Wednesday, 31 October 2007

Off Target

As a medical student in the early seventies, I spent a happy day in Kent exploring two long abandoned institutions – the Joyce Green Smallpox Hospital (closed in 1948) and Long Reach ; the latter was so called because it was the furthest point up the Thames Estuary that a ship showing a fever flag had been permitted to travel. It appeared to us that in an era of immunization and of antibiotics, infectious disease was as much part of medical history as leeches and chloroform.

It seems quite remarkable that in thirty years we have seen advent of AIDS, SARS, and bird flu; even syphilis, a disease that was close to extinction has re-entered the dermatologists differential diagnosis. Those, of course, have been conditions which have been largely out of the control of doctors and health planners, but the same cannot be said of the most recent scourge – Hospital Acquired Infection, a phenomenon that many of us thought had disappeared with Lister, Semmelweis , and Florence Nightingale. Nowadays it is hard to turn on the TV or open the newspaper without hearing the latest horror story about MRSA and Clostridium difficile ; when you talk to patients you realize how very afraid many of them are, and any of you who have ever seen a patient with C diff will know just what a truly horrible condition it is.

According to the Health Protection Agency ( there were over 50,000 cases of C diff infection in England in 2006, and given that it has a mortality of some 10% , that is far more deaths than occur through road traffic accidents, or malignant melanoma, or AIDS; it’s a Harold Shipman every fortnight. Attention has been drawn to the catastrophic events at Maidstone and Tonbridge, and at Stoke Mandeville, which were investigated by the Healthcare Commission, but twenty other hospitals (including my own) had infection rates higher than those in Maidstone. Politicians have been quick to blame doctors for not washing their hands and for being profligate with antibiotics, but is this the real answer? I suspect not. Remarkably, the C diff epidemic sweeping through the English NHS has not been seen in Wales; this is not, as far as I know because Offa’s Dyke or the River Severn have any magical antimicrobial properties, nor that Welsh doctors make freer use of soap and water, or make less use of antibiotics.

The only difference in practice that would explain the phenomenon is that the Welsh NHS has not become such a slave to politically driven access targets. In my own hospital, as in many others, the eagerness of managers to avoid “waiting list breeches” is that patients, usually ones awaiting non-urgent elective surgery are admitted to wards that are already bursting at the seems. Bed occupancy rates of close to, or even exceeding 100% are commonplace, yet the evidence of an association between high occupancy rates, short bed vacancy intervals and high rates of hospital acquired infection are well known. Patients are, all too frequently admitted to inappropriate wards and are moved all too readily from ward to ward. Only recently I saw a nice lady who was on her fourth different ward in 48 hours, and who, although she was quite lucid in every other way, no longer knew where she was. The whole situation is just an accident waiting to happen.

The government’s failure to tackle the problem is a disgrace; they talk vaguely about “deep cleaning” wards (whatever that means) without evidence that it is an effective remedy.

It is time for the medical profession to insist that achieving political targets cannot be allowed to endanger patients lives; if that upsets a few politicians, then so be it.

1 comment:

jayann said...

The bed occupancy rate in Wales in 2006 was 82.9.