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Clostridium difficile infection objectives for NHS organisations in 2019/20 and guidance on the intention to review financial sanctions and sampling rates from 2020/21 February 2019

We support providers to give patients

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within local health systems that are

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1 | Contents

Contents

1. Introduction ................................................................................ 2

2. Clostridium difficile infection objectives ...................................... 5

3. Setting objectives for clinical commissioning groups ................. 9

Annex 1: Clostridium difficile infection case checklist .................. 10

Annex 2: Example Clostridium difficile infection assessment tool and action plan ............................................................................ 15

Annex 3: Key baseline questions to assess the Clostridium difficile infection burden ........................................................................... 16

Annex 4: Clostridium difficile infection objectives for non-teaching, teaching and specialist acute trusts, and CCGs for 2019/20 ....... 20

2 | Clostridium difficile infection objectives for NHS organisations in 2019/20

1. Introduction

Clostridium difficile infection (CDI) remains an unpleasant, and potentially severe or even fatal,

infection that occurs mainly in elderly and other vulnerable patient groups, especially those

who have been exposed to antibiotic treatment.

The NHS has made great strides in reducing the number of CDIs, but the rate of improvement

has slowed over recent years and some infections are a consequence of factors outside the

control of the NHS organisation that detected the infection. Further improvement on the current

position is likely to require greater understanding of individual causes across the healthcare

system to ensure all potential learning is identified and avoid a culture of apportioning blame

through the lapses in care process. Notice of the change in reporting was given last year in

March.

Objectives this year have been set using the data from 1 April 2018 to 31 December 2018.

This data has been annualised and a count of cases calculated for each clinical commissioning

group (CCG) and NHS acute provider (Annex 4) using the new case assignment definitions

(see below). This methodology has been in shadow form on the Public Health England (PHE)

data capture system since 2017/18. The focus will now be on a system-wide approach for

delivery of objectives, with CCGs having responsibility or accountability for delivery of

reductions in the total number of cases assigned to them.

New case assignment definitions: In 2014 the Advisory Committee on

Antimicrobial Resistance and Healthcare Associated Infection recommended

updating the definitions used to attribute/apportion CDIs to align them with

other recognised international definitions; in particular those from the Centers

for Disease Control and the European Centre for Disease Control.1

1 Kuijper EJ, Coignard B, Tüll P; ESCMID Study Group for Clostridium difficile; EU Member States; European Centre for Disease Prevention and Control. Emergence of Clostridium difficile-associated disease in North America and Europe. Clin Microbiol Infect 2006;12 Suppl 6:2-18 McDonald LC1, Coignard B, Dubberke E, Song X, Horan T, Kutty PK; Ad Hoc Clostridium difficile Surveillance Working Group. Recommendations for surveillance of Clostridium difficile-associated disease. Infect Control Hosp Epidemiol. 2007 Feb;28(2):140-5

https://improvement.nhs.uk/documents/808/CDI_objectives_18_19_FINAL_Oct2018.pdf


Changes to the CDI reporting algorithm

The changes to the CDI reporting algorithm for financial year 2019/20 are:

• adding a prior healthcare exposure element for community onset cases

• reducing the number of days to apportion hospital-onset healthcare associated cases

from three or more (day 4 onwards) to two or more (day 3 onwards) days following

admission. For 2019/20 cases reported to the healthcare associated infection data

capture system will be assigned as follows:

• hospital onset healthcare associated: cases that are detected in the hospital two or

more days after admission

• community onset healthcare associated: cases that occur in the community (or

within two days of admission) when the patient has been an inpatient in the trust

reporting the case in the previous four weeks

• community onset indeterminate association: cases that occur in the community (or

within two days of admission) when the patient has been an inpatient in the trust

reporting the case in the previous 12 weeks but not the most recent four weeks

• community onset community associated: cases that occur in the community (or

within two days of admission) when the patient has not been an inpatient in the trust

reporting the case in the previous 12 weeks.

Acute provider objectives for 2019/20 will be set using these two categories:

• hospital onset healthcare associated: cases that are detected in the hospital two or

more days after admission

• community onset healthcare associated: cases that occur in the community (or within

two days of admission) when the patient has been an inpatient in the trust reporting the

case in the previous four weeks.

CCG objectives will be set on the total number of CDI cases assigned to the CCG (hospital

onset healthcare associated, community onset healthcare associated, community onset

indeterminate association and community onset community associated).

Guidance for testing and reporting CDI cases remains unchanged and the safety and care of

patients must be the over-riding concern for everyone. The current protocol for testing and

diagnosing CDI (March 2012) is based on peer-reviewed, published research.

http://www.gov.uk/government/publications/updated-guidance-on-the-diagnosis-and-reporting-of-clostridium-difficile


However, we recognise that no test, or combination of tests, is infallible and the clinical

condition of the patient should always be taken into consideration when making management

and clinical choices.

NHS foundation trust and NHS trust boards, commissioners and regulators will need to be

aware of this change to the attribution. While we do not expect any increase in the total

number of cases, there will be a shift in numbers of cases that are trust assigned, particularly

as healthcare associated cases will include those with recent (last four weeks) hospitalisation.

Based on PHE data, current estimates are that the proportion of healthcare associated cases

will increase to around 65% of the total number of cases.

Financial sanctions will continue to be applied this financial year: the key change is shifting the

culture from the application of sanctions to learning and improving patient safety. Provider and

CCG boards should ensure all cases reported to them are entered on the PHE data capture

system and not just cases associated with previous definitions such as ‘lapses in care’. It is

important that the total number of patients/cases accurately reflects the total burden of this

infection on the provider and the local health and social care system. Local commissioners

should agree how sanctions will be applied.

Notification of intention to review financial sanctions and sampling rates from 2020/21

The faecal sampling and CDI testing rates for all NHS providers will be reviewed to determine

how they compare, especially for similar institutions. PHE already collects data on such

sampling and testing rates on a quarterly basis; providers need to ensure during 2019/20 that

the data is accurate. We are aware that workload variation between laboratories ‒ for example,

the proportion of all faecal samples received that originates from the community as opposed to

from hospitalised patients ‒ will affect CDI testing rates.

Preliminary analyses of the data already submitted to the PHE data capture system show

marked variations, which need to be explained/addressed to minimise the risk of ascertainment

bias on CDI rates. Failure to diagnose CDI raises the possibility of poor outcomes for patients

and missed opportunities for CDI control. There will be a particular focus on providers with high

CDI rates but low sampling/testing rates relative to their peers.

The option to review financial sanctions and the current lapses in care process will be

undertaken ahead of objective setting for 2020-2021.


2. Clostridium difficile infection objectives

Acute providers

For 2019/20, we will continue to encourage organisations across the health and social care

system to carry out clinical case reviews for each CDI case to determine whether it was linked

to any lapses in care related to the care and treatment of the patients, in or out of the hospital

setting and identify any patient safety issues or learning. The co-ordinating commissioner

under each commissioning contract will continue to be able to consider the results of these

assessments to seek assurance that robust systems are in place to prevent, diagnose and

treat CDI infections.

