Beefed-up measures to tackle a hospital infection which cost Epsom and St Helier hospitals £3.6million in fines last year are in place and are working according to the hospitals' nursing director.
In March both hospitals - which could see their A&E, maternity and children's units axed under controversial proposals set out in the Better Services Better Value (BSBV) review - were facing a £4.8million fine for failing to hit infection reduction targets.
A total of 61 patients had caught Clostridium Difficile (C Diff), in the hospitals last year - 29 at Epsom and 32 at St Helier.
This is a bacterial infection which usually affects the elderly who have taken antibiotics and is transmitted via contaminated surfaces.
The trust's target, set by the Department of Health, was to keep the number of cases below 53.
Just another two cases could have seen the fine rise to £5.7million, but it was capped at £4.8million following negotiations with local primary care trusts.
It has now been revealed that NHS Surrey and NHS South West London primary care trusts, who were responsible for enforcing the fine before being abolished at the start of this financial year, have fined the trust £3.6million.
Additionally, the trust has decided to ring-fence £900,000 to build on measures already in place to tackle cases of C Diff.
Pippa Hart, director of nursing and director of infection and prevention control at the hospitals, said "very robust" measures are in place to tackle the infection, as evidenced by the 75 per cent overall reduction in the number of C Difficile cases in the last four years.
Just two cases of C Diff - 1 at Epsom and 1 at St Helier - have been recorded since April - an improvement on the number of cases which have occurred at the same point in the last three years.
But she acknowledges that "we still have further to go".
Ms Hart, a nurse for 33 years who worked in intensive care at the trust before being appointed director of nursing in 2008, said: "Good infection control practice is a range of different things coming together - good hand hygiene and cleaning standards, good antibiotic prescribing, and good practice at ward level to make sure patients are quickly identified.
"The fact that we've had no outbreaks of C Difficile in the last two years indicates that our practices are minimising the risk of cross-infection, and the individual cases that do occur are reviewed carefully to see if there's anything we could have done differently."
The same measures are in place at Epsom and St Helier, which, significantly, include the testing of any patient with a loose stool, a symptom of the infection, for C Diff - a policy which Ms Hart says is not in place at some other hospitals which screen before they test.
She said the trust had been focusing on the control and prevention of C Diff since last April "when we started to see an increase in the number of cases we were having rather than the normal summer decrease".
She said the key aspects of care considered were whether staff were identifying, isolating and testing patients; whether cleaning standards were up to scratch; and whether the prescribing of antibiotics was appropriate and robust.
Since last year, additional ward-based pharmacists who review antibiotic prescribing and can challenge medical staff on this have been employed by the trust, as well as additional nurses who work alongside ward staff to ensure they rapidly recognise the actions required when patients display symptoms of C Diff.
In March this year, a new antibiotic prescribing policy was put in place "to narrow the number of antibiotics our doctors are using even further while balancing the risk of not treating patients appropriately".
Ms Hart, who appears on a number of large infection control posters put up across the hospitals aiming to "engage colleagues and remind them of their responsibilities", says internal and external scrutiny of the hospitals' practices indicate that they have the right measures in place.
She said: "Peer reviews by external organisations last year indicated that we're doing the right things and we just need to keep focusing on that.
"We see very good compliance with our standards when wards, who have patients which contract C Difficile, are put on infection control special measures audits.
"I lead a team which visits the ward, and checks it against 30 components.
"We expect those wards to be at a minimum of 75 per cent compliance with those components.
"We give them clear direction for improvement and continue with the weekly audit until the ward meets the required standard.
"That gives me a lot of assurance that we are seeing robust, appropriate, timely interventions."
The cases for which the trust has been fined are hospital-acquired instances of C Difficile - they do not include the number of patients who are prescribed antibiotics and develop the infection in the community and are then treated for it at Epsom or St Helier.
Ms Hart said: "We still test those patients and treat them, but they don't count towards the numbers which are put against the organisation, they count against the primary care trust and CCGs who will have plans in place to manage that.
"We have shared our antibiotic prescribing policy with our local CCGs so they can see if they want to make any amends to their practices."
The C Diff target set for the trust for this financial year has been reduced by six cases to 47.
Any cases of the infection above this will each incur a £50,000 fine, with the maximum total fine capped at £1.7million.
Ms Hart said that while it is "anxious that it's going to be a challenging year", the trust is "fairly confident".
When this newspaper reported the prospect of a £4.8million fine, residents said they were alarmed that such an amount should be incurred by hospitals running at substantial financial deficits - the main reason cited for the collapse of the merger between Epsom and Ashford and St Peter's Hospital Trust, which led to Epsom's eleventh-hour inclusion in the BSBV review.
But Ms Hart said: "I entirely agree with the concept of targets, we are absolutely signed up to having the minimum number of cases we can.
"Clearly we would have preferred not to receive the fine, but we have improved our financial performance over the last year despite having the fine.
"Our focus is entirely on ensuring our patients receive the quality of care they deserve. The finances are secondary.
"If we get the quality of care right, we'll get the finances right."
Despite being told by the other hospitals in the BSBV review - Kingston, Croydon and St George's - in March that they had not incurred fines for missing their C Diff targets, spokesmen for these hospitals did not reveal, when asked, that they had all, in fact, missed their targets for the last financial year.