Examination of Witnesses (Questions 40-59)
PROFESSOR LORD
DARZI OF
DENHAM KBE, MR
DAVID NICHOLSON
CBE AND MS
RUTH CARNALL
CBE
25 OCTOBER 2007
Q40 Dr Taylor: So in the list of
countries we have been given Holland is best, Germany second best,
then Spain and we come way down the list. The best countries do
this screening, do they?
Professor Lord Darzi of Denham:
They do, absolutely, and to be fair also, if you look at the data
in the National Health Service, the organisations who already
screen for elective surgery. In my visits—I have been around
the country for three months—I have come across a number
of organisations who actually had screening before even my announcement
was made. That is where I picked it up. Screening is part of their
everyday activity when it comes to elective surgery, like orthopaedic
surgery, and they have the least MRSA incidence.
Q41 Dr Taylor: On the same line,
deep cleaning: what is the evidence that that has an effect particularly
on C.diff?
Professor Lord Darzi of Denham:
Deep cleaning is an interesting one. I think there is evidence,
if you look at the data that I have seen in the department, that
those hospitals in which there is something called the PEAT score
(patient environment action team score)—it is a cleanliness
score—the hospitals that have the highest cleanliness scores,
in other words the cleaner ones, also seem to have the lowest
infection rates, so there is a very strong correlation. Whether
that is an impact on the culture of the organisation, it could
be, and that is a point to make. The second point when it comes
to deep cleaning is that it is also about public confidence building,
and patients and the user and the public in the engagement meetings
I have had truly believe the organisations who have the least
cleaning are the those who are associated with the highest infection
rates. So the answer to your question is that there is a correlation,
yes.
Q42 Dr Taylor: A week or two ago
some of the papers had a list of the 20 or so worst hospitals
for c.diff infection. Is it known that they had bad PEAT scores,
because obviously this would tie it up very neatly if their standard
of cleaning were known as judged by that? Could we find that out?
Professor Lord Darzi of Denham:
I could do, yes.
Q43 Dr Taylor: One or two other basic
questions that I think would be helpful to know. Is there any
evidence that where hospital cleaning has been privatised it is
different from where it has remained in-house?
Mr Nicholson: No.
Q44 Dr Taylor: No. You are absolutely
sure about that. The other thing with the deficits and the vacancy
factor is that nurse staffing has been cut. Is there any evidence
that nurse/patient staffing ratios have any bearing on the incidence
of infection?
Professor Lord Darzi of Denham:
Not that I am aware of, no.
Q45 Dr Taylor: I did ask if you were
aware of it. Is there any?
Professor Lord Darzi of Denham:
There is no evidence in the scientific literature. There is plenty
of evidence that you do have to apply some of the good standards
of hygiene, including the beds, the mattresses, changing patients,
the turnover of patients, and so on and so forth.
Q46 Dr Taylor: Do you remember from
the Stoke Mandeville inquiry into c.diff? From my memory the reports
were that clinicians were desperately trying to get the management
to act and it was a complete stop by the management at that stage
because they were fixed on targets. Is there any likelihood that
that sort of thing will happen again?
Professor Lord Darzi of Denham:
I made a statement about that in the interim report and I said
that every clinician, whether it is a ward matron, whether it
is a doctor working there, could report that to the Board of that
acute trust and if he has difficulties with that we will encourage
them to report it to the regulator.
Q47 Dr Taylor: Coming back to the
leadership issue, which I agree is absolutely crucial, do you
think we should go back to the days of the one top matron who
sails around like a battleship in full sail, who has everybody
leaping to attention? The standards in those days were pretty
high. Should we go back to that? Do to you think these modern
matrons are just office sisters given a new title without any
further power? Why do we not go back to the real old matron as
the real leader?
Professor Lord Darzi of Denham:
I think what you are describing is the leadership rather than
the old matron. Old matron had different challenges than the matron
that is working in the Health Service now. I remember those days
very well when you had an old matron. I think what you really
bring to attention is who is in charge, which is the commonest
question I ask, the commonest question the patient asks. Who is
in charge of this ward? You arrive into your ward and you say,
"Who is in charge?" and that is the bit that I think
we need to develop. We need to empower the person who is in charge,
and that person, who is also in charge, do not forget, needs to
be accountable. You cannot empower people without making them
accountable. So, the answer to your question is that all it wants
is someone who knows who is in charge in every part of the hospital,
let alone the top dog—who is the matron, as you probably
said, who is the chief nurse, who should be ultimately accountable—and,
let us not forget, the accountability, if I could come back to
that word, is collective accountability.