Organisations with 10 or fewer cases should aim to remain at or below the annualised

calculated out turn and continue to review cases to identify good practice or areas for

improvement.

This should not be interpreted as suggesting all organisations have reached an ‘irreducible

minimum’ of CDI cases. We need to continue to reduce CDI across the NHS and we strongly

encourage organisations that continue to be outliers to review processes to further improve.

Annex 4 lists the CDI objectives for NHS trusts and foundation trusts and CCGs for 2019/20.

This is based on the out turn for 1 April 2018 to 31 December 2018 using the new case

definitions. PHE has used modelling to annualise these total figures using the new case

definitions and calculated the number of cases for the 2019/20 ambitions. All providers and

CCGs will be expected to reduce total numbers by at least one case based on this modelling.

Application to independent sector providers

The process outlined above applies to NHS trusts and foundation trusts. The same principles will

apply to independent sector providers.

Application to community providers

There are currently no national CDI objectives for community services providers, but

commissioners are advised to apply the same principles as applied to hospital onset


healthcare associated and community onset healthcare associated infections to encourage

learning and improvement. This should include cases associated with community providers,

relevant independent contractors and other health or social care providers but cases from

community services managed by acute trusts will continue to be recorded as acute trust cases.

Following identification of a sample positive for C. difficile obtained within two days of

admission to an acute setting or from a community setting or independent provider (where day

one is day of admission), providers and commissioners should assess the care provided to

identify any areas for learning. Any learning should support the development of an action plan

and subsequent improvement in care as well as forming part of the relevant contract

management processes.

A process of assessing each infection allows clinical teams working across health and social

care to focus their efforts where problems have been identified and ensure that remedial

actions are implemented and lessons learned to prevent future infections. This approach

supports continual learning and improvement of patient safety. It is critical that appropriate

action-planning and implementation follow identification of cases.

It is also important to emphasise that commissioners should have effective systems for

monitoring trust compliance with applying the recommended, evidence-based C. difficile case

definition and testing algorithm.2 A consistent approach across trusts is essential in supporting

the process of learning to enhance patient safety.

All CDIs should still be reported according to national reporting requirements. Where they are

associated with learning/lapses in care they are patient safety incidents and should also be

reported via local risk management systems to the National Reporting and Learning System.3

Staff reporting CDIs as patient safety incidents are encouraged to update incident reports with

any learning from their local assessment processes.

All CDIs that are deemed to be Serious Incidents according to existing national definitions4

(typically CDIs with identified lapses/learning in care and that led to death or serious harm)

should be reported to the Strategic Executive Information System (STEIS), and the ‘lessons

2 Inclusion criteria for reporting C. difficile infection to the surveillance system www.gov.uk/government/publications/clostridium-difficile-infection-criteria-for-reporting 3 Report a patient safety incident www.nrls.npsa.nhs.uk/report-a-patient-safety-incident/ 4 https://improvement.nhs.uk/resources/serious-incident-framework/

https://www.gov.uk/government/publications/clostridium-difficile-infection-criteria-for-reporting

http://www.nrls.npsa.nhs.uk/report-a-patient-safety-incident/

https://improvement.nhs.uk/resources/serious-incident-framework/


learned’ field in STEIS should be updated once the investigation is completed within the

mandatory timeframe.

CDI objectives and sanction regime

Acute providers

For 2019/20, organisations will continue to be encouraged to assess each CDI case to

determine whether the case was linked to a lapse in the quality of care provided to patients.

The Co-ordinating Commissioner under each commissioning contract will continue to be able

to consider the results of these assessments and exercise discretion in deciding whether any

individual case of CDI affecting a patient under its contract should count towards the aggregate

number of cases on the basis of which contractual sanctions are calculated.

For 2019/20, the contractual sanction that can be applied to each CDI case in excess of an

acute organisation’s objective will remain at £10,000.

The option to apply contractual sanctions remains and will be at the discretion of the co-

ordinating commissioners. Sanctions remain an option to ensure organisations continue to

prioritise this important area, while focusing on a new dataset and keeping patient safety as a

top priority for all providers and commissioners.

Confirmed CDI cases should be assessed by the reporting provider and the relevant co-

ordinating commissioner, to determine whether cases should have sanctions applied. The level

of any overall sanction for the provider as a whole will then be calculated on the basis of the

aggregate position against target. The figure used for cases in the contractual formula (Figure

A in Schedule 4F) will reflect the decisions reached separately on individual cases by each co-

ordinating commissioner. The split of any overall sanction between separate contracts will

then be determined through application of the formula in Schedule 4F of the contract (based

on the bed-day split between contracts). The decision to apply sanctions is at the discretion of

the co-ordinating commissioner and is not subject to challenge through contract dispute

resolution procedures.

Where a provider has multiple contracts, most acute providers will have separate contracts and

therefore separate co-ordinating commissioners. The CDI objective continues to apply at the

level of the provider as a whole however. This will require a slightly more complex process,

which should be considered among co-commissioners at the beginning of the financial year.


The level of any overall sanction for the provider as a whole will then be calculated on the

basis of the aggregate position against target for the provider as a whole. The figure used for

actual cases in the contractual formula (Figure A in Schedule 4F) will reflect the decisions

reached separately on individual cases by each co-ordinating commissioner. For 2019/20, the

contractual sanction that can be applied to each CDI case in excess of an acute organisation’s

objective will remain at £10,000.

The split of any overall sanction between separate contracts will then be determined through

application of the formula in Schedule 4F of the contract (based on the bed-day split between

contracts).

The parties to the provider’s various contracts will need to work closely together to make this

process work efficiently and avoid any duplication in the reporting requirements placed on the

provider.


3. Setting objectives for clinical commissioning groups

C. difficile objectives have been set for CCGs (see Annex 4). They will be set on the total

number of CDI cases assigned to the CCG (hospital healthcare onset healthcare associated,

community onset healthcare associated, community onset indeterminate association and

community onset community associated). NHS providers, independent sector and primary care

organisations are required to focus on system-wide numbers for each of the CCGs to

encourage improvement and case reviews for all the case assignment categories.

CCGs should use the objectives provided as baseline of levels of ambition for planning

purposes. NHS England regions, Health and Wellbeing Boards and others should use the

objectives as benchmarks for assessing how well CCGs are tackling CDIs in their areas.

10 | > Annex 1: Clostridium difficile infection case checklist

Annex 1: Clostridium difficile infection case checklist

This checklist was developed by the Public Health England CDI ‘Lapse in Care’

sub-group.

The checklist can guide local assessment of CDI cases to capture the minimum

information needed to determine the learning required to prevent it happening

again. It should ensure a consistent approach to information in CDI case

assessments across the whole health economy to identify recurring themes and

reduce healthcare associated infections.

It will also help you understand what your local co-ordinating commissioners

will be looking for if you wish to discuss cases you consider occurred despite

no lapses in care, as outlined in this guidance.

