AMR0002

Written evidence from Deb Group Ltd

About Deb Group Ltd

1. Deb Group is a UK-based organisation leading international innovation in patient safety, and the largest skincare product provider to the NHS, with 40% of the alcohol sanitiser and soap market. Our products keep people safe and protect NHS staff.

2. Deb employs 200 staff across the UK in research and development, manufacturing and distribution, and our products are exported worldwide, including to the US and Europe.

3. Deb is at the forefront of public health and patient safety initiatives in the UK and globally. We play a crucial part in the World Health Organisation (WHO) Private Organisations for Patient Safety (POPS) Hand Hygiene Group, which aims to harness industry strengths to align and improve implementation of WHO recommendations in less developed countries. We were proud to support Ebola efforts in Africa with donations, as well as ongoing support for World Hand Hygiene Day, which takes place every 5th May.

4. In the UK, Deb is a strategic partner to the NHS, working with proactive organisations and individuals to drive forward change within the health sector that will save lives and precious NHS resource.  We collaborated on the HandZ campaign, led by Andrea Jenkyns MP, to raise awareness of the importance of hand hygiene best practice; the campaign is targeted at three areas specifically – schools, hospitals and care homes.

5. Deb also actively promotes the importance of good skin care regime as part of a holistic approach to hygiene and patient safety. Keeping hands healthy is an important component to improving compliance with the WHO’s Five Moments of Hand Hygiene. In 2018 we collaborated with the Royal College of Nursing on their Glove Awareness Week campaign, raising awareness of skin health and appropriate glove use by nursing staff.

Introduction

6. Since Sir Alexander Fleming’s development of the first antibiotic – penicillin – in 1928, antibiotics have saved millions of lives over generations by fighting infection. The rise of antimicrobial resistance (AMR) is one of the biggest threats to global health in today’s world.

It is indiscriminate, and can affect anyone, of any age, in any country.

7. We congratulate Professor Dame Sally Davies’ for championing this issue and for firmly placing it on the political agenda. We also welcome this inquiry by House of Commons Health Select Committee into AMR as recognition of the scale of the problem.

8. The AMR crisis has been attributed to the overuse and misuse of antibiotics, as well as a lack of new drug development by the pharmaceutical industry. For the purpose of this consultation, we do not seek to comment on the overuse of misuse of these drugs, nor the drug development within industry. We shall focus on our area of expertise, and one that is too often overlooked in the fight against AMR – infection prevention and control. 

9. We are willing to elaborate on our submission and would welcome the opportunity to present evidence in person as well as in writing.

Hand hygiene and antimicrobial resistance

10. The current cost of AMR to the NHS is estimated to be in excess of £180 million per annum, resulting in 3,000 deaths a year in the UK alone.[1] Patients today have a 6.4% chance of contracting a healthcare acquired infection (HCAI) in UK hospitals[2] despite the World Health Organisation (WHO) considering half of infections are preventable through effective hand hygiene. HCAIs cost the NHS in excess of £1bn a year[3] and the average cost of MRSA is estimated to be £7,000 per case[4], while the average cost of C. Difficile infection is estimated to be £10,000 per case.[5]

11. Growth in anti-microbial resistance (AMR) could further increase the severity of healthcare associated infections (HCAIs) and exacerbate costs. The World Health Organisation estimates that 50-70% of healthcare associated infections are transmitted by hands.[6] Hand hygiene and infection control is therefore the first line of defence against AMR in hospitals.
12. As Lord O’Neill’s landmark report on AMR recognises, infection prevention and control, including improved hand hygiene, must be embedded as a priority for health systems at all levels to address AMR. The Review on Antimicrobial Resistance stated:

“Handwashing by clinicians between contact with patients is recognised, for instance, as being one of the single most effective means of preventing HCAIs. However, despite being such a simple and powerful intervention, actual adherence to proper hand hygiene can be remarkably low: only 40 percent on average.[7] Beyond this, there are substantial evidence gaps as to ‘what works’, and what is cost-effective – particularly in the case of new technologies which may offer substantial benefits in things like hand hygiene and the cleaning of care facilities.”[8]

13. 20-30% of HCAIs may be preventable by effective preventative programmes, with potential cost savings of least €2m ($2.5m) per year for a major tertiary care medical centre, in addition to providing major clinical benefits for hospitalised patients.[9]

14. The 2013-2015 UK AMR Strategy recognised the need to combat AMR “by adapting and embedding good [infection control] practice in a way that takes account of the changing resistance patterns”. It notes that “high standards of infection prevention and control will remain crucial to minimise the risk of infection, limit the emergence and spread of multi-drug resistant organisms in human and animals.[10]

15. Whilst the Strategy’s recognition of the role of infection prevention in tackling AMR is welcome, recognition alone is not sufficient. The health service provides care for millions of patients every year and it must always strive to use the latest evidence and technology to advance infection prevention and control measure and improve patient safety. As Lord O’Neill correctly cites in his report, compliance in UK hospitals is as low as 40% on average.[11] This level of hand hygiene compliance is unacceptable in modern day medicine. 

16. As the NHS seeks to improve hand hygiene compliance in hospitals, it must first acknowledge current method of monitoring in hospitals, direct observation, is inappropriate, inaccurate and outdated. It is allowing the spread of poor hand hygiene practice, putting patients’ lives at risk and increasing costs for the NHS.

