Examination of Witnesses (Questions 160-179)
DEPARTMENT OF
HEALTH
8 SEPTEMBER 2004
Q160 Mr Curry: You also said that the
increased throughput in the NHS had, in a sense, taken priority
over these other issues. Would you like to phrase that in a way
you would be happy with, because that is what came over to me?
Sir Nigel Crisp: I said that where
hospitals have got busier, it becomes harder to maintain all your
standards, including cleanliness. What I also said—and this
is not impossible—and the example of Sheffield is a very
good one, and other examples like the one in this Report which
says that if you get the infection control right you can improve
the—
Q161 Mr Curry: So you would say that
every hospital, no matter whether it is housed in some Victorian
building or whether it was a new PFI thing on the edge of town
is capable of achieving the same standards because there is no
link between structure and architecture and—
Sir Nigel Crisp: I would say they
could all improve very clearly. We are talking about different
hospitals; the bottom hospital here with the bottom rate is Moorfields,
which only deals with eyes; so you have to compare like with like.
Q162 Mr Curry: Is there a design element
here? Can you design a hospital to minimise this? We talk about
design to minimise crime; to what extent are the criteria given
to the people in PFI projects for an architecture that minimises
disease, and is that compatible with the financial guidelines
that they have to—
Sir Nigel Crisp: There are all
kinds of design issues here, from the very simple ones about how
patients flow through theatre—whether they come in on a
clean side, as it were, and go out on a dirty side so that you
have a route of how patients flow through an operating theatre.
A lot of that is well understood and a lot of that is well in
place, but there is more that can be done, I think absolutely
straightforwardly in design.
Q163 Mr Curry: Coming back to Annex A
and the point Mr Allen raised about experts being flown in, I
have the fear that the summit will beget a task force, and the
task force will beget an action team, and the action team will
then beget something else, and we will all end up with another
summit before very long. I do not know what world some people
live in—"NHS patients should demand high standards
of hygiene and should feel happy to ask staff if they have washed
their hands". Can you imagine it? My Dad is 87; fortunately
he is very, very fit; can you imagine my Dad saying to the nurse
coming along, "sorry, dear, have you washed your hands?"
He would be massively intimidated by doing that and could think,
"My god, they are going to kick me out". The psychological
relationship between a patient and their staff is not such that
you can go around saying, "have you washed your hands?"
It is a bit daft, is it not?
Sir Nigel Crisp: The point is
that in a clinical situation—
Professor Sir Liam Donaldson:
It is an easy one to make fun of, and I am not saying that it
is the main mechanism by which we will get better compliance with
hand-washing. However, it is not a bad idea to give patients a
bit of power, and that is just one small example of it. In some
hospitals in the United States, the doctors have a badge on, and
the nurses, saying, "if you . . . please ask me" rather
in the same way that we have on the back of buses, "if you
think I am not driving safely or well, phone this number".
Q164 Mr Curry: How many people—
Professor Sir Liam Donaldson:
It is a small thing, but it is symbolic because it shows that
we are willing to listen to patients and we want them to speak
up, not—
Q165 Mr Curry: A nurse will go out of
the ward and into the nurses' room and say, "there is a bloody
bolshy one in room 4".
Professor Sir Liam Donaldson:
Not if we get the cultural change that . . .
Chairman: Six members have indicated
they wish to ask supplementary questions.
Mr Steinberg: It seems to me that you
did not listen and seem to take advice, so what I want to know
is why, after our report in 2000 when, as a result of that, you
introduced a national manual, that that manual has totally disappeared
and been ignored? Why? Who took any information from it and used
it, and who ignored it? If you want to write to us on that one,
you can.[5]
The other important point is that apparently the only thing that
the Health Service employees thought was worthwhile that you have
done over the last four years was to introduce the infection control
insurance standards. The Report tells us that 90% of the NHS who
were involved thought it was a good idea—and you scrapped
it. Since the Report came out the Committee received a letter
from a Bob May,[6]
who presumably you must know, who was the manager of the NHS national
control insurance project for the Department of Health. He has
written all members a letter in which he asks some very pertinent
questions. Presumably, you have not seen the letter. I would ask
that the Chairman allow you to see the letter and respond to it
on the point that he makes.[7]
Q166 Mr Bacon: Sir Nigel, given the fairly
limited time, I did not give you a chance to answer a quite fundamental
question about what causes compliance when you have got good infection
control practice, and at any one time you have some areas of the
country where there are very high levels of compliance and others
where there is not. It is apparently not simply whether it is
a shiny new building or an old Victorian building; and obviously
there are certain issues, as the Report says, like lack of education,
lack of clarity about the guidelines, time pressures. Many of
these things will apply everywhere—certainly time pressures
will. What is it that causes compliance in some areas and non-compliance
in others?
Professor Sir Liam Donaldson:
I would say it is the quality of the managerial and clinical leadership
predominantly because that determines the culture and everything
that flows from it.
Q167 Mr Bacon: Do you think that if they
understood and realised and saw the consequences of not complying
were much, much more serious, like the hospitals not getting any
funding, and saying, "we are sending all your patients to
Denmark", that you would get more rapid change?
Sir Nigel Crisp: Indeed, I think
that is—
Q168 Mr Bacon: Why do you not do that,
then, and give it a try—do a pilot?
Sir Nigel Crisp: In a sense we
are doing that. I do not actually mean sending them to Denmark,
but we are giving patients choice, as we have been discussing,
and I think they will exercise that. We have put this as one of
the major relatively few remaining targets. We have made this
a priority for the Healthcare Commission to inspect against. We
are using all that battery of tools that will raise it up the
individual managers' priority lists. It will be much more . .
.
