Examination of Witnesses (Questions 1-19)
DEPARTMENT OF
HEALTH
8 SEPTEMBER 2004
Chairman: Good afternoon. Welcome to
the Committee of Public Accounts, where today we are looking at
the Report Improving patient care by reducing the risk of hospital
acquired infection. We welcome back to the Committee Sir Nigel
Crisp, who is a permanent secretary at the Department of Health,
his colleague Professor Sir Liam Donaldson, Chief Medical Officer,
and a new witness in our Committee, Professor Brian Duerden, Inspector
of Microbiology. You are all very welcome. I think my colleague
would like to welcome somebody to the Committee.
Mr Bacon: Yes, thank you. May I welcome
also Mr David Lawrence, who is the principal of Astern College
in Norfolk and who is visiting Parliament as part of a job shadowing
scheme organised by the Association of Colleges.
Q1 Chairman: Thank you very much. Sir
Nigel, if I may start with you, you or your predecessor, it makes
no difference, gave various categorical assurances to us when
we last considered this matter in 2000 that significant reductions
in infection rates, you believe, should be possible; and you held
out the prospect of tangible progress by 2003. Do you recall those
assurances?
Sir Nigel Crisp: It was not me.
However, I do read in this Report what the Treasury minute said
at that time which was "tangible progress in implementing
the steps needed to reduce infection", though I do not think
there was an actual commitment to saying that the numbers would
come down in this period, and indeed that is what we have done,
starting with introducing the world's first mandatory surveillance
of MRSA in 2001, going through tightening accountability, and
most recently last week in introducing the hand washing campaign.
So there is a lot starting to happen in terms of making the changes.
If you look at the figures, because the whole point of this is
to reduce the figures, which are on page 25 on table 6 I think
it is, what we have there is showing that when we introduced those
mandatory figures, and I think this is quite an important point
in this table. As soon as we introduced them our numbers went
up which is what you would expect, but actually the shape of the
graph is starting to change. It is not going down but on the bit
that concerns all of us most I think, the MRSA infections, it
is worth noting when you translate these through into numbers
of patients that the difference in three years is only 400 patients.
So it is starting to level.
Q2 Chairman: But as we see from figure
6, page 25, contrary to the assurances we received in 2000, the
evidence—and we can come back to this point but we mainly
had evidence on MRSA because the evidence on other infections
is somewhat limited—is that things have got worse. We can
talk about the graph not rising as fast as it was before but things
are now worse than they were when these assurances were given
to this Committee?
Sir Nigel Crisp: I do not doubt
that but I think the assurances were that we would put in place
the mechanism to make the changes to improve our control of infection
arrangements to ensure that we get the better position to tackle
this. The other point that does need to be said, and one of my
colleagues will say it better than me, is that the task has got
more difficult in the last four years. Patients are iller, we
are doing more things and putting more lines into people's bodies
so there is more risk of infection, so the fact that this is starting
to go the right way, the rate of increase is slowing down, is
important but I do not want to inject any sense of complacency
about this. This is absolutely an essential priority and of the
400 additional patients we are talking about, every one is important
and for every one it is a great tragedy that they have been infected
in this way. So there is a great deal more to do but what we have
is a much better equipped system now to start doing this and to
move in the right direction.
Q3 Chairman: If we look at Appendix 2
we can see that you or your predecessor gave a solemn undertaking
to this Committee that you would carry out all the recommendations
of this Committee. Are you telling us now that all these recommendations
are being carried out?
Sir Nigel Crisp: I think the position
is what is described here which is a commentary that is not as
simple as that. Many have being carried out, some have not, and
there are reasons given.
Q4 Chairman: But why not? Why did your
predecessor give these undertakings if they were clearly not deliverable?
Sir Nigel Crisp: Well, I thought
the particular one that you were asking about which is the one
saying that we would expect to see tangible results in terms of
improvements in the system for managing and controlling hospital
infections, which is the third one—
Q5 Chairman: Yes. Can I put it this way?