1.0 Local CDI assessment – what to include:

1.1 Hospital Data Capture System case number

1.2 Date of birth

1.3 Male/female

1.4 Date of current admission during which CDI was diagnosed

1.5 Initial reason for this admission, underlying conditions, and whether diarrhoea

was present when admitted

1.6 The patient pathway should be clearly stated

1.7 Were any of the following risk factors for developing diarrhoea identified on

admission or when the specimen was taken, including:

• recent laxatives/enemas/anti-emetics/protein pump inhibitors

• enteral nutrition

• inflammatory bowel disease

• previous gastrointestinal surgery


• gastrointestinal malignancy

• ileostomy/colostomy

• other gastrointestinal infection, eg norovirus

• chemotherapy/graft versus host disease

• other immunosuppressive illness or therapies, eg steroids.

1.8 Was bowel habit recorded on admission? Was the Bristol stool chart (BSC)

used? Was it used immediately when symptoms began? Summarise the BSC

results. Were other measures used to monitor for the presence of diarrhoea in

this patient?

1.9 On what date were diarrhoeal symptoms first documented in relation to the

current episode of CDI? Was the patient source isolated at the time? If no,

how soon after onset of diarrhoeal symptoms was the patient source isolated?

What was/were the reasons for delay in source-isolation? If there is

insufficient information available to determine the timeliness of

interventions, then this is a potentially important shortcoming.

1.10 On what date and in which location was the sample taken? Was there a delay

in sampling according to your local guidance? As a minimum, national

guidance should have been followed.

1.11 On what date and at what time was the sample received in the laboratory? On

what date and at what time was the result was reported to the sender?

1.12 Were the sampling, testing and reporting arrangements in this case clearly

compliant with the 2012 Department of Health (now Department of Health and

Social Care) guidance Updated guidance on the diagnosis and reporting of

Clostridium difficile?

1.13 How long did the patient remain under appropriate source-isolation after the

CDI diagnosis? If the patient was removed from source isolation what was the

rationale? Was this consistent with your local guidance?

1.14 If there was any non-compliance above – explain why.

2.0 Chronology of patient pathway

2.1 Provide an outline timeline where the patient was in the three months prior to

the latest CDI diagnosis, eg home, hospital, care home, etc. Ideally, identify if

they had any contact with known CDI cases or carriers of C. difficile (eg GDH-

positive, toxin-negative cases) in these locations and, if so, any relevant

ribotyping/MLVA results that are available.

2.2 Had the patient had any previous confirmed episodes of CDI? If yes, when did

they occur? If performed, what are/were the ribotyping/MLVA typing results of


the current and any past episodes of CDI? Had the patient been told of the

CDI diagnosis and understood the condition?

2.3 If you suspect that the latest case is a recurrence, outline if the previous

episode(s) were correctly treated as per your local CDI treatment guideline.

Was the patient treated with any other antimicrobials between this and the

previous episode(s)? Was this treatment in line with local guidelines?

2.4 Has the patient received other treatment (eg enteral feeding) and/or

medication (eg proton pump inhibitors) possibly relevant to the development of

this episode of CDI? Were these in line with local guidelines?

2.5 If there was any non-compliance above – explain why.

3.0 Antimicrobial therapy

3.1 List all antimicrobial therapy (antibiotic, dose, duration) in the previous 12

weeks.

3.2 Concerning the current episode/admission, were the indication(s) for

antimicrobial treatment duration and the review date written in the patient’s

notes or drug chart? Was the indication(s) for this treatment appropriate at the

point it was prescribed?

3.3 Was initial empiric therapy appropriately modified in response to

microbiological results?

3.4 Were all antimicrobials prescribed compliant with local guidelines? If not, were

they still clinically justified (please provide an explanation)?

3.5 If there was any non-compliance above, explain why.

4.0 Treatment of CDI and outcome

4.1 Was the patient treated for CDI on this occasion? If not, what were the clinical

factors that were used to determine treatment was not required?

4.2 Was the patient told of the CDI diagnosis and did he/she demonstrate an

understanding of the condition?

4.3 Does your local CDI treatment guideline contain a measure of severity? If so,

how was this case categorised?

4.4 If this case was treated, what treatment (drug, dose, duration) was used? Was

this treatment compliant with your local guidance?

4.5 What was the clinical outcome? Did the patient die within 30 days of CDI

diagnosis? If so, was this death linked to CDI? Did CDI appear on the death

certificate (which part); please provide details of all conditions listed?

4.6 If there was any non-compliance above – explain why


5.0 Environmental factors

5.1 Were there any cleanliness/environmental issues reported in relation to the

area(s) in which the patient was cared for prior to the development of CDI

(including the results of recent audits)? Please provide details of any issues.

5.2 Outline details of any additional cleaning measures that have been deployed

in this/these area(s) over the previous three months (eg hydrogen peroxide

vaporisation) either as a pre-emptive measure (eg whole ward decant/deep

clean) or as terminal side room cleaning in relation to previous episodes of

CDI.

5.3 What audit/monitoring measures were in place to assess the efficacy of

cleaning? How robust (quantitative/qualitative) are these?

5.4 What monitoring of hand hygiene compliance was in place at the time

including how robust this monitoring was, eg who did this? What were the

results?


6.0 Organisation issues

6.1 Were there any organisational factors that might have influenced this case?

This could include whether staffing levels/skill mix were in line with local

agreements where this patient was managed.

6.2 Is there evidence that mandatory training and infection, prevention and control

training have been undertaken by staff relevant to this case?

6.3 Is there evidence that communication and documentation related to this

patient was adequate?

6.4 If there was any non-compliance above, explain why and how this could /

could not be related to the development of C. difficile infection.

7.0 Optimisation of diarrhoea control in the organisation

7.1 Does the organisation have a protocol for the management of patients with

diarrhoea? Was this being followed in the clinical area relevant to this case?

More specifically:

7.1.1 Was the documentation of patients with diarrhoea adequate/complete?

7.1.2 Was the rate of diarrhoea increased in the clinical area relevant to the index

case (during the 1 month beforehand)? Was a reason for this found and what

measures were put in place to address this? Were these patients managed in

accordance with local guidance in relation to sampling and source isolation of

suspected infectious causes of diarrhoea?



8.0 Lessons learned

8.1 Outline the lessons learned from this episode of CDI. Are there any recurring

themes seen across this and other assessments? How have these been

addressed?

8.2 Provide a commentary on any recurring themes from previous CDI case

assessments. What is the hypothesis for why these cases are still happening?

What action(s) has the organisation put in place to prevent further cases of

CDI? What factors appear to be responsible for their lack of success?

9.0 Preventability

9.1 State whether you have identified any learning that could have contributed to

the development of this CDI case.

9.2 To facilitate learning and optimisation of patient care, please identify any other

lapses in care, ie that did not contribute to the development of this CDI case.

9.3 If you consider this CDI case occurred despite no lapses in care (and so was

deemed not to be ‘preventable’), outline your reason(s) why.

