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Clostridium Difficile

Volume 518: debated on Tuesday 9 November 2010

Motion made, and Question proposed, That this House do now adjourn.—(Mr Goodwill.)

It was in January 2007 that I last secured a debate on clostridium difficile, or C. diff as it is commonly known. It was the first time that the House had debated the subject, and I recall how at the time Mr Speaker’s office questioned what C. diff was. Indeed, many hon. Members had never heard of it. Since that time, however, sadly the impact of this cruel and often unremitting infection has demanded the public’s and, indeed, the Government’s attention. All hon. Members will probably know of someone in their constituency or family who has suffered from C. diff. Indeed, in that regard I welcome the attendance of Mr Deputy Speaker, who has a deep and personal interest in the issue, following the loss of his mother as a result of C. diff.

I gladly acknowledge that there has been much progress in the three or so years since I last raised this subject. However, C. diff still leaves thousands of people each year suffering great discomfort, loss of dignity and, sadly, loss of life. The media spotlight comes on to the subject when there is an inquiry into a hospital trust and then moves on but, away from its glare, the terrible and often tragic effects of this infection have not gone away.

I know that the Minister will provide me with an answer, which is the primary purpose of this debate—namely, an assurance that the Government take C. diff very seriously and are working hard not only to reduce it but to eradicate it. Much has changed since 2007, not least with the Government’s plans to revolutionise the national health service and empower patients and general practitioners. I hope that this debate will help to identify the challenges and opportunities to tackle C. diff, not only in the hospital setting but in the community.

Some things, or rather someone, have not changed since the previous Adjournment debate in 2007. I refer to the active involvement and national leadership on the issue of C. diff of my constituent Graziella Kontkowski, who has attended the debate this evening, as she did back in January 2007. Tragically, Graziella’s grandmother died as a result of the C. diff infection. Graziella describes being

“helpless, watching my grandmother die a slow and painful death without being able to do anything to help her—it was the worst thing I've ever experienced.”

Since then, she has used her experience and remarkable passion and energy to ensure that other families are able to face and fight C. diff and its terrible effects. Alongside her brother Mark, Graziella set up the online C. diff support group, which can be found at, to make it possible for people who have been infected by C. diff, or whose loved ones have suffered from its effects, to share their experiences and advice with one another. The C. diff support group has about 1,500 members and continues to make a valuable contribution to the public debate on C. diff and to the lives of many who are struggling in similar circumstances to those that Graziella and her family went through.

Graziella also helps to support the work of the Centre for Healthcare Associated Infections, which is based at the university of Nottingham. With the danger of bacteria mutating to become more resistant to antibiotics, its efforts towards the development of new vaccines and rapid diagnostic tests for the detection of the infection are to be commended. Its research can truly be described as life saving, and I encourage members of this House, and members of the public, to consider supporting its work.

I congratulate my hon. Friend on the work that he has done on this very difficult subject. I would like him and his constituent to know that there is a device in America called Zimek, which I have observed. It is the most fantastic system that disperses disinfectant and has eradicated C. difficile in hospital wards. It is undergoing clinical tests in Northwick Park hospital, which is just next to my constituency and where many of my constituents are being treated. I urge the Minister to take note of this. I would be delighted to send him details showing the fantastic effects that the device has had in America, very cheaply and in a way that I believe could save millions of lives in this country.

I am grateful to my hon. Friend. He makes the case for that proposal very well. Indeed, there are several innovative developments, not only in the hospital setting but in trying to look at prevention. Prebiotics is another area that is worth considering. I ask the Minister to look at supporting the centre I mentioned and at how we can support research in this field.

A C. diff infection exacts a great cost from the patient who suffers from it and the family who witness it. It is also financially expensive. In 2008, the Department of Health released a report called “Clean, safe care: reducing infections and saving lives”, which noted that treating one patient with a C. diff infection cost the NHS more than £4,000 per patient. By this estimation, and considering the number of infections reported last year, C. diff cost taxpayers close to £1 billion in the past 12 months.