When as a result of this Committee's hearing, we make various
recommendations, as we shall, and when the Treasury minute comes
back accepting all these recommendations, which I am sure it will,
can you give us a solemn undertaking, because after all people's
lives are at risk here, that all our recommendations will be carried
out in full if the Treasury accepts that they should be acted
upon?
Sir Nigel Crisp: The only qualification
I make to that is twofold: there will be I have no doubt some
further discussion around whether those are practical or not,
but also in one or two of these cases in these recommendations
you can see the circumstances have changed, the reasons why they
have not been—
Q6 Chairman: Make that clear. Do not
just give reassurances to the Treasury minute. If you cannot deliver
something it is much better to say so now.
Sir Nigel Crisp: I accept that.
Q7 Chairman: Would you please look at
paragraphs 3.22-3.23? Can you explain to us why you still do not
know how many deaths are due to hospital acquired infections,
although the Office of National Statistics apparently indicates
that deaths due to MRSA may have increased fifteenfold? Why do
you still lack this basic information?
Sir Nigel Crisp: This is to do
with how we record information about deaths, and can I ask the
Chief Medical Officer to answer this?
Professor Sir Liam Donaldson:
Getting an accurate picture is very dependent on doctors including
the diagnosis of infection or MRSA in the case of this particular
infection on the death certificate at the appropriate time, and
often that is a matter of clinical judgment and opinion as to
whether, in a complex situation where somebody might be seriously
ill with a number of diseases and then acquired MRSA, the MRSA
did contribute to the death or it was simply present but did not
play a part in causing the patient's death. That is the case for
very many causes of death. They are dependent on a clinical opinion
at the time that death is certified. The way in which we have
decided to strengthen this is that in the report I produced for
the government in December of last year, Winning Ways,
I recommended that we should have a detailed audit of all deaths
of this cause. The plans are being put in place to do that—
Q8 Chairman: That was published in 2003
December?
Professor Sir Liam Donaldson:
Yes.
Q9 Chairman: Why did you wait until then
to publish this report?
Professor Sir Liam Donaldson:
Because I think, as far as a general indication of mortality from
MRSA is concerned, death certification gives a reasonable proxy
as it does for many other causes of death, but if we want to establish
the full extent of the cause so as to look at the underlying causes,
then a detailed audit of every death is a much better way of doing
it, but we do not do that with the exception of deaths in the
infant mortality field, and some deaths associated with surgery.
It is a big undertaking to organise an audit of every death, and
it is a feature of the priority that we now attach to this problem
that we are instituting an audit for that.
Q10 Chairman: Sir Nigel, if you look
at paragraph 4.16, you will see that surveys show that the public
is generally unimpressed with ward cleanliness. Why, four years
after the considerable publicity surrounding our last report,
do you seem to have so little success in instilling an absolute
culture in hospitals of cleanliness and washing hands? And, anecdotally,
the day after this Report was published when there was huge interest
in the national press, I was a patient in the Chelsea and Westminster.
I noticed that the toilets downstairs were filthy; there was no
soap available; when I went back the next day to have a blood
test the same situation was there. When I talked to the nurse
on duty, she came from Dublin and she said there was quite a different
culture in Ireland. There it is instilled in you as a nurse that
cleanliness is the first priority. This is not rocket science.
Many of the things we deal with in this Committee are very complicated.
Why can you not instill in your staff this culture of absolute
cleanliness?
Sir Nigel Crisp: Firstly, as that
paragraph says there is a belief that there is a relationship
and there is some overlap between the issues of cleanliness and
the issues of hospital acquired infection. They are not quite
the same but there is clearly an overlap between the two.
Q11 Chairman: I do not think we need
a report to tell us that. I think Florence Nightingale worked
it out in the Crimean War, did she not?