15 | > Annex 2: Example Clostridium difficile infection assessment tool and action plan

Annex 2: Example

Clostridium difficile infection

assessment tool and action

plan Organisations can use this example assessment tool5 to collect the minimum

information needed to determine the learning required to prevent CDI cases. It will

support a consistent approach to gathering information generated by CDI

assessments across the whole health economy and identifying recurring themes,

and will therefore contribute to the reduction of healthcare associated infections.

Organisations and commissioners are encouraged to use this tool but are free to

adapt it according to local guidance.

5 https://improvement.nhs.uk/resources/clostridium-difficile-infection-objectives/

https://improvement.nhs.uk/resources/clostridium-difficile-infection-objectives/

16 | > Annex 3: Key baseline questions to assess the Clostridium difficile infection burden

Annex 3: Key baseline

questions to assess the

Clostridium difficile infection

burden The Department of Health and Social Care Advisory Committee on Antimicrobial

Prescribing, Resistance and Healthcare Associated Infections (APRHAI) developed

these questions to support organisations to understand whether patients presenting

with diarrhoea are appropriately assessed and their illness investigated. When a

patient presents with diarrhoea, it is important to consider the possibility that there

may be an infectious cause. Patients with suspected potentially infectious diarrhoea

should be isolated and have appropriate investigation(s) to determine the aetiology.

If patients with a suspected CDI are not investigated appropriately there is a risk of

sub-optimal treatment and transmission to other patients. The timely submission of

a faecal sample for microbiological testing is a fundamental part of the investigation

of potentially infectious diarrhoea.

Furthermore, reported numbers of cases may provide false assurance of minimal

risk of CDI in patients and/or transmission of C. difficile between patients.

There are three key elements to measuring the burden of CDI. A consistent

approach to:

• which patients are sampled

• how laboratory testing is carried out

• which results are reported

will ensure the prompt recognition and isolation of infected patients in the interests

of patient safety and ensure that recorded numbers of CDIs reflect the true rate of

infection.


Guidance on these three elements was issued to the NHS in 2012.6

Failure to diagnose CDI carries increased potential risk for patients because

treatment and prevention practices may be compromised.

Failure to detect all possible cases of CDI increases the chance of transmission of

C. difficile, including the spread of epidemic/virulent strains.

The seven questions in Table 1 will determine whether the recorded number of

cases accurately reflects CDI burden.

Table 1: Questions to determine whether the recorded number of cases accurately reflects CDI burden

Table 1: Questions to determine whether the recorded number of cases accurately reflects CDI burden

Question How to assess compliance

Notes

1. Are faecal samples sent for C. difficile testing from all patients who develop diarrhoea, regardless of when this occurs, if there is not a clear, non-infection, alternative explanation for its cause?

Ideally assess compliance via audit data that show how many patients have new onset diarrhoea (as defined in guidance: Bristol stool chart types 5-7), and what proportion of these are sampled appropriately. This assessment should include whether necessary samples are sent to microbiology and when are they sent – should be on the same day as new symptoms begin.

Guidance states: If a patient has diarrhoea (Bristol stool chart types 5-7) that is not clearly attributable to an underlying condition (eg inflammatory colitis, overflow) or therapy (eg laxatives, enteral feeding) then it is necessary to determine if this is due to CDI. If in doubt, please seek advice. Assumptions that CDI is not the cause of new diarrhoeal episodes need to be robust and documented in the patient’s notes. There should be a medical assessment of cases to assure that diarrhoea is not of infective origin; reasonable alternative explanations are quoted in the above excerpt from guidance.

2. What is the evidence that this is understood and practised consistently

Direct questioning of healthcare workers or via audit data as above.

As this is the starting point for the entire testing pathway, it is important that healthcare workers understand which patients require

6 Updated guidance on the diagnosis and reporting of Clostridium difficile: www.gov.uk/government/publications/updated-guidance-on-the-diagnosis-and-reporting-of-clostridium-difficile


by all healthcare staff across the organisation?

samples to be sent to microbiology.

3. Are all diarrhoeal samples received in the laboratory from hospital patients aged >2 years, community patients aged >65 years, and community patients aged <65 years wherever clinically indicated tested for C. difficile?

There should be a laboratory standard operating procedure (sometimes referred to an examination procedure) that clearly states which samples received in the laboratory are tested for evidence of CDI. There are likely to be different rules for how hospital inpatient vs community patient samples are processed as set out in DH CDI testing guidance (see right). Have laboratories audited their practice to show that appropriate samples are tested for CDI and inappropriate samples are not tested for CDI (eg samples from infants, non-diarrhoeal samples)?

Guidance states: Diarrhoeal samples should be tested for C. difficile from:

• hospital patients aged >2 years, community patients, aged >65 years

• community patients aged <65 years

wherever clinically indicated.

4. Is all C. difficile testing consistent with the recommended two-stage algorithm?

There should be laboratory standard operating procedure that clearly states how samples received in the laboratory are tested for evidence of CDI. Have laboratories audited their practice to show that samples are tested appropriately?

Guidance states: The first test should be either a glutamate dehydrogenase (GDH_ or toxin gene (PCR) test; if this is positive, the second test should be a toxin (Enzyme immunoassay EIA or cytotoxin) test. If the first test is negative, a second test is not needed. Additional tests may be used, but not instead of the recommended approach. If samples from patients with diarrhoea are not tested appropriately for evidence of CDI there is a risk of false-negative and/or false-positive results.

5. Are all toxin-positive patients reported to PHE?

The number of laboratory-reported CDI-positive samples should match the number of cases reported

Guidance states: All GDH EIA (or Nucleic Acid Amplification Test NAAT) positive, toxin positive


to PHE (after applying de-duplication according to 28-day rule). What is the organisation’s rationale for not reporting toxin positive cases (see question 6. below)?

patients/reports should be reportedto PHE via the data capture system

6. Are clinical criteria or other tests outside of the algorithm referred to in question 4 above used to determine which toxin positive results are reported to PHE?

The number of laboratory-reported CDI-positive cases should match the number of cases reported to PHE (after applying de-duplication according to the 28-day rule).

See 5. above. The results of other tests and/or clinical criteria should not be used to determine which positive patients are reported to PHE.

7. Are toxin positive results obtained >28 days after a previous positive result on the same patient reported to PHE?

The number of laboratory-reported CDI-positive cases should match the number of cases reported to PHE (after applying de-duplication according to 28-day rule).

See 5. above. Patients with repeat positive results more than 28 days apart should also be reported. Such results likely indicate recurrence of CDI. Such recurrences are due to relapse or re-infection, and some may be preventable.

20 | > Annex 4: Clostridium difficile infection objectives for non-teaching, teaching and specialist acute trusts, and CCGs for 2019/20

Annex 4: Clostridium

difficile infection objectives

for non-teaching, teaching

and specialist acute trusts,

and CCGs for 2019/20 The organisation classifications are taken from the Estates Return Information Collection

(ERIC) for 2017/18 published by NHS Digital.

