Examination of Witnesses (Questions 20-39)
DEPARTMENT OF
HEALTH
8 SEPTEMBER 2004
Q20 Jon Cruddas: Following on from that
in terms of staffing issues, page 22, point 2.38 points to issues
around staff shortages and the role of agency staff especially
in London, stating that evidence suggests that both impact on
good infection control practices. Is that your own analysis of
comparative instances across acute trusts?
Sir Nigel Crisp: As I think you
show elsewhere in this document, there are some things which make
the task of infection control harder because they are going to
make it harder, and having a high turnover of staff may well be
one of those things of different staff at different times but
you can still manage that. You can still make sure that in those
circumstances you put in arrangements that manage that effectively,
but something like that, as this makes clear, will make it more
difficult if you have high turnover of staff.
Q21 Jon Cruddas: But evidence suggests
the preponderance of agency labour might have a correlation with
incidence as well as issues around staff shortages?
Sir Nigel Crisp: If you take the
sentence "reliance on temporary agency staff", I am
making the point that I think this is as much about staff turnover
and different staff at different times, than necessarily employment
status. You can have people employed by a few organisations who
are doing a thoroughly good job within the context of a hospital.
Q22 Jon Cruddas: You can, and you have
not got any evidence within the Department of different forms
of employment status, shall we say, correlating with different
incidences of infections?
Sir Nigel Crisp: I would have
to look at what note 26 says on this to say where that evidence
comes from because there is some evidence referred to there.
Q23 Jon Cruddas: But on your earlier
point as well, when you said about the form of contractual relationship
not being significant either way, as it were, there are stories
of good or negative effects?
Sir Nigel Crisp: I do not know
whether or not it is overall significant or not, but the point
is that I do not think you can use contracting out labour as an
excuse for bad cleanliness or bad infection. That is really the
point I am going to make, and it will be harder if you have a
high turnover of staff whether they are employed or agency. This
is just, if you like, common sense. And if you are in a situation
like London where you will have, because the labour market is
structured as it is, a higher level of agency staff, then you
have to manage that differently than if you have got a stable
staff who have been in hospital perhaps in the north where people
have been working together for a long time and standards are established.
You have to keep reinforcing standards. So it does make it more
difficult.
Q24 Jon Cruddas: I accept that. My departure
point was to inquire whether you were going to move towards, or
if there did exist, some sort of model contractual framework,
if you like, which has a much closer role for inspection teams
in terms of bearing down on contractors and in terms of the incidence
within MRSA and the like?
Sir Nigel Crisp: And today, as
it happens, there is a matrons' conference led by the Chief Nursing
Officer looking at the development of a matrons' charter and it
would not surprise me if there would not be some comment there
that the cleaner should also be part of the ward team, whatever
their contractual status, giving some continuity and making the
standards right, but we will see what the matrons themselves have
to say. So there is interest in that: there is focus on that—
Q25 Jon Cruddas: And there is work in
progress?
Sir Nigel Crisp: Yes.
Q26 Jon Cruddas: Can I ask a question
about the patients' choice agenda in this? When this becomes fully
operational presumably patients, individuals constituents, citizens,
will have a series of data about various options in front of them
in terms of choosing hospitals. Is that the proposition?
Sir Nigel Crisp: Yes. The proposition
would be that patients should have as much information as they
want but within that we already publish the MRSA rates for acute
hospitals and have done for three years. Now, I suspect what patients
will do is they will look at some evidence and some will want
to get more information and so on, and I suspect this will be
quite an important point for a lot of patients to know what the
likelihood or the rate is of MRSA. It will be natural. So I suspect
it will be more than core information but we have not at this
moment got a precise specification of what information we can
give the patient.
Q27 Jon Cruddas: That was my next question,
actually, in terms of forms by which the trusts should display
their statistics or inform people within their communities or
whatever, or the role of patients' forums and the like. All of
this is about disseminating information, presumably?
