Select Committee on Health Minutes of Evidence

Examination of Witnesses (Quesitons 260-279)


29 NOVEMBER 2007

  Q260  Dr Naysmith: But it is a change because there have previously been targets and it was 100% but you allowed a system whereby if people could put up a good reason for not achieving the target each case had to be considered, so why did you this time decide on a percentage exception?

  Alan Johnson: On this, as I say, we always made it clear that we would at some stage actually put detail on the target of getting 18 weeks from referral to actual treatment by the end of December 2008. We did not publish one that said there is a 5% wastage rate; we have only published for the first time this 10%.

  Q261  Dr Naysmith: The system of suspensions and deferrals that had to be notified; is that not right Mr Nicholson?

  Mr Nicholson: We have done both in the sense of, if you remember, the A&E target we made the target 98% and this was largely because of the volume of people involved. Tens of thousands of people will go through the 18 weeks programme. If you set out a whole series of rules from the centre, which my guess would be incredibly complex, you get a situation where the system goes into a "how can we sort all these suspensions out?" rather than treating the patients. We thought it was much more sensible to avoid the bureaucracy of that but to focus on a target which we think is effective and suits both patients and clinicians.

  Q262  Dr Naysmith: The target will actually be 90% at 18 weeks.

  Mr Nicholson: Our expectation is 90% of patients who have in-patient treatment and 95% of patients who have non-admitted care, but we will look very closely, as we do with the A&E target, to make sure that the system is not gaming in any way, so for example all the difficult and complicated orthopaedic work is in the 10%. We need to make absolutely clear that that is not the case. That is a much easier thing to do and a more patient-focused thing to do than trying to set up 1,000 different that every hospital has to apply for every individual patient.

  Q263  Dr Naysmith: It sounds sensible but how did you decide on 90%? Was any modelling done?

  Mr Nicholson: We did quite a lot of work with patients, patient groups and looking at the clinical outcomes of existing care and the 95% and 90% are stretching targets. It is at the top end of this.

  Q264  Dr Naysmith: So why did you not use the same approach for the cancer target which I believe is 100%?

  Mr Nicholson: The issue there of course is that the volumes are much smaller and we are much clearer about what the patient pathway is and so you can manage that much better. It simply is a matter of volume for the 18 weeks and the A&E.

  Q265  Dr Naysmith: You told us that once the 18-week maximum had been achieved choice and contestability would be used to drive further reductions in waiting times. You told us that last week. If choice and contestability is an effective policy, why has it not been used up to now?

  Alan Johnson: It is being used up to now. There is more choice coming on stream. From next year the Extended Choices network will mean that people have much greater choice than they have had up to now, so it is a continually evolving situation with more choice becoming available. Of course we concentrate a lot of choice in secondary acute care but there is now going to be a much bigger focus on choice in primary care as well.

  Q266  Dr Naysmith: What we are saying really is that we need the 18-week target as well if choice and contestability is not good enough on its own. That is what it is saying.

  Alan Johnson: I think the 18-week target is about the patient being able to choose to go to that hospital. Do not forget that the median length of time will be eight weeks and 18 weeks will be the maximum that someone would have to wait. If everyone is achieving very short waiting times, then people will not base their choice so much on that; they might base it on health care associated infections or whatever but waiting times has been a very important part of choice because people do see the record of certain hospitals and say, "I would rather go there because I will not have to wait so long."

  Q267  Charlotte Atkins: The Lancet editorial suggested that the plans to deep-clean hospital wards was more of a publicity exercise than being evidence-based. How do you respond to that?

  Alan Johnson: I did not read the article and I am a bit surprised that The Lancet, weighty and lofty journal as I understand it to be, spends its time writing editorials about deep-clean. It would be a fair point to make if the only thing we were announcing was deep-clean. The point about deep-clean is that it sits with a whole series of announcements from "bare below the elbows" to screening on MRSA for all patients, not just elective patients but including emergency patients by the end of this CSR period—a big, big change to introduce. The empowerment of those 5,000 matrons, the extra improvement teams—all of these things are having a real difference. Part of that was deep-clean. I do not think there is any evidence one way or the other about this, I am not sure—and David might know of some. What I do know is that in the hospitals where they do it (and lots of hospitals have this) it gives patients confidence. It is part of the perception of the public that this is a hospital that puts cleanliness and safety as a top priority and it is a clean hospital to go into. This was not some huge great suggestion that the one answer to health care-associated infections was a deep-clean. It is part of a series of measures.

