Patient Safety - Health Committee Contents

Examination of Witnesses (Question 535-539)



  Q535 Chairman: Good morning. Could I welcome you to our fifth evidence session on our inquiry into patient safety? As you are aware, one of our witnesses is on a train somewhere in the South Midlands at the moment, so not too far away, but we are hoping he may get here in this session. We have an area of questioning for him specifically, and we will not ask those questions of yourselves because it is not your area of work, as it were, and expertise. Could I, for the record, ask you to introduce yourself and the current position that you hold?

Dr Holmes: I am Dr Alison Holmes; I am a Director of Infection Prevention and Control at Imperial College Healthcare NHS Trust; I am also an expert member of the Government advisory panel on antibiotic resistance and hospital acquired infection (ARHAI) and I am also a Programme Director at the National Centre for Patient Safety and Service Quality Research at Imperial.

  Professor Esmail: My name is Aneez Esmail and I am a Professor of General Practice at the University of Manchester.

  Q536  Chairman: Welcome once again. What do the patient safety problems in your areas of expertise say about the safety culture inside the National Health Service? Is the in-culture easy to change?

  Professor Esmail: I think the point about primary care, which is where my expertise is mainly, is it is something that has really been left off the agenda in terms of patient safety. I think that we have the least understanding about some of the problems in primary care, but I do think that there is a willingness, and for a long time, in general practice particularly, there has been some sort of understanding of some of the issues and some of the problems. My work shows that there is a willingness to do things about it, but our knowledge base is very limited and very restricted, so I cannot really comment very much on the culture because certainly the work has not been done like it has in the secondary care sector.

  Dr Holmes: From my perspective within the world of infection prevention and control, I have a good news message here because I think actually the model we have developed and worked on has had a significant impact and I think the organisational model that we used and developed is something that would lend itself to many other aspects of patient safety. I think that is a good news story—a local organisational model embedding infection prevention and control within the very fabric of an organisation. It has had an impact. I think it is a lesson for us. There are three other points I would not mind highlighting. I think it is incredibly important and, also, what we have learned locally is, that we must have a framework for surveillance, for gathering data and for continually feeding it back and, of course, that is something that we pointed out in a paper in the BMJ in November[1] about the importance of data, and monitoring, and feedback to get that level of clinical engagement—so the framework for surveillance and feedback is key. The last two points are that it just cannot be a service that is a separate add-on one for some experts, it really must be fully embedded within the organisation for it to work, and clinical engagement is vital.

  Q537 Chairman: I do not know if you are familiar with the publication; it was ten years ago now An Organisation with a Memory was published. Do you think that progress has been made? Clearly, I think, Alison, from what you have said, you think progress has been made in the last ten years. Has it been made, to your knowledge, in other areas as well?

  Dr Holmes: I think progress has been made. I am not sure how much from my coal face view is due to that publication. I think maybe the stage was set for us to make these changes and develop an organisation model, but I would like to highlight that it was actually a pragmatic choice to change the way we work and change how an organisation runs, because the historical model for infection prevention and control, with a small service covering multiple sites and everything, was just not practical and we really had to come up with a new way. I think within the context of An Organisation with a Memory people were very happy to use clinical incident reporting as a way of addressing complacency around hospital acquired infection, for instance. But actually it was a pragmatic solution to what has not worked historically with more complicated organisations. We really had to think about new ways of doing things and embedding it within our culture and our management and clinical systems.

  Professor Esmail: I think a lot has happened since An Organisation with a Memory. I think it did, rightly, set the agenda for us, and those of us who work in primary care. I spent a lot of time trying to persuade organisations about primary care being just as important as the secondary and acute care sector, and we began to try and find out about how big a problem it was. So we did research on trying to find out what others had done around the world, we did small studies to see whether GPs would actually report errors. There was a concern that general practitioners would never admit to doing things wrong, and so we did small studies, for example, to show that they would be very willing to do that. We tried to understand what we could learn from litigation databases. The NHS and the defence organisations do have to deal with litigation arising from things going wrong in primary care, so we looked at that and we discovered a lot about what goes wrong in primary care from that and we began to ask ourselves questions about: how could we engage primary care better? What would be the priorities for doing it? Without a doubt, we are certainly not as developed as in the secondary sector, but I remember at the time having a discussion with the Chief Medical Officer and saying that part of the problem was in primary care. We do not have the same sort of organisational structure that you can have in secondary care. We have a Chief Executive who just says, "This will happen" or "That will happen", or a very powerful medical director. In primary care you have a situation of independent practitioners who are very nervous about any sort of organisational change coming in, people telling them what do, and we have to work with that. There are good points about it, but in trying to implement areas like patient safety culture, when you have to insist, for example, that we want to create reporting systems, all the issues around anonymity and confidentiality, and so on, still have not to this day been worked out really; so to tell people that "you must" and "you have to" is just not going to work in the setting of primary care. I do not think that reflects a desire not to do something about it, but we just have to realise it is going to be very different to how we implement things in the secondary care sector.

  Chairman: We have got some individual specific questions for you now, starting with Doug.

  Q538  Dr Naysmith: Good morning, Dr Holmes. I have a couple of questions for you to start with, some of which you have already made reference to, but let me start with this one. Are healthcare associated infections as big a problem as they are perceived to be, certainly by the media, who seem to focus in on them? Is it a really big important problem in terms of what the National Health Service is doing?

  Dr Holmes: I think we have to acknowledge there is a massive media interest. In terms of the data, in the latest prevalence study of healthcare acquired infections, which is published in the Journal of Hospital Infection 2000,[2] I think, the prevalence was 8% of all hospital in-patients, but, in terms of public perception, the BBC had a national poll last year where hospital acquired infection remains the number one concern above and beyond quality of care, variety of mistakes, et cetera.

  Q539 Dr Naysmith: What I am asking you is if that perception is the right one?

  Dr Holmes: That is why I said the number of the prevalence. It is almost one in ten infections, so it is something that we do have to be concerned about. Two things I would like to draw our attention to. One thing that does not feature quite so much, which is a very important aspect of this, is actually antibiotic resistant infections.

1   Vincent C, Aylin P, Franklin BD, Holmes A, Iskander S, Jacklin A, Moorthy K. Is health care getting safer? BMJ. 2008 Nov 13;337:a2426 Back

2   Smyth E, McIlveny G, Enstone J, et al. Four country healthcare associated infection prevalence survey 2006: overview of the results. J Hosp Infect 2008; 69(3): 230-248 Back

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