Examination of Witnesses (Quesitons 260-279)|
MP, MR DAVID
NICHOLSON CBE AND
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
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
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
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
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 perioda big, big change
to introduce. The empowerment of those 5,000 matrons, the extra
improvement teamsall 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 sureand
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
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
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 sisterward sisters are a very important component
in this as they continue to remind me and we ought to mention
them a bit moreit 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
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
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.