Objectives for 2019/20 are set to the same as each trusts’ number of cases estimated for

2018/19 based on rate for 2018/19 Q1-3 then extrapolated to the full year to give an

estimated count. The objective is then calculated from that count. If a trust has less than or

equal to ten cases the objective will be equal to that count. If a trust has more than ten

cases the objective will be one less than the count.

Non-teaching acute trusts

Org code

Name CDI case objective for 2019/20

CDI rate objective for 2019/20

REM AINTREE UNIVERSITY HOSPITAL NHS FOUNDATION TRUST

56 21.4

RCF AIREDALE NHS FOUNDATION TRUST 10 9.9

RTK ASHFORD AND ST PETER'S HOSPITALS NHS FOUNDATION TRUST

28 17.7

RF4 BARKING, HAVERING AND REDBRIDGE UNIVERSITY HOSPITALS NHS TRUST

24 8.1

RFF BARNSLEY HOSPITAL NHS FOUNDATION TRUST 19 15.3


RDD BASILDON AND THURROCK UNIVERSITY HOSPITALS NHS FOUNDATION TRUST

51 21.4

RC1 BEDFORD HOSPITAL NHS TRUST 14 10.0

RMC BOLTON NHS FOUNDATION TRUST 32 16.5

RXH BRIGHTON AND SUSSEX UNIVERSITY HOSPITALS NHS TRUST

76 25.9

RXQ BUCKINGHAMSHIRE HEALTHCARE NHS TRUST 65 26.4

RWY CALDERDALE AND HUDDERSFIELD NHS FOUNDATION TRUST

40 17.5

RFS CHESTERFIELD ROYAL HOSPITAL NHS FOUNDATION TRUST

34 22.3

RJR COUNTESS OF CHESTER HOSPITAL NHS FOUNDATION TRUST

36 19.6

RXP COUNTY DURHAM AND DARLINGTON NHS FOUNDATION TRUST

45 16.4

RJ6 CROYDON HEALTH SERVICES NHS TRUST 23 13.5

RN7 DARTFORD AND GRAVESHAM NHS TRUST 32 18.4

RP5 DONCASTER AND BASSETLAW TEACHING HOSPITALS NHS FOUNDATION TRUST

44 18.1

RBD DORSET COUNTY HOSPITAL NHS FOUNDATION TRUST

16 17.6

RWH EAST AND NORTH HERTFORDSHIRE NHS TRUST 52 25.3

RJN EAST CHESHIRE NHS TRUST 27 26.2

RXR EAST LANCASHIRE HOSPITALS NHS TRUST 51 16.8

RDE EAST SUFFOLK AND NORTH ESSEX NHS FOUNDATION TRUST

107 25.7

RXC EAST SUSSEX HEALTHCARE NHS TRUST 68 28.3

RVR EPSOM AND ST HELIER UNIVERSITY HOSPITALS NHS TRUST

52 20.7

RDU FRIMLEY HEALTH NHS FOUNDATION TRUST 61 13.9


RR7 GATESHEAD HEALTH NHS FOUNDATION TRUST 40 23.6

RLT GEORGE ELIOT HOSPITAL NHS TRUST 14 13.5

RTE GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST

96 30.2

RN3 GREAT WESTERN HOSPITALS NHS FOUNDATION TRUST

47 23.8

RN5 HAMPSHIRE HOSPITALS NHS FOUNDATION TRUST

60 23.7

RCD HARROGATE AND DISTRICT NHS FOUNDATION TRUST

19 20.2

RQX HOMERTON UNIVERSITY HOSPITAL NHS FOUNDATION TRUST

12 13.7

R1F ISLE OF WIGHT NHS TRUST 19 20.2

RGP JAMES PAGET UNIVERSITY HOSPITALS NHS FOUNDATION TRUST

24 18.6

RNQ KETTERING GENERAL HOSPITAL NHS FOUNDATION TRUST

39 17.4

RAX KINGSTON HOSPITAL NHS FOUNDATION TRUST 45 32.8

RJ2 LEWISHAM AND GREENWICH NHS TRUST 27 8.6

R1K LONDON NORTH WEST UNIVERSITY HEALTHCARE NHS TRUST

68 16.5

RC9 LUTON AND DUNSTABLE UNIVERSITY HOSPITAL NHS FOUNDATION TRUST

19 8.7

RWF MAIDSTONE AND TUNBRIDGE WELLS NHS TRUST 55 21.4

RPA MEDWAY NHS FOUNDATION TRUST 43 26.2

RBT MID CHESHIRE HOSPITALS NHS FOUNDATION TRUST

27 16.3

RQ8 MID ESSEX HOSPITAL SERVICES NHS TRUST 83 42.0

RXF MID YORKSHIRE HOSPITALS NHS TRUST 73 22.2

RD8 MILTON KEYNES UNIVERSITY HOSPITAL NHS FOUNDATION TRUST

22 13.3


RVJ NORTH BRISTOL NHS TRUST 57 18.4

RNL NORTH CUMBRIA UNIVERSITY HOSPITALS NHS TRUST

53 30.7

RAP NORTH MIDDLESEX UNIVERSITY HOSPITAL NHS TRUST

51 31.0

RVW NORTH TEES AND HARTLEPOOL NHS FOUNDATION TRUST

56 30.3

RGN NORTH WEST ANGLIA NHS FOUNDATION TRUST 68 26.0

RNS NORTHAMPTON GENERAL HOSPITAL NHS TRUST 40 16.2

RBZ NORTHERN DEVON HEALTHCARE NHS TRUST 9 11.6

RJL NORTHERN LINCOLNSHIRE AND GOOLE NHS FOUNDATION TRUST

36 15.6

RTF NORTHUMBRIA HEALTHCARE NHS FOUNDATION TRUST

39 14.8

RW6 PENNINE ACUTE HOSPITALS NHS TRUST 103 27.3

RD3 POOLE HOSPITAL NHS FOUNDATION TRUST 34 19.9

RHU PORTSMOUTH HOSPITALS NHS TRUST 63 17.9

RHW ROYAL BERKSHIRE NHS FOUNDATION TRUST 24 12.9

REF ROYAL CORNWALL HOSPITALS NHS TRUST 64 28.4

RH8 ROYAL DEVON AND EXETER NHS FOUNDATION TRUST

31 12.6

RA2 ROYAL SURREY COUNTY HOSPITAL NHS FOUNDATION TRUST

26 18.8

RD1 ROYAL UNITED HOSPITALS BATH NHS FOUNDATION TRUST

59 28.5

RNZ SALISBURY NHS FOUNDATION TRUST 9 6.0

RXK SANDWELL AND WEST BIRMINGHAM HOSPITALS NHS TRUST

41 19.4

