Examination of Witnesses (Questions 20-39)
PROFESSOR LORD
DARZI OF
DENHAM KBE, MR
DAVID NICHOLSON
CBE AND MS
RUTH CARNALL
CBE
25 OCTOBER 2007
Q20 Jim Dowd: I accept that readily.
In my own area we have got the de facto outer south-east
London under review where we have got the four PCTs acting together
and deciding the future of the acute sector, in particular between
Queen Mary, Queen Elizabeth, Farnborough and Lewisham. That in
itself is an indicator that the PCT is not the right unit to make
these far-reaching decisions. You need de facto a sub-regional
PCT to do it.
Ms Carnall: I think you can get
the best of both worlds. I think they can come together to look
at issues that span the population, such as the future of major
hospitals. Equally, when they are working with local GPs, trying
to work with smaller communities, trying to look at the interface
between health and social care at local level, I think they are
better based around borough boundaries, and certainly the local
authorities in London will very jealously protect the 31 separate
PCTs and see real value in the opportunities for integration at
local level that that gives. I take the approach you are trying
to get the best of both by enabling them to work together in sectors
where that seems appropriate and supporting them in local activities
where possible.
Jim Dowd: I am sure they will welcome
the increased co-operation between PCTS and the borough councils;
I am not sure they would defend the PCTS as an entity beyond that.
Nonetheless, I leave it there.
Q21 Sandra Gidley: Moving on now
to quality of care and infection levels, spending in the NHS has
doubled over the last ten years, so why do we still have dirty
hospitals and why are infection rates as high as they are in some
hospitals?
Professor Lord Darzi of Denham:
What you say is very important, and that is why, if you look at
my interim report, safety in healthcare is and should be our priority.
It should be part of our culture, it should be part of our every
day working practices, and two challenges within safety is hospital
acquired infections and cleanliness. This is not new: cleanliness
and hospital acquired infections. If you go back even 40 years
ago, the only defence we had against infection at the birth of
the NHS was cleanliness, we did not have antibiotics in those
days, and cleanliness is part, and should be part, of the safety
culture of every healthcare provider.
Q22 Sandra Gidley: I would agree,
but why has it not been over the past few years?
Professor Lord Darzi of Denham:
As I said in my interim report, quality, whether that is cleanliness
or hospital acquired infections is crucial. Certainly as a clinician,
cleanliness is part of my culture as a practising surgeon. We
aid the patient on that journey with preventing infections, whether
these are hospital-acquired or intra-operative infections or post-operative
infections. Let us not forget about MRSA or clostridium difficile—infection
is associated with healthcare provision, and whether it is a nurse,
whether it is a doctor, whether it is a chief executive, ultimately
the most important thing as part of that pathway is the cleanliness
of the provider, the unit that we work in, which should be the
pride of the organisations we work for and prevention of infection.
It is a very, very valid point and the answer is what I suggested
in the interim report: cleanliness and hospital acquired infection
should be our priority. That is why I did not want to wait until
June or July next year, I wanted that to be in the interim report
and that is why I made set of recommendations in relation to that.
Q23 Sandra Gidley: Are you saying,
in effect, that cleanliness has not been a priority in the past
and that perhaps the amount of money spent on other targets has
taken health professionals' eye off the ball? For example, we
had before us last week Professor John Appleby and he intimated
that the vast amounts of money that have been spent on reducing
waiting times might have been better spent on improving the quality
of care for patients. Do you agree with him?
Professor Lord Darzi of Denham:
I think we are comparing apples and oranges. Cleanliness is not
a target; it is not something that should be a priority: cleanliness
should be part of our every day work. You cannot go to a hospital,
you cannot be a healthcare professional if cleanliness is not
part of your every day life.
Q24 Sandra Gidley: I think everybody
in the country would agree with you, but clearly that has not
been happening. Why has it not been happening and is it because
of the focus on targets?
Professor Lord Darzi of Denham:
I do not believe it is the focus on the target. In actual fact,
I also believe, if I am correct—you probably saw Sir Ian
Kennedy's response in relation to that in relation to the outbreak
recently—managing healthcare systems is a very complex system.
You do not prioritise one against the other. Waiting lists and
waiting targets were things of the past. I remember seven years
ago my waiting list was over 18 months. I had another target:
I could not cancel a patient more than three times. These were
the days we are talking about. It is not because we concentrated
on that and got our eyes off the ball in relation to what matters
most. I could not be dropping washing my hands before an operation
or seeing a patient. It should be part of the culture of any healthcare
provider.
Q25 Sandra Gidley: It should be,
but clearly it is not.
Professor Lord Darzi of Denham:
It is a leadership issue.
Q26 Sandra Gidley: Possibly. If it
is not targets, could it have been financial pressures? We had
figures released last week which showed that many hospitals have
bed occupancy rates between 95 and 100%. That gives them a 60%
increased probability of infections in those hospitals. So, are
financial pressures to blame for people not concentrating on what
is really a basic?
