expert group to review and update the guidance, and its draft recommendations are expected by April 2007. I hope that it will be some comfort to the hon. Member for Enfield, Southgate to learn that action is in hand to keep on top of the issue. Preliminary indications are that the basic elements of the existing guidance are sound.

To strengthen clinical practice in C. difficile control, in May 2006 a seventh high impact intervention aimed specifically at C. difficile infection was added to the saving lives toolkit that had been launched in June 2005. That has been widely promoted throughout the NHS.

Following the Healthcare Commission report and the publication of the surveillance data showing more than 50,000 cases reported from trusts in England in 2005, a further professional letter was issued in 2006 by the chief medical officer, the chief nursing officer, the chief pharmacist officer and the chief executive of the NHS, amplifying the policies and clinical practices that need to be implemented to control C. difficile. They included the following: first, the need for an antibiotic prescribing policy to control the use of broad spectrum antibiotics to prevent their overuse and to limit the length of time for which intravenous antibiotics are prescribed; secondly, ensuring that all trusts have prompt access to laboratory diagnosis of C. difficile infection seven days a week, so that tests can be done within 18 hours of the onset of symptoms or the admission of a symptomatic patient; thirdly, ensuring prompt isolation, segregation or cohort nursing of all patients diagnosed with the infection; and, fourthly, enhancing infection control procedures, with rigorous hand washing after each contact with a patient with a C. difficile infection. I think that picks up the point made by the hon. Member for Enfield, Southgate, but it cannot be emphasised too much that those basic procedures must be followed. Finally, there will be enhanced environmental cleaning and decontamination to remove the C. difficile spores that survive for a prolonged time in the environment after being shed by patients with diarrhoea.

At the same time, trusts were told that the NHS operating framework for 2007-08 and the NHS contract would set out the requirements for primary care trusts to agree a local target with their acute hospital providers for a significant reduction in C. difficile infections. The scale of the target would be determined by the level of C. difficile infection currently in the trust. I urge my hon. Friend the Member for Loughborough (Mr. Reed) to talk to his PCT and his main acute trust to find out exactly how ambitiously they are setting that target. I welcome the intervention of his local newspaper in raising awareness of the issue; it should be locally driven, with locally set targets to bear down on the problems that he is experiencing in his area.

Guidance is also embodied in the code of practice on hygiene and health care associated infection, which came into force under the Health Act 2006 in October last year. The code requires all NHS bodies to implement appropriate policies for prevention and control of the infection. Compliance with the code will be assessed by the Healthcare Commission as part of the annual health check, and I want to stress the fact that the commission will issue improvement notices under the Act when it finds trusts that are not complying with its requirements. We are encouraging the commission to consider that further measure when there is evidence of failure to comply with basic standards.

To help trusts make the necessary physical improvements to the patient environment to help to prevent and control infection, the December 2006 professional letter announced the launch of a £50 million challenge fund to which all trusts could apply for capital funding to make the relatively small- scale improvements to their physical environment that will enhance their ability to control C. difficile and other health care-associated infections. I can update the House. There has been an encouraging response to the invitation to apply to that fund; a number of applications have been received and I believe that that will result in targeted, localised improvements in NHS trusts up and down the country to help trusts get a grip on the issues.

To conclude, C. difficile infection is a serious problem in the NHS because of our success in treating a range of serious illnesses and in increasing the life expectancy of the population. That creates a greater number of patients more vulnerable to the infection. Nevertheless, the infection is also a result of insufficient attention to proper preventive measures. It requires rigorous implementation of hygiene and infection control measures and vigilance in the application of prudent antibiotic policies. All of that is included in the Government strategy for the control of health care-associated infections and will be enforced through the code of practice.

I believe that we know what measures will, taken together, make a difference in this area. What we want to see is the issue gripped from the top of health care organisations to ensure that the necessary measures are implemented and that problems are kept under close scrutiny. More regular reporting of C. difficile data is required, so that we can keep a closer track of problems that trusts may be experiencing. Local Members should discuss these matters with their local trusts in their local areas, as that sort of combined approach will help us all to get a grip on the problem in every locality.

I congratulate the hon. Gentleman again on securing this debate. I hope that it will contribute to improving public awareness of what he is right to identify as a very important topic.

Question put and agreed to.

Adjourned accordingly at twenty-nine minutes to Eleven o’clock.