Q48 Dr Taylor: That is my next point,
because collective responsibility is fine but I still have to
say that no longer can a consultant on the ward really make sure
that the nursing standards are up to his or her standard because
that is the ward sister's responsibility and the two are no longer
able to co-operate as they were.
Professor Lord Darzi of Denham:
Yes.
Q49 Dr Taylor: Can you do anything
about that?
Professor Lord Darzi of Denham:
Yes, I can. I do it every day I go to work. I bring everyone together,
we sit down and decide exactly how we are going to do this, and
that is the bit that is very important. That is leadership.
Q50 Dr Taylor: How can you get that
happening across the whole country?
Professor Lord Darzi of Denham:
That is what we need to work on. One of my themes is considering
the structural leadership in the NHS. The idea that I walk in
as a consultant as I did 15 years go and gave orders and walked
off and everything happened: that does not happen. I think what
you have been told is the right thing. You need to sit down, you
need to build on a team. We all know how you build a team. You
need to provide the leadership within that team. These are basic
principles. Some organisations, if I could come back to that,
Dr Taylor, do that brilliantly in the NHS, do it better than anywhere
I have seen even across the Atlantic, they do it brilliantly,
and what we need to do is analyse those, understand those and
build these teams around the same principles as you are referring
to.
Q51 Dr Taylor: If you look at the
Healthcare Commission's recent health checks, I think there are
19 trusts that are labelled as weak on quality of care. Is this
the sort of issue you will be addressing with them?
Professor Lord Darzi of Denham:
Yes, absolutely. That is why we have an institute for innovation
and leadership. The reason we have that institute is to help.
It is interesting you say 19. What is important to recognise here
(and I say this as a clinician who works in these organisations)
is that the vast majority of them have the right structures, have
the right cultures, have the right leadership. What we need to
do is help the 19 that you are referring to in making sure that
we implant the basic genes of leadership and the skills in delivering
it.
Q52 Chairman: Is there a correlation
between bed occupancy and hospital acquired infection?
Professor Lord Darzi of Denham:
Whenever you talk about epidemiology and science there are always
two schools of thought in relation to this, and it depends who
you ask and what the background is. There is some evidence, if
you look at our data from the NHS, that those who have a bed occupancy
above 90% have had a higher MRSA bactoraemias but, interestingly
enough, the same organisations who have had that occupancy have
also managed to bring their MRSA rates down without the change
in bed occupancy.
Q53 Chairman: This Committee has
commented and ministers have often commented about the efficiency
or the productivity inside the National Health Service, and, obviously,
one of the measures is bed occupancy. Presumably productivity
is related to that and risk is related to it as well, but what
you are saying is there may be that but really there should not
be?
Professor Lord Darzi of Denham:
There should not be. If you applied the principles of cleanliness
and all the principles, as I said, when it comes to clostridium
difficile—
Q54 Dr Taylor: But if you have got
a bed occupancy of 95% or 100% you do not have the time to do
the cleaning between; so is it not absolutely essential that you
cannot have your bed occupancy rate above 90%, whatever the pressures
on you to meet targets?
Professor Lord Darzi of Denham:
I think in what you are saying on the one hand you are right,
bed occupancy rates above 95% or 100% are a challenge to any healthcare
provider. The question is would that bed occupancy lead to higher
rates of infection. I think it leads to other hazards in the system
besides infection is what I am concerned about. I think what you
are bringing in here is: is it directly related to infection?
The answer to your question is: we have looked at this. Those
who have a bed occupancy above 90% have had higher amounts. They
have managed to drop it by lower bed occupancy rates.
Q55 Dr Taylor: C.diff in particular
relates to the high occupancy rates?
Professor Lord Darzi of Denham:
Yes, you need time to change. You absolutely need time to turnover
patients. You absolutely make sure that you apply all the principles
of cleaning in between the turnover of the patients.
Q56 Dr Taylor: And this is pretty
well impossible with 95% and above, well, 90% and above occupancy
rates.
Professor Lord Darzi of Denham:
Yes.
Q57 Dr Taylor: However well the leadership
is.
Mr Nicholson: It is possible.
Some of our best performing organisations have very high occupancy
rates, so just driving the occupancy rate down will not in itself
necessarily deliver a better position: it is how you manage the
bed, how you organise your cleaning teams, how you get the operation
of the ward sorted out. That is much more important than that.
Q58 Mike Penning: Minister, in your
interim report you identified a vision for the NHS looking forward?
Professor Lord Darzi of Denham:
Yes.
Q59 Mike Penning: You wanted a fair,
personalised, effective and safe NHS?
Professor Lord Darzi of Denham:
Yes.
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