Professor Lord Darzi of Denham:
I do not believe it is financial pressure. I believe it is a leadership
issue. I believe it is one of these things when you are working
in a complex system that there should be a collective accountability
to the infection. Infections do not just arise in the operating
theatre. They could arise prior to the patient coming into the
hospital from the community setting. That is why one of the recommendations
I made, which is evidence-based, which is something close to me,
is that every patient coming in for elective surgery should be
screened. That might challenge some organisations in identifying
the funding to support it. That is why we made the announcements
of about £130 million to screen patients coming in for elective
and eventually, within three years, emergency surgery, because
if we screen patients prior to coming in we can isolate those
patients who are carriers of MRSA who could actually self-infect
themselves. At the same time we also introduced a number of different
other parameters, screening was one and the other one which was
announced by the Prime Minister is deep cleaning of hospitals,
all to refocus the mind in bringing that collective accountability
of what I am referring to, which is cleanliness. It is part of
the culture of any healthcare staff, any ward, any structure,
any building that is involved in healthcare provision.
Q27 Sandra Gidley: So you think the
problem in the past has been poor leadership in the NHS on this
issue. If it is a leadership issue, and there is a problem the
problem, presumably, has been poor leadership?
Professor Lord Darzi of Denham:
It has been poor leadership in some of these organisations that
have had significant outbreaks of the type that we have seen in
the last week. I work in organisations which deliver healthcare
and I know exactly the ones who have the right leadership in ensuring
that that is part of the culture of everyone who works there.
Q28 Mr Scott: Minister, a brief point
on that. What you have said, as Sandra quite rightly said, no-one
could disagree with about cleanliness, et cetera. The question
comes back to, I know you are saying poor leadership, but somebody
is above that leadership and why has this been allowed to happen
for such a prolonged period of time with so many people, unfortunately
and tragically, losing their lives?
Professor Lord Darzi of Denham:
Firstly, let us look at what happened last week. I could not agree
more. What happened in Maidstone was more than tragic. What we
need to do is to be mature enough and understand why an organisation
like that has been through what it has been through. Leadership
is one, but if I could look at it from more of a scientific perspective,
it seems that they had a systems failure within that organisation.
It is not an individual, it is a collective number of individuals
where we have failed at a local level to identify the hazards
and these hazards led to that outcome that we have seen, as I
said, a most tragic outcome, but that is not happening in every
NHS organisation. It is very important that we recognise that.
Q29 Mr Scott: In fact without going
into personalities, because that would be totally wrong, the partner
of that very administrator, surprisingly enough, was the administrator
of my trust and chose to resign at a similar time through problems,
so it obviously is wider than just the one area of Maidstone.
Professor Lord Darzi of Denham:
Firstly, I do not know the partner of that person.
Ms Carnall: I can pick up the
HRT trust; David can perhaps pick up the wider questions about
the country as a whole. There were a series of problems in that
hospital, as you know. It is a brand new hospital. We were not
satisfied with the quality of care being provided there. There
were large numbers of complaints, some quite serious. There were
significant financial problems, but, most importantly, a rapid
deterioration of that financial problem during the course of the
year. It does have an accumulated deficit, but what worried me
more was the way that went dramatically worse in-year when, frankly,
most organisations in London are putting themselves in a much
stronger financial position. So it was against the grain. Certainly
there was a lack of confidence in local partners in the organisation
as a whole, Members of Parliament, local authorities and local
PCTs, and subsequently, in pretty extensive discussions with us,
the Chief Executive there decided to resign and leave the trust
and we have put new leadership in there. In addition to that,
we are going to put independent clinical teams into the trust
in order to review in more depth some of the concerns that we
have about quality of care. So, there will be no attempt to disguise
anything that has happened there, any of the quality care issues
that are there. There the independent clinical teams that we have
put in, or will put in, will come from University College London
and the Royal National Orthopaedic Hospital. Those clinicians
will not have any constraints put on them, either to do with the
finances of the trust or its leadership or anything else, they
will be entirely free to come up with recommendations focused
exclusively on issues of quality of care. I believe the trust
is in a good position now to move forward. I do not believe it
has got any intrinsic problems in terms of structure or anything
else. It is a fantastic new hospital, it is in the right place
to serve the population and I have every confidence that it will
be turned round quickly.
Q30 Mike Penning: What happened in
Maidstone is terrible, but it is happening around the country.
We do not know what is happening in other areas. Can you tell
me how many people died from hospital acquired diseases last year?
Professor Lord Darzi of Denham:
I will be more than happy to get you the figures of that. David.
Mr Nicholson: Hospital acquired
infections are something that are affecting every health service
in every developed world and we are battling on to get at it.
One of the issues, of course, is that many of the things were
historically not measured—for example c.difficile. We are
only now getting proper measurements so we can tell what the scale
of the issues are, because these things are dynamic and are developing
over time.
Q31 Mike Penning: As a department
you have no idea how many people died in NHS hospitals from hospital
acquired diseases in the last 12 months?
Mr Nicholson: There is an audit
that began that I understand is going to be reported in the next
two or three weeks which will identify deaths in relation to MRSA.