It is true that C. diff has received a far more coherent and concerted response from the NHS in the past three years than it had previously. It is equally clear that this focus has had a positive effect on the quality of care and on survival rates in our hospitals. Last year the infection was noted on fewer than 4,000 death certificates and was considered to be responsible for deaths in 1,712 cases. That is less than half the rate in 2007, when more people died as a result of C. diff than as a result of road accidents. However, as the Secretary of State for Health has said:

“There is no tolerable level of preventable infections.”

I am grateful to his Department for making it clear that a zero-tolerance approach to health care-associated infections is a priority for the Government. During the week beginning 26 September, 190 new cases of infection were reported by hospitals in England and Wales—an average of 27 cases a day, or more than one every hour. There is no room at all for complacency.

One problem of which we need to be aware is the number of incidents of recurring C. diff symptoms in patients. I am greatly concerned that hospitals are releasing those who have suffered with the symptoms of the infection too early, which leads to many having to return to hospital with the same problem. I am glad that the Department has recently made it clear that hospitals are responsible for the care of a patient for up to 30 days after they have been discharged.

I am glad that the Minister fully shares my concern. It is good to know that hospitals cannot expect any additional payment for treating those who have suffered a recurrence during those 30 days. However, I ask him whether there could be any sanctions on trusts that sadly fail to reduce the rate of infection.

Along with the Department of Health, my constituent Graziella has produced a leaflet, which my hon. Friend the Minister helpfully distributed just before the debate. It is called “C. difficile—now you are going home”, and it sets out the best ways for patients to protect against the infection spreading. It is intended to be given to patients so that they can be aware of the risks and know how to prevent other vulnerable people from catching the infection. However, although both Graziella and I would like to see this leaflet distributed by every hospital and GP, there is no requirement that that happen. Many patients return home without the information in that fantastic leaflet about how best to protect themselves and others. Will the Minister consider requiring—or, in the more localising language that Conservative Members prefer, incentivising—hospitals to provide the leaflet or similar information to all patients leaving their charge who have had the infection?

Although improvements have been made in acute trust hospitals such as my local North Middlesex university hospital, it is important that we do not lose sight of the need to pay attention to what is happening in our primary care trusts. In fact, in every month of last year, PCTs reported far more cases of C. diff than acute trusts. Enfield PCT, which is by no means extraordinary in this regard, reported 144 cases in patients aged over two in just the past year.

To pick up on my hon. Friend’s point about Enfield, as he knows, at our local hospital, Chase Farm, there has been an extraordinary improvement in recent months, particularly since August. That is essentially down to a massive concentration of effort on this one problem, and there, in part, lies the solution.

I am grateful to my hon. Friend, and I support the work that has happened. It has very much been prompted by Graziella, who has been going from ward to ward to ensure that what people say is being done is, in fact, reflected in their actions.

We also need to get to grips with the problem of C. diff in the community. In the past, there has been too little interest in what happens to a patient once they leave the hospital walls, and too little attention to the problem of infection being spread between hospital and home, or worse, between hospital and care home. Sadly, many of my hon. Friends will have witnessed that situation. That two-way corridor of infection must be addressed, as must the associated lack of care that care home residents can sometimes receive, as they are sadly away from the public eye.

Given the clear danger of allowing infections to spread within an enclosed community of elderly and vulnerable people, I would be interested to know what the Department is doing to monitor cases within the care home setting, and specifically to monitor whether cases are being reported consistently and dealt with promptly and according to the most recent hygiene code.