Q169 Jim Sheridan: Professor Duerden,
in response to a question from Mr Williams, you said it would
be difficult to define clearly just exactly how many people died
from MRSA and what would be a contributing factor. Is that broadly
what you said?
Professor Duerden: That is what
I said, yes.
Q170 Jim Sheridan: It is just that it
rings alarm bells with me personally because that is the same
kind of language that people in your profession used 20 or 30
years ago when people were dying of asbestosis and asbestos-related
diseases.
Professor Duerden: I am sorry
if it sounds that way. The problem with an infection in ill patients
is how much is the infection contributing and how much is the
underlying disease contributing, which is what we have to tease
out.
Q171 Mr Williams: Coming back to the
figures we had a bit of a discussion about right at the beginning,
in the Report on page 24, it says that there are at least 300,000
hospital-acquired infections a year, and you have signed up to
that.
Sir Nigel Crisp: Right, yes.
Q172 Mr Williams: I understand therefore
that there are 7,400 MRSA cases.
Professor Duerden: Yes.
Q173 Mr Williams: If you work on these
figures, that MRSA is 40% of Staph;[8]
that Staph is 50% of blood infection; and blood infections of
6% of hospital-acquired infection, then the figure is not 300,000;
it is over 600,000.
Professor Duerden: Yes, and there
is a mis-match in the bullet points here. The top line says "at
any one time 9% of hospital patients has an infection" and
on the next line it says that is 300,000. There were 7.7 million
in-patients in the last year.
Sir Nigel Crisp: The second bullet
point is wrong, Mr Williams.
Q174 Mr Williams: It is wrong, although
you signed up to it. It brings the figure to less than half of
what it really is. The figure is doubled with what the Report
says.
Sir Nigel Crisp: In our report
we have used the 9% and—
Q175 Mr Williams: So let us be clear—I
do not want any misunderstanding—you are now agreeing that
the figure for hospital-contracted diseases is probably, on the
basis of the statistics we now put together, in excess of 600,000
a year, not the 300,000 shown in the Report.
Professor Duerden: That is the
estimate that we have. The 9% is based on a survey in 1996, saying
that overall 9% of patients have hospital infection, and we have
7.7 million patients to deal with.[9]
Q176 Mr Williams: I am not worrying about
the numbers, I am trying to get the numbers right, which is very
important. The overall problem is far, far bigger than we have
been briefed by the Report and so on to believe it to be. That
is okay for the Report; it will help us in drawing our conclusion,
so that is clarified. There is a second point I would like to
clarify. I tried chasing the library today, although in fairness
it was short notice. Annex D gives the names of the hospitals
where there were more than five deaths in a year, and there is
a footnote on the second page, which is page 12 of our supplementary
brief. "The figures for deaths were in 2002. Hospitals with
less than five deaths have not been listed to minimise the risk
of disclosure of confidential information. A table of these remaining
hospitals was placed in the House of Commons Library." In
fairness to the library, they were not able to find it in time.
I do not understand why there is a risk of disclosure of confidential
information.
Professor Sir Liam Donaldson:
This applies to a lot of official statistics, Mr Williams. If
the Office for National Statistics were to release statistics
with small numbers attributable to particular institutions or
areas of residence, it is possible that someone—a journalist
or someone else—might be able to find out who that individual
is and approach them. Those are some of the rules in handling
statistics.
Q177 Mr Williams: I am sorry, I do not
understand that; they are dead, are they not? What if we had a
situation where the Secretary of State has said that you have
a right to know and the public have a right to know? I cannot
understand why you find this particularly appropriate.
Professor Sir Liam Donaldson:
If I may suggest, we can do you a note, having talked to the Office
for National Statistics.[10]
I guess officials were just following what they thought was .
. .
Mr Williams: That is fine. Thank you.
Q178 Mr Jenkins: Sir Nigel, in response
to Mr Sheridan on the role of the new matron, you said, "we
want to give these people more power". Where does this power
come from? Is it already existing? Does somebody already have
this power and, if so, why are they not doing the job with this
power?
Sir Nigel Crisp: I am meaning
that you will have found in a number of hospitals that the director
of infection control already existed. We have given them more
power and authority by making them report directly to the board.
That is one way to make somebody have more power without transferring
it necessarily to somebody else. That person also has more power
because that person is going to be giving an independent report
of the event, as we discussed earlier. That is the sort of thing
I am talking about. I am not saying we should take away power
from somebody else to do it; I am saying, let us give these people
more prominence and make sure they are treated as people who have
to be listened to when they are raising questions about cleaning
or whatever it is. It varies from hospital to hospital. That is
what I am talking about, putting them in a more powerful position.
Q179 Mr Jenkins: We know that the high
occupancy rate is a continuing problem with infection control.
Did you do any work with regard to the implications of the large-scale
bed closures in the 80s? Are they partly responsible for this
position we find ourselves in now? Do we need more beds?
Sir Nigel Crisp: Our view from
the bed inquiry we had four years ago, or something of that sort,
is that we needed a relatively small number of more beds, and
those are being put in, but what we concluded more recently—and
again you and I, around this table, have had this discussion before—was
that we want more ring-fenced beds. We want more treatment centre
beds and more dedicated hip places and things like that, which
incidentally will improve infection control as well. We did do
that inquiry about five years ago I think which said to us that
we did need more beds.
Professor Sir Liam Donaldson:
There was an innocent explanation for some of the changes in that
the popular view amongst experts was that because of the advent
of day surgery we would need smaller hospitals. I can remember
being told very authoritatively by an expert that there is no
new hospital being built that is too small, and that has been
shown to be inaccurate.
5 Ev 36 Back
6
Ev 32-34 Back
7
Ev 36 Back
8
Staphylococcus aureus Back
9
Ev 34 Back
10
Ev 37 Back
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