RK5 SHERWOOD FOREST HOSPITALS NHS FOUNDATION TRUST

79 40.0


RXW SHREWSBURY AND TELFORD HOSPITAL NHS TRUST

43 18.5

RJC SOUTH WARWICKSHIRE NHS FOUNDATION TRUST

24 16.1

RAJ SOUTHEND UNIVERSITY HOSPITAL NHS FOUNDATION TRUST

51 29.1

RVY SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST

16 12.8

RBN ST HELENS AND KNOWSLEY TEACHING HOSPITALS NHS TRUST

48 20.3

RWJ STOCKPORT NHS FOUNDATION TRUST 51 24.2

TBC SOUTH TYNESIDE AND SUNDERLAND NHS TRUST 87 27.7

RTP SURREY AND SUSSEX HEALTHCARE NHS TRUST 47 21.5

RMP TAMESIDE AND GLOSSOP INTEGRATED CARE NHS FOUNDATION TRUST

27 19.1

RBA TAUNTON AND SOMERSET NHS FOUNDATION TRUST

32 21.8

RNA THE DUDLEY GROUP NHS FOUNDATION TRUST 49 21.9

RAS THE HILLINGDON HOSPITALS NHS FOUNDATION TRUST

24 17.0

RQW THE PRINCESS ALEXANDRA HOSPITAL NHS TRUST

27 17.6

RCX THE QUEEN ELIZABETH HOSPITAL, KING'S LYNN, NHS FOUNDATION TRUST

44 29.7

RFR THE ROTHERHAM NHS FOUNDATION TRUST 11 8.1

RDZ THE ROYAL BOURNEMOUTH AND CHRISTCHURCH HOSPITALS NHS FOUNDATION TRUST

30 16.4

RL4 THE ROYAL WOLVERHAMPTON NHS TRUST 40 14.3

RA9 TORBAY AND SOUTH DEVON NHS FOUNDATION TRUST

36 31.4

RWD UNITED LINCOLNSHIRE HOSPITALS NHS TRUST 110 28.0


RTX UNIVERSITY HOSPITALS OF MORECAMBE BAY NHS FOUNDATION TRUST

37 19.1

RJE UNIVERSITY HOSPITALS OF NORTH MIDLANDS NHS TRUST

93 20.3

RK9 UNIVERSITY HOSPITALS PLYMOUTH NHS TRUST 63 21.4

RBK WALSALL HEALTHCARE NHS TRUST 26 17.4

RWW WARRINGTON AND HALTON HOSPITALS NHS FOUNDATION TRUST

44 24.6

RWG WEST HERTFORDSHIRE HOSPITALS NHS TRUST 34 15.1

RGR WEST SUFFOLK NHS FOUNDATION TRUST 20 15.8

RYR WESTERN SUSSEX HOSPITALS NHS FOUNDATION TRUST

64 19.2

RA3 WESTON AREA HEALTH NHS TRUST 14 16.7

RKE WHITTINGTON HEALTH NHS TRUST 19 19.6

RWP WORCESTERSHIRE ACUTE HOSPITALS NHS TRUST

53 20.6

RRF WRIGHTINGTON, WIGAN AND LEIGH NHS FOUNDATION TRUST

20 14.1

RLQ WYE VALLEY NHS TRUST 36 40.9

RA4 YEOVIL DISTRICT HOSPITAL NHS FOUNDATION TRUST

9 8.9


Teaching acute trusts

Org code



R1H BARTS HEALTH NHS TRUST 92 16.0

RXL BLACKPOOL TEACHING HOSPITALS NHS FOUNDATION TRUST

65 28.6

RAE BRADFORD TEACHING HOSPITALS NHS FOUNDATION TRUST

30 12.2

RGT CAMBRIDGE UNIVERSITY HOSPITALS NHS FOUNDATION TRUST

95 28.6

RQM CHELSEA AND WESTMINSTER HOSPITAL NHS FOUNDATION TRUST

26 9.3

RVV EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST

95 27.9

RJ1 GUY'S AND ST THOMAS' NHS FOUNDATION TRUST

26 7.9

RWA HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST

80 24.8

RYJ IMPERIAL COLLEGE HEALTHCARE NHS TRUST 77 22.7

RJZ KING'S COLLEGE HOSPITAL NHS FOUNDATION TRUST

110 23.6

RXN LANCASHIRE TEACHING HOSPITALS NHS FOUNDATION TRUST

84 29.4

RR8 LEEDS TEACHING HOSPITALS NHS TRUST 259 42.7

R0A MANCHESTER UNIVERSITY NHS FOUNDATION TRUST

173 25.7

RM1 NORFOLK AND NORWICH UNIVERSITY HOSPITALS NHS FOUNDATION TRUST

35 11.3

RX1 NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST

120 24.0


RTH OXFORD UNIVERSITY HOSPITALS NHS FOUNDATION TRUST

89 24.9

RAL ROYAL FREE LONDON NHS FOUNDATION TRUST 100 30.6

RQ6 ROYAL LIVERPOOL AND BROADGREEN UNIVERSITY HOSPITALS NHS TRUST

53 21.6

RM3 SALFORD ROYAL NHS FOUNDATION TRUST 39 15.4

RHQ SHEFFIELD TEACHING HOSPITALS NHS FOUNDATION TRUST

166 32.0

RTR SOUTH TEES HOSPITALS NHS FOUNDATION TRUST

81 28.5

RJ7 ST GEORGE'S UNIVERSITY HOSPITALS NHS FOUNDATION TRUST

48 16.2

RTD THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST

113 24.9

RRV UNIVERSITY COLLEGE LONDON HOSPITALS NHS FOUNDATION TRUST

87 35.1

RHM UNIVERSITY HOSPITAL SOUTHAMPTON NHS FOUNDATION TRUST

64 17.4

RRK UNIVERSITY HOSPITALS BIRMINGHAM NHS FOUNDATION TRUST

218 24.0

RA7 UNIVERSITY HOSPITALS BRISTOL NHS FOUNDATION TRUST

57 22.4

RKB UNIVERSITY HOSPITALS COVENTRY AND WARWICKSHIRE NHS TRUST

60 15.8

RTG UNIVERSITY HOSPITALS OF DERBY AND BURTON NHS FOUNDATION TRUST

117 26.2

RWE UNIVERSITY HOSPITALS OF LEICESTER NHS TRUST

108 21.5

RBL WIRRAL UNIVERSITY TEACHING HOSPITAL NHS FOUNDATION TRUST

88 34.6

RCB YORK TEACHING HOSPITAL NHS FOUNDATION TRUST

61 19.0


Specialist trusts

Org code



RBS ALDER HEY CHILDREN'S NHS FOUNDATION TRUST

0 0.0