As we move boldly to a health care system that puts the patient and their recovery at the heart of every decision, it is essential that health care-associated infections such as C. diff are on GPs’ radars, especially as they take on responsibility for commissioning in their area. There needs to be an assumption in favour of testing for the infection when patients are suffering from diarrhoea. GPs must also be properly aware of the need to check up on patients, and avoid prescribing them certain drugs that are known to increase the risk of infection and the likelihood of patients suffering from severe symptoms. The C. diff support group has identified a number of worrying cases of GPs prescribing antibiotics. I also ask colleagues to look on its website and check out Imodium, which is known negatively to affect patients suffering from C. diff.

In December 2008, the Department of Health’s report on C. diff strongly recommended that

“all cases of diarrhoea among people in the community aged two years and above should be investigated for C. diff unless there are good clinical reasons not to.”

Such good practice needs to be extended to all GPs. Does the Minister know what more the Government can do to ensure that GPs are fully briefed on C. diff and that they are responding to this knowledge efficiently and consistently?

Perhaps the Minister would consider enabling the NHS computer systems in both hospitals and GP surgeries to tag an alert to Imodium and other drugs that are known to increase the risk of C. diff in vulnerable patients. Doctors intending to prescribe such drugs would be reminded to consider whether the patient might have the infection before doing so.

As for the careful monitoring of patients in the community, I would be interested to know what, if any, guidelines GPs follow with regard to the treatment of patients with C. diff. Perhaps the Department would be willing to provide such advice to doctors. Doctors could perform a simple blood test on elderly patients in the community to provide an early warning against the possibility of renal failure.

I very much welcome the Health Secretary’s attendance today and his commitment to comprehensive, trustworthy and easy-to-understand information on how to look after patients’ health. The data on C. diff infection rates already exist and can be found online, but they are often inaccessible in their format. They can be sketchy and incomplete at best.

Yesterday, NHS Choices listed 12 hospitals within five miles of one of the postcode areas in my constituency. Of those 12 hospitals, data on the prevalence of C. diff cases within the last 12 weeks were available for only two of those hospitals—North Middlesex University hospital and St Ann’s hospital. On the same day, the Department published business plans with a focus on transparency. To ensure that we see even more marked improvements in the next three years, will the Minister tell us what he intends to do to ensure that “easy to understand” information is available, especially on those websites that patients are most likely to use and at those locations that they are most likely to frequent?

Finally, I look forward to the time when the Minister can declare to the House that preventable healthcare-associated infections such as C. diff can be eradicated. However, I am conscious, as the Minister will be, of George Bush’s regret when he prematurely declared “mission accomplished” and there is much to be done before we can get near to such a declaration. I hope that this debate, which supports the great work of campaigners such as my constituent Graziella Kontkowski, can move us closer to a time when we have no need to raise this important issue in the House again.

I congratulate my hon. Friend the Member for Enfield, Southgate (Mr Burrowes) on securing this debate on C. difficile. He has shown a strong interest in this issue for a very long period. Let me make it clear that the NHS should aim for a zero-tolerance approach to all health care-associated infections. I hope that what I say in my speech tonight will reassure my hon. Friend that we as a Government regard C. difficile as a priority and we will use all the levers at our disposal to support further significant progress in reducing this problem in our hospitals, care homes and other health facilities.

For most of the last decade, we saw unchecked increases in the number of MRSA and C. difficile infections, causing misery for thousands of patients and their families. However, in more recent years, the NHS has improved its infection prevention and control practices, which has led to a significant reduction in both C. difficile and MRSA bloodstream infections. I should like to take this opportunity to congratulate all NHS staff who were involved in turning the tide for their hard work in achieving that. From a high of around 56,000 infections in 2006, C. difficile infection has fallen to just over 25,000 in 2009-10. From almost 8,000 infections in 2004, numbers of MRSA have also fallen substantially to fewer than 2,000 in 2009-10. However, despite the progress that we have made, we can go further.

I would be grateful if my hon. Friend allowed me not to, because I have very little time in which to say a lot in answer to the questions from my hon. Friend the Member for Enfield, Southgate.

