Examination of Witnesses (Questions 80-99)
DEPARTMENT OF
HEALTH
8 SEPTEMBER 2004
Q80 Mr Davidson: It is more expensive.
This is the point. I wanted to come on to the question of the
extent to which other targets that you have are running counter
to the objective of reducing MRSA and other infections, and in
particular this question of the efficiency target of bed usage.
It just seems to me that these are clearly in contradiction, unless
there is an additional resource available. I am trying to clarify
how you manage to balance this out. Sir Nigel made the very fair
point earlier on that you are dealing with some other issues as
well and that this is not your sole purpose in life. Can you give
us some guidance about how you manage to make those sorts of balances,
and which becomes the more predominant driver in these circumstances?
Sir Nigel Crisp: Can I pick up
the example of the case study in Essex, which shows that if you
apply good infection control practices, it increases the number
of patients that were treated. The two things are not necessarily
in opposition. That is what we have got to try and do, not set
these things up in opposition. I agree with you that if occupation
rates go up and we do not do anything else, it will make it harder
to get infection control right; but the Broomfield Hospital study
shows—case study D on page 21—that in the year prior
to doing this 417 arthroplasties were performed and the following
year there was 17% more, and they not only reduced infection.
That is what we need to be doing, to align both these things.
The other thing that this Committee has discussed before is our
treatment centres of separating off elective patients from emergency
patients. That also will allow us to get to grips with it. We
are finding things that will allow us to do both of them, both
activity levels—reduce waiting times and also infection.
Q81 Mr Davidson: Coming back to the points
that Mr Steinberg made, you were indicating that there are a number
of things you need to do. That suggests to me that they have not
already been done, which raises the question why they have not
already been done, when you have had four years, and some of these
lessons presumably were identifiable and identified at the time
of the last report.
Sir Nigel Crisp: Some of them
were, but taking the treatment centre programme where we are very
deliberately taking procedures out of busy hospitals and treating
them in a much more streamlined way, that was not how we were
thinking of these things four years ago—we were only just
starting to think about those things four years ago. My real point
is that we need to get both our objectives of more people treated
and higher standards of infection control tackled at the same
time; they do not have to be opposite to each other.
Q82 Mr Davidson: But they frequently
are at the moment.
Sir Nigel Crisp: They can be.
Q83 Mr Davidson: Give me another example
of how they can be.
Sir Nigel Crisp: The point that
has already been made, which is that if you are—
Q84 Mr Davidson: That is cheating because
we have already had that one. Give me a different one.
Sir Nigel Crisp: A theoretical
example is that in a ward where you have a high turnover of patients,
where you are moving patients into beds pretty rapidly after other
people have left them, in those circumstances it is harder to
control infection.
Q85 Mr Davidson: I want to come back
to staffing and staff turnover. I want to clarify to what extent
the loss of the culture of cleanliness, which was to some extent
time-consuming and could be seen as using time that was effectively
wasted, was squeezed out because of the drive towards efficiency
and getting people moving quickly and so on. To what extent was
that pushed aside because of these other targets? We want to learn
whether or not the imposition of new targets often has unintended
consequences, and whether there is a mechanism that would have
allowed us to have spotted these things at the time, which we
could then utilise in the future.
Sir Nigel Crisp: I accept the
point. If you go back 10-15 years, there has been a process of
trying to make the NHS more efficient and effective, and part
of that has reduced costs in housekeeping areas—and whether
catering or cleaning, again, has been looked at by this Committee.
However, that is quite a long-term process. If that is managed
properly and effectively, it does not have to affect the standards.
Q86 Mr Davidson: It clearly did. What
is not obvious to me is why the mechanisms that should have been
there at the time to learn about what was happening as change
was being introduced, did not seem to operate. Presumably, there
must have been some people who said, "there have to be different
ways here in terms of cleanliness, if you speed this up and speed
that up"—but why was that listened to or was it listened
to and misjudged, or are these entirely new bugs?
Sir Nigel Crisp: There are two
slightly different perspectives. The strict general management
position is that four or five years ago we did not have a clear
set of priorities. We were dealing with some very pressing issues
for this Committee and others about waits in A&E and waiting
times. We were not on top of these big issues. We are now on top
of them, and it does not surprise me that we are seeing the next
set of issues coming forward about the NHS quite rightly being
about quality and not just this aspect. We are getting the waiting
lists down but there is more to do—and I am not complacent
about that either—but actually we need to concentrate even
more now on quality. That does not mean to say that there were
not voices saying that five years ago, but I believe it is important
that we started to tackle cancer, coronary heart disease waiting
times, because people such as this Committee were telling us that
is what we had to do.
Professor Sir Liam Donaldson:
If you have drives for efficiency, which we did, and you do not
have any measures of outcome because you are not prepared to invest
in the information to assess outcome, then you are heading for
disaster. The second thing, which has not been mentioned so far,
is that there was a degree of clinical complacency. Whilst there
were antibiotics available with which people felt they could treat
these infections, they did not need to worry about it, and they
did not anticipate that we would start to run out of therapies.
Antibiotic resistance is as old as antibiotics. Penicillin was
introduced during the war, and within about a year a high proportion
of some of the organisms that it treated were resistant to it.
Q87 Mr Davidson: That is very helpful.
I have never been entirely clear in my own mind about the extent
to which the deaths and difficulties are as a result of, as it
were, the natural evolution of bad things, which it is more difficult
for us to deal with, and on the other hand slack practices that
allowed existing bad things to get in where they should not have
been. Can you give me a feel for that because, obviously, one
is more excusable than the other?