Sir Nigel Crisp: They are not
quite the same thing, is the point I am making. What we need to
do on hospital acquired infection is not the same as we need to
do on cleanliness. On cleanliness we have put in a lot of additional
resource and a lot of additional effort over the last three years
I think in particular in order to improve standards, and we have
seen standards improve. The example you show there shows that
that has not gone far enough and that is partly why, in the summer,
we brought together the two issues of the hospital acquired infection
and cleanliness report, because they are so closely linked, in
order to make sure that we put much more priority on to both of
the two issues, and those followed from that, as you know, including
the Clean Your Hands campaign, which is an overlap between
the two.
Q12 Chairman: Do you remember appearing
on the Today programme after the NAO Report was published[1]
and do you remember what The Sun called you the next day?
Were you hurt by their attack on you, when you seemed to pass
responsibility for cleanliness to patients themselves? I think
words like "arrogant", "smug" and "complacent"
were used which I am sure in your case is very unfair because
I know you are a devoted public servant, but you can see that
the wrong impression may have been made by that report?
Sir Nigel Crisp: That may be but
what I was saying in that programme but obviously did not get
it across was that it is very important that we listen to patients.
People misinterpreted that as saying that it is down to patients
to make it clean but if you listen to what I actually say it is
let's tell patients what to expect, and the reason is the point
you have just made which is that our surveys show an improved
record of cleanliness, so people moving up the chain and the traffic
lights are improving. But let's actually hear what patients have
to say, and that is what I was saying. But that was not a solution
to the problem; that was an important point, listen to the patients.
Q13 Chairman: I am glad I have given
you an opportunity to reply to The Sun. I think permanent
secretaries should always be given an opportunity to do that.
Sir Nigel Crisp: You are very
kind.
Q14 Chairman: Sir Liam, why do you still
lack basic information on the level of antibiotic prescribing,
and this is dealt with in paragraph 4.30?
Professor Sir Liam Donaldson:
We have not been as good in hospital practice as in general practice
at gathering detailed data on prescribing patterns and that has
been a weakness in the past. Over the last year there has been
a lot of changes made to plans for hospital information, including
the introduction as part of the new information technology programme
for the NHS of electronic prescribing, so we are very confident
that over the period of the next year we are going to have much
better data available on prescribing not just antibiotics but
other drugs in hospital.
Q15 Jon Cruddas: Can I firstly turn in
the recommendations on page 7, recommendation T, which says "NHS
trusts should require consultation with infection control teams
to be a mandatory step in contract tendering procedures for new
build projects and for cleaning laundry and catering services".
What is your response to that proposition?
Sir Nigel Crisp: We agree with
it and what we have said is that we are drawing up a new model
contract to be developed with professional bodies and leaders
which will include that.
Q16 Jon Cruddas: So at the moment there
is not a generic or model contract for laundry?
Sir Nigel Crisp: No, there is
not a single model contract for how you let the services so we
are drawing up a new one, and that will reinforce the message
that infection control teams and matrons should be involved in
drawing up cleaning contracts.
Q17 Jon Cruddas: What is the timescale
on that, because that signals that there is a possible correlation
between incidences and, let's say, variety in the sort of contractual
performance of the contract.
Sir Nigel Crisp: We have not got
a date for that but this will be certainly within the next year.
What is important in contracting out is you have a good contract,
and what this is doing is strengthening the relationship we have
with those private firms and being very specific that the infection
control team should be involved, which is good practice anyway,
and we expect that to be what will happen.
Q18 Jon Cruddas: And that will be a voluntary
model contract?
Sir Nigel Crisp: We would expect
that contract to be used or if there is a very good reason why
it is not being used that reason to be understood. But it will
be developed in the NHS, so this is developed by the people who
are going to implement it.
Q19 Jon Cruddas: The objective being
across the estate effectively a new regime, hopefully, which will
be tighter in terms of procedures of inspection teams with prospective
contractors?
Sir Nigel Crisp: Exactly. We do
already have some model arrangements but this will pick that up,
exactly.
1 Today programme, 14 July 2004. Back
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