Planning the vanguard of infection prevention and control

Remember all the stories about dirty hospitals, infected patients and people frightened of going into hospital for fear of picking up a superbug? Although they were over 10 years ago, those stories are still fresh in the mind. Last week, in amongst all media coverage of the financial crisis in the NHS, nestled a clutch of stories on infections and antibiotics. In case you missed it, it was World Antibiotic Awareness Week.

One key message was the need to stay ahead in the race against infections. But how?

Today we publish an analysis of health care associated infections (HCAIs) over the last 15 years in the NHS in England. The report shows that rates of MRSA in NHS trusts fell fast from 18 blood stream infections per 100,000 bed days ten years ago to 2 per 100,000 now. The trend for Clostridium difficile infections is similar.

The precipitous decline in some health care associated infections followed marked political and media attention; after which national targets with mandatory monitoring were introduced. There were other interventions at the same time such as public health campaigns, but targets and monitoring focused managerial attention like nothing else.

This near revolution reminds me of the dramatic reduction seen in teenage pregnancies across England and improvement of school results in London, both over the same period. With teenage pregnancies and the school results, the jury is still out as to what led to the improvements. Yes there was a concentrated national- and region-wide focus. But success is more likely to have been due to a combination of factors, as the challenges were complex.

In the NHS everyone knows that targets and command can only work under certain conditions, as neatly set out by members of the Foundation’s policy team in a recent analysis On targets. These conditions include having a small number of targets, focused on well defined problems which have known solutions and for which progress can be unambiguously measured. On targets also set out how targets might be withdrawn appropriately.

These conditions clearly don’t apply to the challenges of progressing the Vanguards, doubling NHS productivity or implementing the Five Year Forward View. Rather they need a range of responses, coordinated over a ten year span. Expect politicians to tune out at the mention of a decade, but they can be engaged with some short-term prods (coordinated not random) that could help.

As both our latest report and World Antibiotic Awareness Week underline, short-run successes against infection shouldn’t lull us into thinking we’ve won the race. Antibiotic resistant infections and the rise in bugs like E. coli present new challenges. To stay ahead of these threats a more sophisticated and multifaceted plan is now needed for the medium term. In the NHS this approach is at odds with the usual version of policymaking – reactive, made at breakneck speed, with short-term politicised objectives. Instead, the so-called ‘system stewards’ need to co-develop and own the plan with a larger group within the NHS and social care system, more extensive and longer than the Five Year Forward View. It is an approach which needs to include community and primary care as we move to deliver more care outside hospitals, not least because the important role these sectors play in ensuring safe prescribing and antibiotic use.

A coherent, coordinated plan would not just focus on targets, technology, payment reform, regulation and structural reform of providers. Crucially, it would also focus on developing people – better planning, skilling, nurturing – and, as described in Don Berwick’s review A promise to learn: a commitment to act, on developing the NHS as a learning system using systematic approaches to quality improvement. Such an approach should not be the responsibility of any particular arm’s length body, but be a central element of NHS policy and practice. Without this, progress on tackling health care associated infections, safety and productivity will lag.