  Q268  Charlotte Atkins: The reality is if you just look at my own constituency North Staffs Hospital was one of the worst hospitals in the country in terms of infection control and 12 miles down the road, admittedly a small hospital, is Leek Moorlands Hospital which scored "excellent" on all three categories in its PEAT scores. Is it not about management, certainly the screening of patients, but also making sure that doctors and nurses wash their hands and that there is a culture within the hospital where the gels are not just sitting there but they are actually used, not just by professionals but by relatives and anyone who is involved with patient care?

  Alan Johnson: It is indeed. It is about washing hands; it is about responsible prescription of antibiotics; it is about isolation of cohort nursing. It is about those three things but, as I say, the cleanliness of the hospital really matters to people. We spent £370,000 on the first deep-clean we announced at Maidstone because to the public in Maidstone we had to restore confidence in their local hospital. It is the most gleaming, clean hospital that I have ever seen and I do not think it was just for my visit. The problems there, if you read that report, were the very problems you mentioned: nurses were not trained properly; they were badly prescribing antibiotics; everything that could go wrong did go wrong. The deep-clean is just one part of restoring confidence and one part of tackling this huge problem of health care-acquired infections.

  Q269  Charlotte Atkins: Given that, how cost-effective is it? Maybe you are factoring in there public confidence as being an element but if you are just looking in terms of deep-cleans managing to reduce infections, how cost effective is it?

  Alan Johnson: It is important to ensure that all parts of the hospital are clean and that was second nature in hospitals, as I understand it, before antibiotics invented. The only way you tackled these issues was by scrupulous cleanliness. As to its cost-effectiveness, I think it will be cost-effective because I think what happens at the moment is that the cleaning that goes on is not as centred and focused as a deep-clean will be, so it will have an effect on the cleanliness of the hospital but, as I say, in terms of public perception and public confidence that that hospital is safe we are not able measure that in terms of whether that is cost-effective but I am sure that is the principal benefit that we will get from deep-clean.

  Q270  Charlotte Atkins: You can have as many deep-cleans as you like; if after the deep-clean has happened the management does not insist on the cleaning regime being properly carried out and those sorts of infection control measures embedded within the culture of the hospital, then it is not going to make any progress.

  Alan Johnson: The deep-clean on its own will not make any progress. It has to be seen within all those measures and of course the fact we now have a statutory hygiene code, which was not in force at the time of Maidstone and Tunbridge Wells; it has only been in force since the 2006 Act. That is now statutory and the measurement against that, as well as all the other changes we have made, I think is the reason why we have now seen a 10% reduction in MRSA and a 7% reduction year-on-year on Clostridium difficile; 13% on the last quarter.

  Q271  Charlotte Atkins: How does that statutory control also relate to ambulances because a recent Unison report indicated that there was huge variation between different ambulance services. I am surprised, coming from Staffordshire, that there is not always in every ambulance service a dedicated team of cleaners going in there and making sure that an ambulance is absolutely clean.

  Alan Johnson: I have just seen the Unison report. We do not think that this is a major reason for health care-associated infection spreading. We think that there are flaws in that report but we will look at it very carefully and we will consider it very carefully because this is an absolute priority for us. Safety is an absolute priority and it has got to be a priority right throughout the NHS. If that means looking at how we clean ambulances then we will look at that again.

  Q272  Charlotte Atkins: Is not part of the problem though quite deep-seated in the sense that very often cleaning staff are not seen as part of the core workforce. Going back to the days when they were privatised and everything else, they are just really seen as a team of people that come in, sort out the ward maybe in the morning but are not on the ward all the time, and they are just a separate element within the hospital and not really embedded within the hospital workforce?

  Alan Johnson: The major problems, as you have pointed out, were about washing hands, prescription of antibiotics and isolation of cohort nursing. I wish I could say there is absolutely clear evidence one way or the other about whether you have contract cleaners or directly employed. Maidstone had directly employed cleaners and it was an awful mess. It is the quality of that cleaning, it is the control of the matron and the ward sister—ward sisters are a very important component in this as they continue to remind me and we ought to mention them a bit more—it is their ability to ensure that they have the authority to say to senior trust management "there is a problem here and it needs to be tackled immediately" so they can cut through the different layers of the structure in the trust which is why we have given the power for nurses and ward sisters to report at least quarterly direct to the board on cleanliness of their wards. Cleaners are an element in this but whether it is contract cleaners or it is directly employed cleaners it has to be the right number of cleaners, properly trained and valued, I think you are absolutely right, as part of the health team in that hospital. I have seen them being a part of the health team when they are contract cleaners and I have seen them not being part of the team when they are directly employed, so it is management and how you manage those cleaning services.

