The Objective should be no avoidable infections.  Setting a national bar is perverse in that it states there is a level that is acceptable.  There will always be some infections, and it is not possible to define an irreducible minimum.  As far a bacteraemias are concerned, there are some Trusts who are achieving zero MRSA bacteraemias through the interventions in Saving Lives being rigorously implemented.  If a Trust has a bacteraemia then the common sense approach is to carry out the route cause analysis to identify why and put measures in place to avoid it again, but sometimes it is not always possible to identify why, provided the methodology used is sound and the Trust Board considers this as a priority on their agenda at Board meetings, then that is the Objective we are seeking - "Every Infection Matters" (Bedford Hospital NHS Trust)

There are some Trusts that need much tougher targets, whilst others have an outstanding track record, and continue to improve.  There is an opportunity to bring performance in line across the board and having more specific local targets will achieve a better outcome for patients.

The formula outlined above would require yearly recalculation and makes more sense, whilst the target set by John Reid was a key driver in the achievements seen nationally, we started at a much higher level, now the focus needs to be local.

The baseline should be from 1 April 2008 - 31 March 2009.  Since year on year improvements are a requirement in the Public Service Level agreements, this is not an unreasonable goal, and is measurable.

The MRSA Objective should be extended beyond MRSA bloodstream infections.  "Rate of MRSA cases" in the Operating Framework commitment implies all MRSA infections, and as such we should be striving to include at least surgical site infections, as there is data collection already happening in hospital trusts where high risk procedures are measured. The public do want an overall reduction in all infections and feedback shows they feel misled when headlines in local papers state "zero MRSA" in hospital trusts, when in fact this only relates to bloodstream infections. 

MRSA Action UK believe there must be a strong emphasis on the use of route cause analysis supported by the Care Quality Commission's assessments as this will send a strong message to healthcare providers across the wider healthcare economy that we should take a zero tolerance approach to avoidable infections, the use of route cause analysis will identify which infections were avoidable and ensure measures are taken to avoid future occurrences.  We are pleased to see it is the intention for CQC to increase the frequency of the periodic review with a view to a quicker response to addressing areas of concern.  This will focus providers' and commissioners' minds.

For the denominator bed day rates enables good time series analysis as this has been used in the past, however admissions may be more attractive to 'non-statisticians' for clarity.  Showing the number of MRSA bacteraemias as a proportion of admissions (excluding zero days) would be a very clear way of presenting the data, and will help people who want to make a choice about where they are treated, people wanted to know the individual risk to them based on their own circumstances, this latter point also supports our view that data should be published at hospital level on the NHS choices scorecard.  We would recommend admissions as the denominator with bed day rates also published, at least in the first year, for comparison.

MRSA Action UK supports the view that there should be no adjustment for case mix. It could send the wrong message in terms of tolerance, trusts need to manage risk based on their particular case mix.

MRSA Action UK believe a Statistical Confidence interval should be published for the purposes of performance management and comparability, the mandatory Surgical Site Infection data collection shows confidence intervals so this is a useful tool.  There should be a uniform approach to publishing performance data on MRSA for both people managing performance and the public.

MRSA Action UK welcome the opportunity get PCO's engaged, splitting between 48-hour cases would help to achieve this engagement, and give a fairer reflection on Trust performance.

C.difficile has very different controls and as such trying to put the same time factors on detection may give the impression that we are 'over standardising' the issues rather than looking at why we are using these metrics. 

Other metrics can be used to look at performance with other providers, for example the use of performance measures being collected from Care Homes on residents HCAI status in care plans, whether these are admissions or discharges, this encourages partnership working and helps the NHS meet its constitutional obligation to provide all patients with a care plan, and discuss the treatment of colonisation and / or infection.

We believe is it vital to get the resources required right, therefore you would need to look at the expenditure of Trusts with the best track record on preventing bacteraemias, it may be that in the short term the investment needed will be substantial, however longer term the cost benefits will show with the numbers of people contracting infections reducing.  You cannot put a price on life and quality of life.