Despite the progress made, we can go a lot further to reduce infections, particularly of C. difficile. The previous Government’s approach was to introduce a rather crude national target for reducing infection rates that placed no specific obligation on individual organisations to improve their prevention and control systems or to reduce their own infection rates. We therefore find ourselves in a situation where, despite significant reductions at a national level, many organisations have made little or no improvement on their position years ago. The job of controlling C. difficile infections in the NHS is far from complete, and the NHS, in both secondary and primary care, must continue to prioritise reducing these infections. We will expose those poor-performing organisations that were able to ride on the coat tails of others, and force them to put their house in order.

My hon. Friend asked about monitoring care homes. I can assure him that, as part of our commitment to a whole-health economy approach to infection prevention and control, last month the adult social care sector became subject to the code of practice on the prevention and control of infections. Adherence to the code is a statutory requirement, and we expect to see improvements in infection prevention and control practice in the social care sector as a result of its introduction, in the same way as has happened in hospital settings. In addition, we have strengthened Care Quality Commission powers to ensure that, where required, appropriate action can be taken to address poor practice. Care homes should report single cases of suspected C. difficile to the resident’s general practitioner, and a suspected outbreak should be reported to the local health protection unit. I am confident that this additional strengthening of the measures will go some way to help reduce the problem in care homes.

The Government expect the NHS and social care organisations to take a zero tolerance approach to health care-associated infections, as I said at the beginning of my remarks. When patients have the relevant information, they can be the most powerful agents for change. In line with this, one of the first things we did was to publish weekly MRSA and C. difficile infection numbers by hospital, and the data are now available within weeks rather than months, giving a far more accurate picture of what is happening at a particular hospital. Patients can now clearly see and take account of this when choosing where to have their treatment.

My hon. Friend asked about making more information available. I can reassure him that one of the key parts of the White Paper on health reform in the NHS is on empowering patients by providing even more information relevant to them from independent sources. That means it will be reliable and accurate. It will also be provided in a way that is easily understandable, so that patients can see the areas of health care—in whatever shape or form—that are of particular interest to them. I would encourage anyone to respond to the consultation on the information revolution document that my right hon. Friend the Secretary of State published recently, so that we can consider all views on how to get this right and empower patients with information.

We also made it clear in the coalition agreement that we will use quality outcome measures, including HCAIs, to drive improvements in the areas that really matter to patients. In the near future, I want all organisations to be operating at the level of the best today. The challenge, therefore, will be greatest for those who have so far made the least progress. We have also decided to extend mandatory surveillance beyond MRSA and C. difficile, to provide a fuller picture of HCAIs within the NHS, which the previous Government resisted. As my right hon. Friend the Secretary of State announced last month, we will extend mandatory surveillance to include MSSA—meticillin-sensitive staphylococcus aureus—with infections such as E. coli to follow in due course, based on expert advice.

I know that my hon. Friend the Member for Enfield, Southgate has a strong interest in the different settings where C. difficile infections occur. For some years, such infections were essentially seen as a hospital problem, with hospitals being the focus for both central and local efforts to tackle them. However, that focus is not sufficient, as he mentioned. An unfortunate outcome of the previous focus on hospital-acquired C. difficile infections is a lack of awareness of the risks in primary care. Although we have seen substantial decreases in C. difficile infections in acute trusts, those occurring in primary care trusts—referred to as community-associated infections—have decreased at a far slower rate.

The origin of community-associated cases is not clear and needs further investigation. A significant proportion may be due to previous contact with previous health care facilities. In other cases there may have been no known links to health care, while others may be associated with antibiotic treatment in the community by GPs. GPs have a vital role to play in reducing the inappropriate use of broad spectrum antibiotics—those that attack a wide range of bacteria, but which can increase the risk of contracting C. difficile. GPs need to consider C. difficile when prescribing antibiotics, particularly to at-risk groups such as those who have recently been discharged from hospital or the elderly, as my hon. Friend rightly mentioned. Because such antibiotics can increase the risk of contracting C. difficile, prudent antibiotic prescribing is key. Although only a small number of C. difficile infections emanate from general practice, this is not an excuse to do nothing—not when the impact on individuals can be so great.

