Health Service Focus

Infection prevention and control: the role of commissioners

NHE talks to Rose Gallagher, Royal College of Nursing adviser for infection prevention and control, and Debbie Wright, assistant director of infection prevention and control at Aintree University Hospital NHS FT and a representative of the Infection Prevention Society, about a new ‘toolkit’ for commissioners.

No person should be harmed by a preventable infection – this is a vision shared by both the Infection Prevention Society (IPS) and the Royal College of Nursing (RCN), who have worked together to review infection control guidelines for commissioners following the NHS reforms.

The revised guidelines are aimed at both commissioners and providers, especially CCG leads on infection prevention and control (IPC), specialist IPC nurses supporting commissioners, directors of IPC at provider organisations and their teams, plus local authorities.

In his foreword to the guidance, Mike Durkin, director of patient safety at NHS England, says: “NHS England is pleased to support resources, such as this guidance, for providers and commissioners of care that will help them to establish a health care associated infection (HCAI) reduction plan, which reflects local and national priorities.”

‘We are the envy of Europe’

Rose Gallagher, IPC adviser at the RCN, helped lead the revision of the guidance following the changes to commissioning under the Health & Social Care Act 2014.

She told NHE: “We’ve come a tremendous way in the NHS across the UK in reducing some infections. The focus has been on MRSA andC. difficile, and we achieved that because we had the support of governments, we had leadership, we had investment in resources, and we had a suite of tools to support healthcare workers and provider organisations make those changes.

“We really are the envy of Europe insofar as what we’ve managed to do in reducing infections, but of course those are only two infections caused by two organisms. There’s an awful lot more work needs to be done and we’ve started that process: applying what we’ve learnt from MRSA and C. diff to other infections.

“We need to capitalise on that learning and continue to move forward – the job is not done.”

A separate briefing paper from October 2013 explaining where IPC fits into the complex and varied new commissioning landscape is also currently being updated.

Gallagher said: “That recognises that things change and that some improvements have been made – for example, the de minimis limit for MRSA has been removed, but we still have it for C. diff for foundation trusts. But a different set of language is used for non-foundation trusts.”

Support for commissioners

Debbie Wright was another of the main authors of the revised guidance. She is now assistant director of IPC at Aintree University Hospital NHS FT, but was for many years responsible for IPC at Central Lancashire PCT, so is familiar with the issue from both a commissioner and provider viewpoint. In that role, she was a lead for the IPS/RCN Commissioning Network.

She said: “It is an important issue for commissioners. There’s differing levels of support available to commissioners in terms of IPC.”

She added that the NHS reforms did create initial confusion and concern about the future for IPC, because it was felt that some expertise would be “lost” as the structures changed: “It wasn’t clear where that function should fit with the commissioners. For example, some of the IPC commissioning expertise went directly into CCGs, some went to local authorities (that’s where my former post ended up), and some just weren’t appointed.

“At that time there was a real lack of clarity about IPC and commissioning. But I do think it’s settled down slightly, and people are now reviewing what they actually need,” Wright said.

C. difficile was a case in point, she said. “It took us a long time to get CCGs to be held to account for C. diff. We’ve always held acute trusts to account for C. diff numbers, and now that’s gone, so I did wonder whether there was going to be a change of focus or not as much drive from the CCGs on that.”

Gallagher explained how this document is just one in a series that the RCN and IPS have been producing in recent years to raise awareness of IPC issues.

“It’s been about maintaining the profile of IPC, but also about trying to support organisations to make sure they have either their own expertise or sufficient access to specialist IPC expertise to support their commissioning.”

Because not all CCGs and CSUs have such specialist advice, the newly-updated toolkit is a vital resource.

“The commissioning nurse workforce for infection control had effectively been dismantled from their positions in the commissioning arms of PCTs. We knew they were now in a number of organisations and therefore there was significant variation in access to and support for local authorities, CSUs, CCGs and so on – and we did lose some posts as a result of those changes as well.”

Gallagher said it was important that both commissioners and providers have a ‘zero tolerance’ policy, never accepting that infections are “inevitable”.