Professor Sir Liam Donaldson:
The slacker practice which undoubtedly came about, and is what
we are majoring on now, could be compensated for by treatment
with antibiotics which used to work in some of these conditions
but which no longer do because of the growth of antibiotic resistant
organisms. If you put that with the fact that we are now putting
tubes and wires and all sorts of other devices into patients,
who would have died 15 years ago, then we are saving more lives
because we are opening up therapeutic opportunities for more people.
We are paying the penalty of profligate use of antibiotics in
the past, which was a feature of practice, but undoubtedly because
we have not linked measures of outcome to efficiency drives to
reduce starting levels to more cost-efficient levels, we have
not been able to assess the negative side of improved efficiency
in some of the areas. It came about too when nursing staff levels
were reduced because people felt that you could manage with fewer
staff, but clearly that was not the right thing to do.
Q88 Chairman: To tie it up with the Report,
you were asked by Mr Davidson about comparative data, and there
is reference in paragraph 3.7 on page 24. For that we hear that
the first European comparative data for MRSA was published in
2002. Would that tie up with what you believe, Sir Liam?
Professor Sir Liam Donaldson:
Yes.
Q89 Chairman: If that is right, if you
refer to annex A on page 4 of the supplementary memorandum vii,
you will see that the Secretary of State for Health, Dr Reid,
is on his feet in the chamber at the moment, talking about this
very subject, said that the whole NHS should learn from the best
at home and abroad. If the first comparative data was published
in 2002 why have we had to wait for this announcement in 2004
for the fact that we are now going to learn from abroad?
Professor Sir Liam Donaldson:
I think because it has not been entirely clear exactly how those
other countries have achieved what they have achieved, and often
there has been no proper evaluation or research of the exact changes
you would need to replicate in order to achieve their levels of
resource.
Chairman: Other colleagues can come in
on that.
Q90 Mr Williams: Looking at annex C,
we find that by the measures used there the incidence of MRSA
in this country is 71 times as high as in Denmark, and 41 times
as high as in the Netherlands and Sweden. Those are not small
levels of magnitude, are they?
Professor Sir Liam Donaldson:
Well—
Q91 Mr Williams: Are they or are they
not?
Professor Sir Liam Donaldson:
Small levels of difference, no they are not.
Q92 Mr Williams: I am glad to hear that.
I did not want any prevarication of that or we would not get very
far! In fact, of 22 countries shown here, only three have a worse
level than the UK. That is nothing to be proud of.
Professor Sir Liam Donaldson:
Absolutely not, no.
Q93 Mr Williams: So why is it that they
have identified and been able to tackle the problem when we seem
very belatedly even to have realised the problem existed?
Professor Sir Liam Donaldson:
Firstly, I should point out that the levels of hospital infection
per se—there are not such great differences between
countries. It is when we come to the MRSA. When we are quoting
40%, it is 40% of the staphylococcal infections; it is not 40%
of all hospital admissions, just to be absolutely clear. The countries
that have been successful are in the minority. Other parts of
Europe, the United States, other parts of North America and ourselves,
have much higher levels than the Netherlands and the Scandinavian
countries. That is the baseline we are starting from.
Q94 Mr Williams: No-one suggests that
the figure for general level of admissions is relevant to this.
If you look at the figures, 300,000 people a year contract infection
while they are in hospital. Of these, blood infections account
for only 6%, so that is a small proportion of a large number.
Half of those consist of the staph non-resistant type, but nearly
half again are MRSA. Putting all those figures together, I work
out that each year 3,600 people acquire MRSA as a result of going
into one of our NHS hospitals in England alone. That is appalling,
is it not?
Professor Sir Liam Donaldson:
Can I ask Professor Duerden, who has looked at the figures, to
comment on that figure?
Professor Duerden: The figures
for MRSA bacteraemia are published and have been published now
for the past three years from mandatory surveillance, and they
show the number of cases that are actually recorded.
Q95 Mr Williams: I have told you what
the figures are; they are 3,600: the NAO has given us the figures.
They have given us the percentages and I have told you what the
percentages mean. It is 3,600 a year. I am not asking for an argument
about it. Is that or is it not a fact, and, if it is not, how
has the NAO got it wrong?
Sir Nigel Crisp: I think we are
saying the figure is actually 7,400 rather than 3,500. I do not
think the NAO has got it wrong.
Q96 Mr Williams: I suggest you look at
the percentages that have been shown in the briefing.
Professor Duerden: That is because
the percentages that have been extrapolated—the 7,400 is
from figures produced by the Health Protection Agency only six
weeks ago.
Q97 Mr Williams: A suggestion has been
put forward that the switch to contracted-out cleaning is a major
element in this. Has there been any study of the correlation between
the incidence of MRSA and contracting out of cleaning?
Professor Sir Liam Donaldson:
All I can say is that I asked recently for a list of the worst
10 hospitals on the cleanliness measures, and the worst 10 on
MRSA, and there was no hospital on both lists, so I think this
is a complicated subject, and it is being studied further.
Q98 Mr Williams: With respect, to say
it is being examined further—the top 10 that you have taken
there—it would be a matter of a couple of hours' work for
statisticians to work out whether there is or is not a correlation
between the hospitals that have been listed in annex C or annex
D.
Professor Sir Liam Donaldson:
I am suggesting there is no simple correlation because when you
look—
Q99 Mr Williams: We do not know, because
you have not done it.
Professor Sir Liam Donaldson:
I have looked at—
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