RQ3 BIRMINGHAM WOMEN'S AND CHILDREN'S NHS FOUNDATION TRUST

0 0.0

RP4 GREAT ORMOND STREET HOSPITAL FOR CHILDREN NHS FOUNDATION TRUST

5 6.2

RBQ LIVERPOOL HEART AND CHEST HOSPITAL NHS FOUNDATION TRUST

4 8.9

REP LIVERPOOL WOMEN'S NHS FOUNDATION TRUST 0 0.0

RP6 MOORFIELDS EYE HOSPITAL NHS FOUNDATION TRUST

0 0.0

RPC QUEEN VICTORIA HOSPITAL NHS FOUNDATION TRUST

0 0.0

RT3 ROYAL BROMPTON & HAREFIELD NHS FOUNDATION TRUST

12 9.6

RAN ROYAL NATIONAL ORTHOPAEDIC HOSPITAL NHS TRUST

1 3.4

RGM ROYAL PAPWORTH HOSPITAL NHS FOUNDATION TRUST

11 19.2

RCU SHEFFIELD CHILDREN'S NHS FOUNDATION TRUST

12 32.8

RBV THE CHRISTIE NHS FOUNDATION TRUST 31 57.8

REN THE CLATTERBRIDGE CANCER CENTRE NHS FOUNDATION TRUST

4 15.7

RL1 THE ROBERT JONES AND AGNES HUNT ORTHOPAEDIC HOSPITAL NHS FOUNDATION TRUST

3 5.8

RPY THE ROYAL MARSDEN NHS FOUNDATION TRUST 67 117.6


RRJ THE ROYAL ORTHOPAEDIC HOSPITAL NHS FOUNDATION TRUST

3 9.7

RET THE WALTON CENTRE NHS FOUNDATION TRUST 8 15.5

Clinical commissioning groups

CCG code

Name CDI case objective 2019/20

CDI rate objective 2019/20

00C NHS DARLINGTON CCG 15 14.0

00D NHS DURHAM DALES, EASINGTON AND SEDGEFIELD CCG

61 22.4

00J NHS NORTH DURHAM CCG 49 19.8

00K NHS HARTLEPOOL AND STOCKTON-ON-TEES CCG 104 35.9

00L NHS NORTHUMBERLAND CCG 71 22.2

00M NHS SOUTH TEES CCG 92 33.2

00N NHS SOUTH TYNESIDE CCG 87 57.9

00P NHS SUNDERLAND CCG 103 37.0

00Q NHS BLACKBURN WITH DARWEN CCG 45 30.6

00R NHS BLACKPOOL CCG 51 36.3

00T NHS BOLTON CCG 53 18.8

00V NHS BURY CCG 47 24.7

00X NHS CHORLEY AND SOUTH RIBBLE CCG 63 35.7

00Y NHS OLDHAM CCG 79 33.6

01A NHS EAST LANCASHIRE CCG 77 20.5

01C NHS EASTERN CHESHIRE CCG 57 29.1

01D NHS HEYWOOD, MIDDLETON AND ROCHDALE CCG 59 26.9

01E NHS GREATER PRESTON CCG 32 15.9


01F NHS HALTON CCG 39 30.4

01G NHS SALFORD CCG 65 26.0

01H NHS NORTH CUMBRIA CCG 99 31.0

01J NHS KNOWSLEY CCG 45 30.6

01K NHS MORECAMBE BAY CCG 121 36.8

01R NHS SOUTH CHESHIRE CCG 44 24.3

01T NHS SOUTH SEFTON CCG 60 37.8

01V NHS SOUTHPORT AND FORMBY CCG 30 25.5

01W NHS STOCKPORT CCG 97 33.4

01X NHS ST HELENS CCG 36 20.2

01Y NHS TAMESIDE AND GLOSSOP CCG 72 28.0

02A NHS TRAFFORD CCG 68 28.9

02D NHS VALE ROYAL CCG 19 18.0

02E NHS WARRINGTON CCG 53 25.5

02F NHS WEST CHESHIRE CCG 87 37.1

02G NHS WEST LANCASHIRE CCG 22 18.9

02H NHS WIGAN BOROUGH CCG 71 21.8

02M NHS FYLDE AND WYRE CCG 75 39.1

02N NHS AIREDALE, WHARFEDALE AND CRAVEN CCG 23 14.3

02P NHS BARNSLEY CCG 35 14.3

02Q NHS BASSETLAW CCG 26 22.0

02R NHS BRADFORD DISTRICTS CCG 61 18.0

02T NHS CALDERDALE CCG 45 21.7

02W NHS BRADFORD CITY CCG 9 10.9

02X NHS DONCASTER CCG 85 27.6

02Y NHS EAST RIDING OF YORKSHIRE CCG 72 22.8


03A NHS GREATER HUDDERSFIELD CCG 37 15.3

03D NHS HAMBLETON, RICHMONDSHIRE AND WHITBY CCG

31 20.1

03E NHS HARROGATE AND RURAL DISTRICT CCG 31 19.3

03F NHS HULL CCG 56 21.5

03H NHS NORTH EAST LINCOLNSHIRE CCG 35 21.8

03J NHS NORTH KIRKLEES CCG 51 26.4

03K NHS NORTH LINCOLNSHIRE CCG 28 16.5

03L NHS ROTHERHAM CCG 51 19.3

03M NHS SCARBOROUGH AND RYEDALE CCG 20 18.0

03N NHS SHEFFIELD CCG 211 36.6

03Q NHS VALE OF YORK CCG 88 24.5

03R NHS WAKEFIELD CCG 97 28.5

03T NHS LINCOLNSHIRE EAST CCG 77 32.8

03V NHS CORBY CCG 12 17.6

03W NHS EAST LEICESTERSHIRE AND RUTLAND CCG 76 22.8

04C NHS LEICESTER CITY CCG 73 20.7

04D NHS LINCOLNSHIRE WEST CCG 49 20.6

04E NHS MANSFIELD AND ASHFIELD CCG 92 46.0

04F NHS MILTON KEYNES CCG 36 13.2

04G NHS NENE CCG 157 24.0

04H NHS NEWARK AND SHERWOOD CCG 41 34.2

04K NHS NOTTINGHAM CITY CCG 61 18.6

04L NHS NOTTINGHAM NORTH AND EAST CCG 24 16.0

04M NHS NOTTINGHAM WEST CCG 16 14.4

04N NHS RUSHCLIFFE CCG 32 27.7


04Q NHS SOUTH WEST LINCOLNSHIRE CCG 48 38.1

04V NHS WEST LEICESTERSHIRE CCG 97 24.5

04Y NHS CANNOCK CHASE CCG 20 14.9

05A NHS COVENTRY AND RUGBY CCG 89 19.1

05C NHS DUDLEY CCG 93 29.2

05D NHS EAST STAFFORDSHIRE CCG 43 33.6

05F NHS HEREFORDSHIRE CCG 79 41.2

05G NHS NORTH STAFFORDSHIRE CCG 48 21.9

05H NHS WARWICKSHIRE NORTH CCG 32 16.7

05J NHS REDDITCH AND BROMSGROVE CCG 41 22.7

05L NHS SANDWELL AND WEST BIRMINGHAM CCG 96 19.1

05N NHS SHROPSHIRE CCG 43 13.5

