In the 19th century, hospitals were dangerous places – little was understood about the transmission of infectious diseases and hygiene was poor. Vast improvements were made once the link between hygiene and infection was established and antiseptic use began in operating theatres. In the 21st century, hospital acquired infections (HAI) are a growing problem in Britain’s health service, under pressure to increase throughput and activity, cut staffing and meet targets.
HAI lead to 14 days longer in hospital, an extra £3,154 spent on health care for the affected person, six extra days off work and a 10% increase in the chance of dying. It is estimated that in England and Wales, HAI lead to an extra £1 billion being spent per year. One in ten people leaving hospital are affected by HAI. The estimate of annual deaths from HAI in Britain is 5,000.
The human cost should be paramount, but the economic cost is what is of immediate importance for hospital management. With hospitals striving to meet targets related to star-rating categories and collecting their financial bonuses, bed occupancy and hospital activity remain as high as possible. The waiting list target for surgical procedures is now set at six months. Financial penalties will be levied against hospitals with people on the list for longer. In order to urgently address the waiting list problem, consultant surgeons are currently being asked to operate on Saturdays. They are being paid hourly private sector rates to do this (presumably as a pay off for the fact that waiting list pressure is what contributes to people seeing surgeons privately) – while the nurses, theatre technicians and domestics remain on their usual pay.
Reducing HAI
Best practice for reducing hospital acquired infections in general includes good hygiene in clinical practice (hand washing and disinfection), isolation of infected patients and use of barrier precautions (gloves and aprons), a clean environment and control of patient and staff movement within hospitals. Movement of patients within hospitals is related to high bed occupancy rates and making use of every available bed. Understaffing means that nurses and doctors are dealing with more patients each, which, coupled with insufficient hand- washing, increases the risk of cross-infection. There are insufficient single rooms on wards and the practice of squeezing five beds into four-bedded bays is on the increase. Both add to the risk of cross infection and increasingly cramped conditions make effective cleaning more difficult.
Privatising cleaning, reducing numbers
Over the last 20 years, the number of cleaners in British hospitals has halved, from 100,000 in 1984 to 55,000 in 2004. In 1986 there were 67,000 full-time domestic posts and now there are 36,000. Since 1983, with the advent of Market Testing, the NHS name for competitive tendering, the cheapest bidder has won and cutting costs is always equivalent to cutting staff numbers. The low pay and poor conditions contribute to the increasingly high turnover in staff every year in the private companies. In January this year, the Business Services Association, the representative body for the major private cleaning companies, said ‘the point at issue is not how many cleaning staff are employed but how efficiently they carry out the tasks assigned to them’.
Bed occupancy
In 2000, the National Audit Office (NAO) identified high bed occupancy levels as a contributory factor in HAI. They recommended a reduction in occupancy rates to 82%. Four years later, the NAO report in 2004 showed that three quarters of all trusts were still operating above that level. Equally worrying in the 2004 report was the finding that 12% of Infection Control Teams reported that their chief executive had refused or discouraged a recommendation from them to control an outbreak by closing a ward or hospital to admissions.
This lack of priority to HAI given by the Labour government is significant in view of how MRSA (Methicillin-resistant Staphylococcus aureus), the cause of most HAI, was used as party political point scoring tool in the run up to the general election in May. In the Netherlands, screening for MRSA is routine with subsequent isolation of infected patients in hospital, bed occupancy rate is around 60% and they have particularly low rates of HAI.
The British government spent between £600 and £700 million on contracts with the private health care sector in 2003. They aspire to spend in excess of £10 billion in 2008. Health care ranks in the top three most active sectors in terms of British private equity transactions. Private companies are attracted to the health care market because of its wide-ranging opportunities for profit not health improvement.
The government is encouraging schemes such as payment by results for Foundation Hospitals, and overseeing a significant reduction in numbers of beds and staff in new hospitals built by Private Finance Initiatives.
Reducing hospital acquired infections by measures that include more beds, more staff, better pay and conditions for the domestics and more time and attention to people’s care is not part of the Labour government’s agenda.
Hannah Caller
FRFI 185 June / July 2005