Sir Nigel Crisp: I have no doubt
at all that we should make sure that MRSA rates and recent cleaning
reports are displayed by trusts prominently where people can see
them. I am sure that is right. But the exact format we use for
that I think we need to ask people in the NHS about, and also
patients. It was part of the point I was making in that Radio
4 interview: let's make sure patients have the information, and
to make sure we can tell the patients.
Professor Sir Liam Donaldson:
I just have a brief comment. On page 27 there is a graph showing
variation in the incidence of wound infections by hospital and
by type of operation. That may not be the format ultimately that
the information is provided in but certainly that is the sort
of information that we would like patients to have, and there
is clearly a big variation for most of the operations according
to where you are treated, and that is the very thing that patients
need to help them to take a decision and make a choice.
Q28 Jon Cruddas: Finally from me, by
2005 there will be targets for acute trusts to reduce MRSA. Do
you have a national target in mind given that you have all the
capital building problems, and the evidence suggests there is
a correlation between new build in terms of design and so on,
in terms of incidence—you have all these procedures in play
in terms of work in progress. Where are we going to be in a couple
of years?
Sir Nigel Crisp: We have not got
a number yet. At the moment all we have said is it has to produce
the first target but I have no doubt we will be wanting to put
some numerical values in there.
Q29 Jim Sheridan: On the patients' charter
I can well understand the facility for patients to complain after
they have left hospital about unclean facilities or unclean practices,
but would you understand there would be some reluctance of patients
complaining at the time they are in hospital, because after all
they are dependent on the staff to get these people back to fitness
again?
Sir Nigel Crisp: I agree with
that and that is why we have also made some suggestions—only
suggestions at this stage—that things called patients' forums
should have a role in this, but these patient forums are independent
so the question is whether they are willing to take up that responsibility.
Q30 Jim Sheridan: What is a patient forum?
Sir Nigel Crisp: Every trust has
a group of patients who have a responsibility to make sure that
the patient view is understood within the hospital.
Q31 Jim Sheridan: And are these patient
forums volunteers or appointed or what?
Sir Nigel Crisp: They are volunteers
and they then go through an appointment process. These are new
bodies, they only came out in December so they are only just starting
their work, but they are drawn from volunteers locally, not appointed
by the hospital or by the Secretary of State but appointed independently.
Q32 Jim Sheridan: And is there a brief
clearly laid out for them on the criteria they have to meet? What
is required of them?
Sir Nigel Crisp: Yes, there is,
but the brief is also a bit about what they decide are the important
issues for their service because you will well understand the
patients' forum in a mental health institution will be different
from an acute one, and from one in primary care.
Professor Sir Liam Donaldson:
Adding to that briefly, I think the point you make about the patient
being afraid to complain is a very well made point but we have
been working very hard on the culture of the local NHS over the
last five years with the introduction of clinical governance where
quality and safety are centre stage, and we would certainly deplore
a situation where a patient raising a concern about their care
was not regarded as a very positive step, so in all our work with
staff we have been ensuring that they actively welcome and act
on any concerns raised by patients. I think the two very important
points are to give the people the information in advance so that
they can compare hospitals and services and, secondly, on the
cleanliness side having a direct line to house-keeping from a
bedside phone so you can summon someone along to clear up a dirty
area, just as in some hotels they have that facility.
The Committee suspended from 4.00 pm to
4.08 pm for a division in the House.
Q33 Jim Sheridan: Just picking up the
point Mr Cruddas was making about the contracting out of services,
you mentioned that cleaners were very much encouraged to be part
of the ward team, but given that cleaning and catering is usually
contracted out to the lowest bidder, it is very often the case
that those employed as cleaners, caterers, etc, are employed on
a very quick turnaround, and there is very little, if any, training
given to these people. I know you say they should be a ward member
but are they valued as a ward member, because at the end of the
day they have to be paid, and if these services have been contracted
out to the lowest bidder then we are only getting what we reap.