We will increase GPs’ awareness of the impact of antibiotic prescribing on contracting C. difficile infections and increasing antibiotic resistance. As part of that, we will use antibiotic awareness day on 18 November to focus attention on the need to reduce the unnecessary use of antibiotics. As my hon. Friend showed in his speech, we have produced leaflets and other materials that GPs, pharmacists and other professionals can use to raise the issue with patients and the public. Those materials make it clear that everyone has a role in improving prescribing and patient outcomes. To improve the evidence base, we are considering how to improve the monitoring of community associated cases. That links into our concern about the large number of readmissions to hospital within 30 days of discharge, which my hon. Friend also mentioned. The action that my right hon. Friend the Secretary of State took in the summer to alleviate the problem will, I believe, go a long way towards helping to find a solution to it.

Let me now turn to some of the questions that my hon. Friends have asked in this debate. I am grateful to my hon. Friends the Members for Watford (Richard Harrington) and for Enfield North (Nick de Bois) for drawing to my attention the equipment, which came from America, that is currently being tested in Northwick Park hospital. As they may be aware, the Department has established a mechanism, known as the rapid review panel, by which new products can be evaluated for their effectiveness against infections. As they said, the equipment is currently being tested at Northwick Park hospital. We await with interest the results of those tests, to see whether the equipment would be useful in the constant battle against such infections.

My hon. Friend the Member for Enfield, Southgate also asked what more the Government could do to ensure that GPs are fully briefed on C. difficile and respond to such knowledge efficiently and consistently. As I mentioned with social care, the forthcoming application of the code of practice to primary care will give a significant boost to improving GPs’ awareness and knowledge of infection prevention and control. We will publish the code shortly, and although primary care will not be subject to the requirements of the legislation until April 2012, the registration process with the Care Quality Commission will start much earlier, with all the benefits that this will secure, through increased focus and awareness. I trust that that will go some way towards reassuring my hon. Friend.

My hon. Friend also spoke about requiring hospitals to provide information to patients leaving their care. As he said, Graziella, with the Department of Health, has produced a leaflet on C. difficile, which he has seen. The best way to protect patients against the infection spreading is to provide them with information. The intention is to give the document to patients so that they are aware of the risks, and know how to prevent other vulnerable people from catching the infection. However, although both she and I would like the leaflet to be distributed by every hospital and GP, there is no requirement for that, and many patients are sent home without the information that they need to protect themselves.

We believe, as does my hon. Friend, that it is important for patients to have access to information. I certainly expect hospitals to provide that information to all relevant patients on their discharge. It is important to ensure that such leaflets are available for the NHS to use, and copies are available on the Department’s Clean, Safe Care website, but we must be careful not to be prescriptive on decisions about patients’ care that are best made at local level. I trust that many practitioners and hospitals at local level will recognise the importance of the leaflets and ensure that patients have them drawn to their attention.

Time is running out, and on the questions to which I have not had the opportunity of replying I will write to my hon. Friend so that he receives answers. I say again that we treat the matter seriously, and in the short time remaining I shall answer the final question about careful monitoring of patients in the community. Guidance, entitled “Clostridium difficile infection: how to deal with the problem”, has been published by the Department of Health and the Health Protection Agency, and provides evidence-based advice on how to treat C. difficile. We will take the opportunity in the forthcoming publication of the code to reiterate the value of that to GPs in their decision making, and I hope that my hon. Friend will find that reassuring and helpful.

When patients enter a health care setting, they expect to be taken care of and to be made better, not to contract a potentially fatal infection. I hope that I have reassured my hon. Friend that the Government share his deep concern and are determined to see significant progress in reducing C. difficile infections further.

Question put and agreed to.

House adjourned.