05Q NHS SOUTH EAST STAFFORDSHIRE AND SEISDON PENINSULA CCG

37 16.6

05R NHS SOUTH WARWICKSHIRE CCG 68 25.6

05T NHS SOUTH WORCESTERSHIRE CCG 72 23.6

05V NHS STAFFORD AND SURROUNDS CCG 28 18.3

05W NHS STOKE ON TRENT CCG 63 23.8

05X NHS TELFORD AND WREKIN CCG 27 15.3

05Y NHS WALSALL CCG 51 18.0

06A NHS WOLVERHAMPTON CCG 48 18.5

06D NHS WYRE FOREST CCG 23 22.7

06F NHS BEDFORDSHIRE CCG 52 11.6

06H NHS CAMBRIDGESHIRE AND PETERBOROUGH CCG

187 21.2

06K NHS EAST AND NORTH HERTFORDSHIRE CCG 109 19.2

06L NHS IPSWICH AND EAST SUFFOLK CCG 88 21.5


06M NHS GREAT YARMOUTH AND WAVENEY CCG 57 26.4

06N NHS HERTS VALLEYS CCG 117 19.7

06P NHS LUTON CCG 22 10.0

06Q NHS MID ESSEX CCG 136 34.6

06T NHS NORTH EAST ESSEX CCG 65 19.5

06V NHS NORTH NORFOLK CCG 43 24.8

06W NHS NORWICH CCG 49 22.8

06Y NHS SOUTH NORFOLK CCG 45 19.5

07G NHS THURROCK CCG 23 13.4

07H NHS WEST ESSEX CCG 53 17.5

07J NHS WEST NORFOLK CCG 71 40.2

07K NHS WEST SUFFOLK CCG 56 24.3

07L NHS BARKING AND DAGENHAM CCG 20 9.6

07M NHS BARNET CCG 104 26.8

07N NHS BEXLEY CCG 34 13.6

07P NHS BRENT CCG 67 20.3

07Q NHS BROMLEY CCG 55 16.6

07R NHS CAMDEN CCG 56 22.1

07T NHS CITY AND HACKNEY CCG 32 11.3

07V NHS CROYDON CCG 60 15.6

07W NHS EALING CCG 56 16.4

07X NHS ENFIELD CCG 67 20.0

07Y NHS HOUNSLOW CCG 32 12.0

08A NHS GREENWICH CCG 26 9.0

08C NHS HAMMERSMITH AND FULHAM CCG 27 14.7

08D NHS HARINGEY CCG 55 20.2


08E NHS HARROW CCG 49 19.9

08F NHS HAVERING CCG 34 13.1

08G NHS HILLINGDON CCG 43 14.2

08H NHS ISLINGTON CCG 30 12.6

08J NHS KINGSTON CCG 60 34.4

08K NHS LAMBETH CCG 37 11.6

08L NHS LEWISHAM CCG 39 12.9

08M NHS NEWHAM CCG 22 6.2

08N NHS REDBRIDGE CCG 30 9.8

08P NHS RICHMOND CCG 31 15.8

08Q NHS SOUTHWARK CCG 49 15.7

08R NHS MERTON CCG 28 13.7

08T NHS SUTTON CCG 44 21.7

08V NHS TOWER HAMLETS CCG 32 10.4

08W NHS WALTHAM FOREST CCG 28 10.2

08X NHS WANDSWORTH CCG 49 15.3

08Y NHS WEST LONDON CCG 34 15.0

09A NHS CENTRAL LONDON (WESTMINSTER) CCG 34 18.9

09C NHS ASHFORD CCG 18 13.8

09D NHS BRIGHTON AND HOVE CCG 91 31.4

09E NHS CANTERBURY AND COASTAL CCG 37 17.6

09F NHS EASTBOURNE, HAILSHAM AND SEAFORD CCG 75 39.2

09G NHS COASTAL WEST SUSSEX CCG 133 26.4

09H NHS CRAWLEY CCG 16 14.6

09J NHS DARTFORD, GRAVESHAM AND SWANLEY CCG 65 25.0

09L NHS EAST SURREY CCG 34 18.1


09N NHS GUILDFORD AND WAVERLEY CCG 34 16.0

09P NHS HASTINGS AND ROTHER CCG 51 27.0

09W NHS MEDWAY CCG 52 18.8

09X NHS HORSHAM AND MID SUSSEX CCG 69 29.4

09Y NHS NORTH WEST SURREY CCG 64 18.4

10A NHS SOUTH KENT COAST CCG 61 29.3

10C NHS SURREY HEATH CCG 11 11.3

10D NHS SWALE CCG 27 23.1

10E NHS THANET CCG 43 30.3

10J NHS NORTH HAMPSHIRE CCG 28 12.6

10K NHS FAREHAM AND GOSPORT CCG 61 30.4

10L NHS ISLE OF WIGHT CCG 43 30.4

10Q NHS OXFORDSHIRE CCG 136 20.3

10R NHS PORTSMOUTH CCG 40 18.7

10V NHS SOUTH EASTERN HAMPSHIRE CCG 36 16.8

10X NHS SOUTHAMPTON CCG 44 17.5

11A NHS WEST HAMPSHIRE CCG 160 28.3

11E NHS BATH AND NORTH EAST SOMERSET CCG 56 29.7

11J NHS DORSET CCG 160 20.7

11M NHS GLOUCESTERSHIRE CCG 194 30.9

11N NHS KERNOW CCG 148 26.2

11X NHS SOMERSET CCG 83 14.9

12D NHS SWINDON CCG 44 19.5

12F NHS WIRRAL CCG 121 37.5

13T NHS NEWCASTLE GATESHEAD CCG 183 36.8

14L NHS MANCHESTER CCG 166 30.5


14Y NHS BUCKINGHAMSHIRE CCG 101 18.8

15A NHS BERKSHIRE WEST CCG 59 12.1

15C NHS BRISTOL, NORTH SOMERSET AND SOUTH GLOUCESTERSHIRE CCG

201 21.1

15D NHS EAST BERKSHIRE CCG 60 13.9

15E NHS BIRMINGHAM AND SOLIHULL CCG 341 29.1

15F NHS LEEDS CCG 283 36.1

15M NHS DERBY AND DERBYSHIRE CCG 235 23.2

15N NHS DEVON CCG 274 23.1

99A NHS LIVERPOOL CCG 122 24.9

99C NHS NORTH TYNESIDE CCG 43 20.9

99D NHS SOUTH LINCOLNSHIRE CCG 41 27.7

99E NHS BASILDON AND BRENTWOOD CCG 63 24.0

99F NHS CASTLE POINT AND ROCHFORD CCG 43 24.3

99G NHS SOUTHEND CCG 47 25.7

99H NHS SURREY DOWNS CCG 81 27.9

99J NHS WEST KENT CCG 113 23.3

99K NHS HIGH WEALD LEWES HAVENS CCG 32 18.5

99M NHS NORTH EAST HAMPSHIRE AND FARNHAM CCG

34 15.9

99N NHS WILTSHIRE CCG 95 19.1

© NHS Improvement 2019 Publication code: CG10/19

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