That is the information that we are hoping to be published in
two or three weeks' time.
Q32 Chairman: Can I pick up on two
or three things about Maidstone and Tunbridge Wells Trust. The
ex chief executive said that there had been a fixation there in
terms of waiting times and financial targets. That was denied
by the department and by the Healthcare Commission. Would you
like to give your personal view about that statement that was
made by the then chief executive?
Professor Lord Darzi of Denham:
I probably should bring David in here, because this is a management
issue, but I do not accept that statement, as a clinician who
works in an organisation, that because of this we failed to do
this. I made it very clear early on: cleanliness and hospital
acquired infections is part of what we do every day we go to work.
David.
Mr Nicholson: It seems to me,
as someone who has worked in the NHS for 30 years, completely
unacceptable to say that. It is an absolutely basic part of anybody
responsible for managing healthcare systems and a hospital. It
is completely unacceptable that someone would say that. Their
first priority is the quality of service and safety to their patients.
That seems to me to be absolutely clear. We have made that absolutely
clear to all chief executives.
Q33 Chairman: Do you think there
is a balance to be struck between leading a trust and guarding
against hospital acquired infection? Is there a balance in that,
or do you think there is no way that one becomes a priority over
the other?
Mr Nicholson: Any manager in any
system has to manage a whole variety of things at the same time.
The idea that as a manager you only do one thing and then you
go on to do something else simply does not work. Managing healthcare
acquired infection is a basic part of any manager's responsibility,
and I think what we have seen over the last few years is that
managers in the system have needed help and support to do that,
hence the whole raft of policies and money, resources and activities
over the last four or five years to enable and support people
to do it better, hence the things that are in the report in relation
to healthcare acquired infection.
Q34 Chairman: I have got that page
in front of me. In relation to this current report, how will the
review ensure that hospital trusts get the balance right between
all these wider issues and tackling MRSA and c.difficile?
Professor Lord Darzi of Denham:
There will be major sets of recommendations in relation to that,
but it is like telling me when I go and see a patient that I am
responsible for the operation but I am not actually responsible
for a patient who might develop a chest infection after the operation
because they could not breathe properly. It is ludicrous to think
that we can think like that. This is part of what we do, and that
should be part of the ethos of any organisation. It is a collective
responsibility. If there is one thing I have heard in politics,
it is collective responsibility. The days in which I was responsible
as an individual for the patient has changed into the collective
responsibility of all the team that I am a member of, whether
that happens to be a nurse on the ward or that happens to be a
junior member of staff, and that collective responsibility in
its priority is the safety of that patient. Every single of member
of staff has to wash their hands if they are seeing a patient
or touching a patient. That is part of what we do every day. Every
member of staff who prescribes antibiotics to a patient needs
to be aware of the side-effects of antibiotics. The reason we
have clostridium difficile is because we have not been prescribing
antibiotics based on proper evidence-based guidelines. That is
where c.difficile has come from. It is an inhabitant bacterium
in our guts. If we get rid of the good bacteria with antibiotics,
the clostridium difficile starts producing spores; so you need
to know how to prescribe. These are basic principles. It is something
for which all of us need to take the responsibility, all the team
members who are responsible for that patient.
Q35 Chairman: In the national press
on Monday there was a report that the department had sat upon
a report from the Healthcare Commission since, I think, 3 May
this year in relation to hospital acquired infection. Is that
true? You will have seen this. It was in Monday's Daily Telegraph.
Mr Nicholson: No.
Q36 Chairman: It was said that there
was a draft report from Maidstone and Tunbridge Wells. Is that
true?
Mr Nicholson: There was a draft
report that came into the department in May that related to Maidstone
and Tunbridge Wells. What it did not have in it was any conclusions
or recommendations, and at the time the factual base of it was
being challenged by the trust; so it was not, by any stretch of
the imagination, what people would describe as a full draft report
with everything in it.
Q37 Chairman: If a healthcare commission
inspects NHS establishments on our behalf, both as patients and
members of the public, how long does it take for an inquiry, if
you get an adverse report from a healthcare commission, before
you actually look into this in detail?
Mr Nicholson: In terms of Maidstone
and Tunbridge Wells, it was the Strategic Health Authority that
brought the Healthcare Commission in and, as soon as the Healthcare
Commission came in to do their review, action started to be taken;
so right from literally the day that the Healthcare Commission
came into that hospital things started to change. What we do not
do is wait until the very end to do the work that we need to do
in order to improve services for patients.
Q38 Chairman: So what implications,
if any, were there in this draft report being held in the department
and not being published by it? Were there any implications in
terms of C.diff?
Mr Nicholson: No, absolutely not.
Chairman: We will move on then. Richard.
Q39 Dr Taylor: Can I go back to what
you said about introducing MRSA screening for elective and emergency
patients. What is the evidence that screening will produce a lower
incidence of MRSA?
Professor Lord Darzi of Denham:
If you look at a number of European countries, Holland being one,
Denmark being another, it is part of the practice that if you
come in for elective surgery you get screening and, if you are
carrier, you can at least decolonise the patient.
| 
