Examination of Witnesses (Question 535-539)
DR ALISON
HOLMES, PROFESSOR
MATT GRIFFITHS
AND PROFESSOR
ANEEZ ESMAIL
5 FEBRUARY 2009
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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