Antimicrobial resistance

Antimicrobial resistance, and the consequences of use of antibiotics to treat HCAIs, is another big factor, Gallagher said. “We’re in a very different position to where we were in 2006-07. We’ve really got to keep up this focus on infection prevention, particularly with antimicrobial resistance becoming an increasing threat and challenge to modern medicine.

“We have to take what we’ve learnt and expand it to thinking differently about how we prevent, track, and manage urinary tract infections, pneumonia, and other conditions that all carry significant morbidity and mortality. Many may be preventable, but not all, and all will certainly use antibiotics – which is further driving resistance.”

Indicators to choose from

Gallagher and Wright explained how the current toolkit is essentially a ‘bridging document’ ahead of a bigger piece of work coming later.

The bulk of this version of the toolkit is a basket of suggested indicators – additions to the national indicators that commissioners can pick and choose from according to local conditions, data and intelligence.

The document notes: “Commissioning organisations will hold providers to account for their performance, and assess their contribution to sustained improvement in IPC practices that reduce HCAIs and antimicrobial resistance.

“To achieve this they will evaluate local objectives systematically across the organisations they commission services from. They will ensure that there is proportionality to risks associated with different care settings. Commissioning teams will review surveillance data so that they can monitor progress against nationally set objectives for specific organisms, other agreed indicators and learning identified from post-infection reviews (PIR) or root cause analysis of incidents.”

Wright said: “The guidance does need to be used appropriately and reflect local need. Commissioners need to understand their providers and work with them on areas for improvement – it should be used jointly, not ‘we’re going to do this to you’. Working together produces much stronger results.”

Commissioners need to ensure they pick from the basket of indicators in a sensible way – and not try to use all of them.

Gallagher added: “It’s not ‘one size fits all’ across the country. Many elements will be common to NHS hospitals or community providers, but there is enough room there for people to select what’s a priority for them to influence through commissioning. It’s really down to local need and local intelligence.”

The future

Gallagher continued: “In ‘version 3’, at the request of our members, we are now looking to create indicator specific tables for different care settings. So, rather than having one big indicator basket, we’re looking at one for primary care, one for social care, one for mental health and one for secondary care. That will hopefully help direct the thinking of the different provider organisations to be able to pick out more easily what potential indicators might be beneficial for them.

“We’re also challenging some of the thinking behind ‘100% compliance with all elements’ as well, because we recognise that it’s about improvement over time, working towards full compliance – but that we won’t achieve full compliance overnight.

“Moving forward with ongoing revisions, our aim is to try to build an evidence base around how commissioning helps support outcomes through infection prevention. We’re doing it in the absence of any existing evidence base, so we’re really keen to learn from this work and to work towards improving and supporting at all levels of commissioning.”

Maintaining the visibility of infection prevention

The toolkit references all the other key documents and requirements that commissioning organisations need to adhere to, and it assumes compliance with the code of practice for infection control that all provider organisations have to have for CQC registration.

Gallagher said: “Just because they are compliant with the code of practice doesn’t mean that further improvement can’t be made.”

The only two mandatory objectives in the national outcomes framework are on MRSA and C. difficile infection – “but clearly there is a lot of other work that needs to go on behind that to improve the IPC generally”, Gallagher said.

“We need to maintain its position and visibility in the expanding improvement landscape, because IPC is now only one of a number of improvement areas, alongside things like falls, pressure ulcers, and so on.

“There is also an increasingly close relationship with public health and wellbeing, to try to keep people well in order to keep them away from hospitals to reduce the number of interventions. Anything that affects health affects IPC, and antimicrobial resistance sits alongside that.

Considering that she has seen how IPC works at both commissioning and provider organisations, we asked Wright how this has influenced her perspective.

She said: “It’s quite interesting; I’ve moved into a very different culture from where I was. I was the lead commissioner for quite a few hospitals and we had a very collaborative view on how we were going to work.

“The acute trusts know what their issues are and want to improve – it must be about support from commissioners, not putting additional burdens into the system.

“We need to work together to be able to be able to improve patient safety and infection protection.”

The full document, ‘Infection prevention and control commissioning toolkit: Guidance and information for nursing and commissioning staff in England’ is available here

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