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Statement to the House of Commons by the Rt Hon Alan Johnson MP, Secretary of State for Health, 15 October 2007:  Maidstone and Tunbridge Wells

Mr Speaker, the Healthcare Commission’s report into the  outbreaks of Clostridium Difficile at Maidstone and Tunbridge Wells NHS Trust is a truly shocking document.

On behalf of the Government and the National Health Service, I would like to apologise to all those who have been personally and directly affected, and to offer my condolences to the families of those who have died.

Clostridium difficile is the major cause of serious bacterial infectious diarrhoea.  It can colonise the gut, causing inflammation of the colon and, in the worst cases, prove to be fatal. It is normally controlled by the presence of other bacteria but when these are killed, for example, by antibiotic treatment, it can grow and cause disease.

Tackling Healthcare Acquired Infections is one of the four priorities in the NHS Operating Framework. In October 2006, the Code of Practice on the prevention and control of Healthcare Associated infections became a statutory procedure. And we have made it clear that tackling healthcare acquired infections should be a priority for all local NHS organisations. This is vital to ensuring patient confidence in the NHS.

• We’ve set the target that trusts must reduce the number of C Difficile infections by 30% by March 2011.
• Mandatory surveillance of C Difficile infections was extended to people aged 2 and over from April this year to help monitoring of the local targets.
• We’ve doubled the number of improvement teams which are helping trusts reduce MRSA numbers, and who will now help tackle C Difficile.
• We’ve announced deep cleans within all trusts. We’ve published new guidance on uniforms, so staff are “bare below” the elbow. And we are creating a new regulator, with stronger enforcement powers who will be expected to inspect investigate and intervene on healthcare acquired infections.
• We’ve announced MRSA screening for all elective admissions next year; and for all emergency admissions as soon as possible over the next three years.
• In July, we made an additional £50 million available for reducing HCAIs.    
  
• The MRSA/Cleaner Hospitals action plan has also been expanded to cover C. Diff.  It has already had a considerable impact in tackling MRSA and is expected to have a similar impact on C.Diff.

While all of these measures are crucial, the report from the Healthcare Commission into Maidstone and Tunbridge Wells NHS Trust shows that we need far more vigilance and determination in our drive to eradicate hospital acquired infections.

The NHS Chief Executive has written to every NHS trust today, appending the Healthcare Commission’s report, seeking reassurances from every NHS Chief Executive that infection control is a major priority in every NHS organisation.

We established the Healthcare Commission in 2003 to ensure continuous improvement in health services and to undertake specific investigations into Trusts where allegations of serious failings are raised.

Because Maidstone and Tunbridge Wells trust had consistently been among the 25% of trusts with highest rates of Clostridium difficile since mandatory surveillance began in January 2004, the Strategic Health Authority proactively asked the HCC to undertake this investigation in July 2006.  

The HCC interviewed over 200 past or present staff.  They also reviewed in detail the case notes of 50 cases of people who had contracted c difficile during admission to the trust and had then died.

The Healthcare Commission Report revealed significant failings in stopping the spread of C. difficile.  It estimates that if the 50 cases reviewed were representative of the 345 who died, and the reviewers’ assessments are extrapolated to all of the 345, C. difficile was probably or definitely the main cause of death in approximately 90, and definitely the cause in 21 cases.

The HCC found that the trust board was unaware of the high infection rates and did not spend enough time considering issues relating to infection control.  The Commission report made clear that the individual appointed to be the Director of Infection Prevention and Control had no real understanding of the role from the outset.  Management of the infection control team was considered inadequate and there was confusion over who actually managed the infection team.

Overall, the governance system that was intended to bring clinical risk to the attention of the Board did not function effectively and the Board appeared to be insulated from the realities and problems occurring on the wards.

The HCC makes recommendations for action by the trust, including reviewing the trust’s: Board leadership; priority of infection control at Board level; management of risk; clinical guidelines; and staffing levels and training.  These actions will be performance-managed by the SHA. 

Following the recommendation of the Health Care Commission Report, the South East Coast Strategic Health Authority has commissioned an independent review into the leadership of the Trust during the period of the outbreaks. An interim report will be made available to the Strategic Health Authority by November.

Although employment is a matter for the local NHS Trust board, I have instructed the trust in this exceptional case to withhold any severance payment to the former chief executive of Maidstone and Tunbridge Wells NHS Trust, pending legal advice.

I can tell the House that James Lee, the Chair of the Trust, has today offered his resignation [which I have accepted]. I have asked David Nicholson, the Chief Executive of the NHS, to ensure that a suitable replacement is found so that the Trust can move forward quickly to act on the recommendations of the report and restore public and patient confidence in NHS services.

In addition to the independent review into leadership at the Trust, I have asked the Department of Health to carry out a separate review into the role of the Chair of the Trust and the decision-making process that led to the terms and conditions of the Chief Executive’s departure.

I am particularly concerned by the Healthcare Commission's assessment that "The Trust delayed announcing the outbreak and then produced figures that almost certainly underestimated the number of deaths" and have asked that our independent report into the Trust's leadership at the time of the outbreak examines this specific point.

The report identified five national recommendations. It may be helpful to the House if I set these out together with the actions being taken in response:

• The diagnosis of C.difficile needs to be regarded as a diagnosis in its own right, with proper continuity of management. 
  - National guidance has been available since 1994 and a revised version will be published shortly.
• Further consideration needs to be given to the education and supervision of trainee doctors, with a view to improving the recording of C. difficile on death certificates. 
  - The need for good reporting of healthcare associated infections on death certificates has just been reinforced by a CMO professional letter published on 4th October. Further measures will be considered in response to this Report.
• Antibiotics should be targeted, of the narrowest spectrum possible, and used for the shortest possible time. 
  - We recently published a summary of best practice on this issue.
• The NHS and HPA should agree clear and consistent arrangements for the monitoring of rates of C. difficile infection. 
  - In April 2007 we improved the mandatory reporting of C Difficile by introducing a web-based reporting system and requiring data on 2 year olds and above to be reported (rather than 65 and above only).
• The board of every NHS Trust must understand the roles and responsibilities of the Director of Infection Prevention and Control, and receive regularly, information about incidence and trends.  
  - The report itself acknowledged that Duty 2 of the Hygiene Code addresses this issue.

Mr Speaker, the situation uncovered by the Healthcare Commission at the three hospitals is truly scandalous. We must all shoulder our share of the blame, but I hope that the House will recognise that the awful failures in Maidstone and Tonbridge are entirely misrepresentative of the standards of care that patients and the public rightly expect.