Sir Nigel Crisp: I understand
the point entirely. In some hospitals, where they manage this
well, contracted out staff will be treated as part of the staff
of the hospital and part of the induction programme and part of
the training and part of the ward team, and it is worth noting
that maybe we need to talk about cleaning the wards separately
from cleaning some of the other areas in the hospital because
actually the issues are not the same for offices, corridors and
out patients and so on. But what I think will happen today at
the matrons' conference is that they will come forward with some
proposals about how we do that in future and how we make sure
that that good practice which happens in many places is transferred
elsewhere.
Q34 Jim Sheridan: Is that best practice
shared through all the local health points? Are there shared experiences
and information and best practices? What evidence do we have of
that?
Sir Nigel Crisp: We do at the
moment but what the publication put out in July was saying is
that we can do a lot more about that and can make sure that it
is bought to the attention not just if you like of the people
who are responsible for the cleaning of the hospital but to the
attention of the pool of hospitals as well.
Q35 Jim Sheridan: But who co-ordinates
that information? Who is responsible for making sure that a hospital
in London shares an experience with a hospital in Newcastle?
Sir Nigel Crisp: Right now at
the moment it is run through NHS Estates. What we are just doing
though is asking the Chief Nursing Officer to take responsibility
overall for making sure that this is implemented. In other words,
we move it from a more technical background into putting it at
the forefront with nurses, because we believe that is a very important
place in terms of giving nurses more authority and more oversight
into what is happening.
Q36 Jim Sheridan: Moving on, would you
not accept that there is a direct correlation between low pay,
low morale and MRSA in the local hospitals?
Sir Nigel Crisp: I do not think
I have seen any evidence that tells me that is the case; that
is a straightforward answer. I would be interested to see that.
I think low morale is often associated with low standards and
I would expect it to be just on a common sense basis, and one
of the things we have to do about morale is to make sure people
are valued, and I think part of this is making sure we do make
sure that people who do some very basic things in hospital, as
the Chairman says some of the things we want to take for granted,
that these people are properly valued as part of the team, and
that is not just about pay.
Q37 Jim Sheridan: On the famous Today
programme you did say that we had a matrons' charter?
Sir Nigel Crisp: I said we would
create a matrons' charter, and that is what the conference is
about today.
Q38 Jim Sheridan: Public perception in
hospital was, or used to be, that you had a matron who made sure
the ward was clean and made sure that people were doing what they
were supposed to be doing, and that has long since gone and I
think that is where the trust has gone from the general public.
There is a perception amongst the general public that hospitals
are not clean.
Sir Nigel Crisp: I am sure that
is right. This is slightly different between England and Scotland
and in England, and I do not know about Scotland. We introduced
modern matrons again about three years ago, and there are something
like 500. This is not individual matrons for the whole hospitals;
this is matrons who are nurses who have responsibility for an
area of a hospital which includes responsibility for the environment
in that area which is the point you are making. We have introduced
more than we said we were going to, or rather NHS hospitals have
introduced more than they said they were going to, and what we
want to do is to give these people more power to answer the sort
of point you are making, and I do understand and recognise that
is what people feel. As your Chairman said, there are undoubtedly
examples where the standards are not good enough.
Q39 Jim Sheridan: Can we now just run
through for my own satisfaction, if MRSA is found in any particular
ward, do we immediately close the ward? Do we partially close
it? Who makes that decision? Where is that decision made?
Sir Nigel Crisp: It is made locally
and it will be slightly different depending on the circumstances.
Professor Duerden: When MRSA is
found in a patient, treatment of that patient is important—prevention
of spread from that patient to others, and that comes in with
good nursing practice; potential for isolating that patient if
necessary; and cleaning the environment around the patient, particularly
after they have been discharged so you have a clean environment
for the next patient coming in. You would only go to the lengths
of closing a ward if there was evidence of spread to other patients
within that ward causing an outbreak of infection, and then you
would have to consider whether the right thing to do in that local
situation was to close it, move the patients out, and clean the
whole ward before going back to normal practice.
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