  Q273  Jim Dowd: Do you think it is reasonable though, and we have heard the story about the ambulance this past week, to expect the ambulance crews and paramedics to actually take some responsibility for keeping their equipment clean and in a safe condition?

  Alan Johnson: Yes it is, absolutely.

  Charlotte Atkins: But Staffordshire Ambulances actually have a separate team to do it as opposed to expecting the paramedics to do it.

  Jim Dowd: That is what they are after.

  Chairman: Let us not have a debate here. You can put it down for the adjournment if you want. Lee has a question.

  Q274  Mr Scott: I visited my own daughter in hospital in Northern London earlier this year and although I washed my hands with the gel, people were wandering in and out and nobody was making sure they washed their hands, and most of them were not washing their hands. This does come back to the problems that were in Maidstone and Tunbridge Wells, and indeed in my own trust, where it starts at the top. Our doctors and nurses are doing a wonderful job and are under a lot of pressure but it is the bosses above them who perhaps are not putting the mechanisms in place to make sure that this regime works. How is that going to be tackled?

  Alan Johnson: The "wash your hands" campaign has been very successful in drawing this to people's attention. I think you are right there is still a problem. The "bare below the elbows", incidentally, has been happening in the Royal Marsden and other hospitals for years. Some of the surgeons who would come along in a white coat perhaps would feel that they were somehow exempt from this policy whereas if everyone is bare from the elbows down it means you wash your hands properly, no watch, no jewellery, et cetera. That was very much to put people on an even keel, if you like. The other thing is making patients assertive enough and confident enough to say to a clinician, "I did not notice you washed your hands." It is a big ask of people when they are in that position, given the rightful respect that clinicians get. In Maidstone there was a failure on the hand-washing policy, a failure not just by members of staff or visitors or whatever, a failure by clinicians and by nurses to abide by that policy. You can pass all the laws and regulations you like, as you will appreciate, but this is a culture thing, that people when they walk into the ward have to be sure that they wash their hands and for C-difficile of course it is soap and water and not just the alcohol rub, which is why in some hospitals they insist on three alcohol rub washes and then a hand wash with soap and water. It was the case in Birmingham where I was last week. It is catching on now and there is a real focus on this because the public are empowered, they know more about it and they are watching to see whether people are washing their hands.

  Q275  Dr Taylor: Can I pick you up on one thing you said. You said very clearly the matron and ward sisters were the important people. Does that mean you share my feeling that we should be going back to the days of the matron, the really powerful person working with a team of ward sisters where the powerful matron really was the figurehead?

  Alan Johnson: You know better than I what the Hattie Jacques version of a matron was. I think they are as powerful now as they were then. When we get to 5,000 matrons we will have one for every two hospital wards and they will have the power over the cleaning contract as well as the power to report directly to the board, so I am agreeing with you, although I am not sure whether that is the total power that Hattie Jacques would have had in the Carry On film in 1959.

  Q276  Dr Taylor: Moving on and coming to public health targets, particularly thinking of obesity, when we did an inquiry into obesity a couple of years ago it was obvious that the problem extends across health, education, transport, traffic, industry, sport, it goes across so many different departments. How are you going to try to co-ordinate the efforts across all these departments and which department do you think should actually take the lead?

  Alan Johnson: We will take the lead and that is already decided.

  Q277  Dr Taylor: Right.

  Alan Johnson: The Foresight Review, which was very important, quite clearly made the parallel between obesity and climate change, not me, and they made the comparison on the basis that it needs cross-government work and if you are not careful you get to a point where it is too late to write back. They make these kinds of comparisons with the two. The inter-governmental committee which we are setting up at the moment is in response to that Foresight report so that we have all those departments, you are quite right, in terms of child obesity. The DCSF and the Department of Health have already got a joint committee up and running but on the general obesity stuff it is going to cross government; the Department of Health will lead and all those departments you mentioned will be part of it.

  Q278  Dr Taylor: What will it be called just so we can follow its progress?

  Alan Johnson: I hope it is not called the Obesity Committee. We are still thinking up a title for this but actually it is about much wider than obesity, it is about health and public health.

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