17. Direct observation artificially inflates reported compliance as staff wash their hands more frequently when they know they are being monitored – the Hawthorne effect. Peer reviewed research conducted by Deb has shown compliance on wards is in fact 18-40%, far lower than the 90-100% often recorded. The Government has recognised the flaws of current hand hygiene compliance data. Minister of State for Health, Stephen Barclay MP, has stated in the House of Commons that he “recognise[s] the limits of direct observation and how behavioural change may respond to those.”[12]

18. Accurate hand hygiene data can trigger behaviour change, improving hand hygiene compliance. Accurate data generated electronic hand hygiene monitoring has been demonstrated to lead to a 22% reduction in healthcare associated infections[13]. Using electronic monitoring of hand hygiene as a means of reducing infection would reduce the avoidable costs that result from caring for patients with infection.
19. Two acute hospital trusts in England are currently piloting electronic monitoring technology. The CQC report for one trust directly quotes “innovative practice to increase hand hygiene, using the latest technology monitoring the use of alcohol sanitising gel” as an area of “outstanding practice”.

What results have been delivered by the UK AMR 2013-2018 strategy?

20. The 2013-2018 Strategy highlighted the role of infection control in preventing AMR. However, as it was number one, of seven key areas for improvement, it did not go far enough in highlighting the fundamental role prevention plays in contributing to resistance. The World Health Organisation estimates that 50-70% of hospital-acquired infections are transmitted by hands – the scale of this was not reflected in the 2013-2018 AMR strategy, nor were any meaningful strategies put forward to improve hand hygiene.[14]

21. The Strategy highlights the fall in recent years of MRSA infections, citing a “concerted effort” to improve hand hygiene as the reason for this. Whilst it is true that MRSA infections have steadily declined over the last decade, rates of MRSA and C. Difficile now remain stubbornly stable at c. 800 and 14,000 annual infections respectively. Meanwhile, other healthcare associated infections such as E. Coli are on the increase, rising by 19% between 2012/13 and 2015/16, to 38,182.[15]

22. The Strategy pointed to the need to build on the success of “falling infections” by “adapting and embedding good practice”, but it did not seek to outline how this would be done and did not make any commitments to improve hand hygiene compliance.

23. The Strategy also called for action on gram negative infections such as Klebsiella. It is welcome that the Secretary of State for Health and Social Care has acted on this recommendation to refocus on gram negative infections, announcing government plans in November 2016 to halve these bloodstream infections by 2020. Included in the broader announcement[16] was the decision to appoint a National Director of Infection Prevention, now Dr Ruth May, and plans for the NHS publish staff hand hygiene indicators for the first time. The Secretary of State announced that, from 2017, this indicator would be produced by monitoring hand gel usage which would be reported to the Care Quality Commission (CQC). These announcements were warmly welcomed by Deb as an important step in improving hand hygiene and the transparency surrounding compliance.

24. However, policy progress on developing a national hand hygiene indicator has stalled and the implementation of staff hand hygiene indicators is yet to be published. Progressing with the implementation of the hand hygiene indicator is crucial to improving infection rates. It is important hand hygiene compliance rates are published openly and transparently to allow proper scrutiny of compliance and benchmarking between trusts.

25. Staff hand hygiene indicators should not be calculated by weighing or counting cartridges used in hospital hand sanitiser dispensers, as without factoring in patient bed numbers and staffing levels, the information is meaningless in showing hand hygiene compliance levels. Instead, electronic hand hygiene monitoring offers the potential to improve health outcomes and save money at a time when health services are coming under increasing pressure.

What should be the key actions and priorities for the Government’s next AMR strategy, due to be published at the end of this year?

26. The role of hand hygiene in tackling AMR cannot be overstated. It is the first line of defence in preventing infection, without which, resistance cannot develop. The next AMR strategy must re-emphasise and refocus hand hygiene as central to reducing bacterial resistance and outline clear steps to improve hand hygiene compliance in hospitals.

27. The Government recognises the inadequacy of direct observation as a means of monitoring hand hygiene compliance (see point 17) and there is a myriad of data validating the argument that direct observation falsely inflates compliance. As we mention, the Government has also committed to publishing a staff hand hygiene indicator for the first time. Fully implementing the staff hand hygiene indicator policy and developing a system to overcome the pitfalls of direct observation must be key actions for the Government in the next AMR strategy.

28. Health Minister Stephen Barclay has said “the Government are actively looking at the extent to which technology can facilitate [improving compliance]”. Improving hand hygiene requires behavioural changes that are reliant upon frequent, accurate and relevant feedback. Utilising electronic monitoring to improve data collection is in line with the Carter Review’s aspiration to have “real-time monitoring and reporting at their [NHS leaders’] fingertips”.[17]

29. Electronic monitoring can deliver real-time, accurate data to drive behavioural change, improving hand hygiene and reducing infection. The use of technology to reduce infection must therefore be a priority for the next AMR strategy.

30. The Government must deliver on its existing policy to publish national hand hygiene compliance indicators and ensure that the data is accurate. This will help to improve hand hygiene compliance, reduce the spread of infection and therefore contribute to efforts to address AMR.

31. Deb is committed to promoting good hand hygiene through collaborations with the WHO and the RCN, and educating the inhabitants of tomorrow’s world through the HandZ campaign. A key priority for the Government must be to continue educating the public – in schools, hospitals and beyond – about antimicrobial resistance, restating the importance of good hand hygiene in preventing infection.

19th June 2018.