Patient Safety - Health Committee Contents

Examination of Witnesses (Question 560-579)



  Q560  Sandra Gidley: When did people stop washing their hands in the NHS? I can remember reading Jean Becomes a Nurse when was about 12, and there was a whole chapter on hand-washing. When did people stop washing their hands in the NHS and why do we need such a big campaign on hand-washing? It is such a basic.

  Dr Holmes: Absolutely, but continuous reinforcement is needed. The other thing that is important there—I mentioned before issues about staff ratios—hand hygiene and staff ratios is important, but it needs to be embedded in the culture, it needs to be taboo not doing it, in just the same as surgeons and scrubbing. It needs to be behaviour that is completely reinforced, that is engrained there, we have got to have role models and it is always reinforced.

  Q561  Sandra Gidley: So the data is really tracking progress against what you are doing.

  Dr Holmes: There is a huge amount of national data but also local data. In terms of what is coming from the NRLS, it is the hand hygiene programme, which I am most familiar with, which has been incredibly valuable.

  Q562  Sandra Gidley: When you are looking at the data, the information that is coming back, how useful is that for a hospital to say: "Right we tried X, Y and Z to improve our infection control rates. It is obvious that Y is the one that is having the most effect", or is it just not useful in that way?

  Dr Holmes: It is incredibly useful, and the point you raise is really important because the data needs to be used to target action, and to target action you need more information round that. You either need to drill down to each case, you need to look at themes or you need to look at where are you seeing these cases—what risk groups. So, absolutely, data drives and feedback drives activity, targets action; so it has to be useful data that you can drill down and get more information and investigate. Root cause analysis is very useful around some particular cases, but even just knowing the demographics, the speciality—all of that is incredibly valuable—and feeding it back to the people who can do something in a timely manner is absolutely critical, far more than any individual finger pointing. Continuously feeding data drives quality improvement, particularly if you are measuring something that is meaningful to the people who are getting that information.

  Q563  Sandra Gidley: So we gave got the datasets about right.

  Dr Holmes: I think we could do a lot more. MRSA bacteraemia is one thing: I think it is fantastic that the data is there it has driven massive change; I think we could do far more. I am particularly anxious about vulnerable patient populations in our intensive care units or our neonatal units, but we are working through networks to get more information and people are welcoming data.[6]

  Q564 Sandra Gidley: Say you had extraordinary influence on our report, is there anything specific that we should be collecting or looking at that currently we are not? Are we missing something?

  Dr Holmes: I think we need to have much better data around bloodstream infections in our intensive care units, in our renal and dialysis units and in our neonatal units. These are a highly vulnerable, high risk population. They may not be quite as vociferous, but they are highly vulnerable and I think that is an area we should be looking at.

  Q565  Charlotte Atkins: Good morning. I am sorry I was not here for the earlier part of the session. Dr Holmes, how do we embed and enforce safe ways of working that will really enforce good infection prevention control?

  Dr Holmes: I think there are four main ways of doing this. We must ensure that within an organisation, so from my perspective the trust I am working in or the academic health science centre at Imperial that I am working in, we must have a shared vision and a shared belief so that all of us, every one of us, no matter what our role, profession, and that this vision is a good thing to do. For me, it is infection prevention. Everybody must feel it is important and we have a role. So from the Chief Executive through all personnel—clinical, managerial, administrative—ensuring you have a shared belief. The second thing I alluded to is we must have reinforcement systems, and positive reinforcement systems as well. So everything we do must make good infection prevention practice the easy thing to do and also positively reinforced all the time, driving internal networks to get good information, having a research agenda that also supports it and also that all our measures include measures about infection so that all our key performance indicators, whenever people are looking at them, will always have something about infection, outcomes and processes. So a shared belief, ensuring we have reinforcement systems and then, thirdly, we have to provide skills for people. We need trained staff and we need people who actually understand what their role is and how to embed and deliver good practice and supporting whatever role they have. Then lastly, I mentioned before with antibiotic prescribing, but in the context of an organisation and culture there must be consistent role models from the Chief Executive, medical directors, nurse directors, heads of estates and facilities—all of them must be involved and be role models—but then there is another aspect of that. We also must make this aspirational for people who are involved in it, not the worst possible job, and also we must develop better research. I think, being on the research agenda, it is very important, and that also drives clinical engagement as well.

  Q566  Charlotte Atkins: You are talking about leadership, and so on. Do you think that there is sufficient leadership from our senior clinical staff in terms of making this a top priority?

  Dr Holmes: I think that is absolutely key. We were mentioning earlier about antibiotic prescribing. Antibiotic control and infection control go hand in hand: you do not care about antibiotic resistant organisms if they do not spread. How we use antibiotics to treat infection, it is all joined up—antibiotic control, infection control—and, if we do not get engagement from senior clinicians who influence prescribing and shape the behaviour of junior doctors, we will not be able to embed it and make it part of our culture, so senior clinical leadership is vital. Also, what I was saying earlier, actually it is important that senior clinicians take on senior roles within infection prevention and it is not seen as solely a nursing role but actually it is a multi-disciplinary role. It is not solely the premise of the nursing directorate: all clinicians, whatever role you are in, must be engaged.

  Q567  Charlotte Atkins: Surely it is not just about prescribing, it is also a matter of washing hands and actually saying that it is totally unacceptable for anyone, including senior consultants, to come in here without washing his or her hands.

  Dr Holmes: Completely. I am sorry; I take that as a complete given. Why I was highlighting the issue about antibiotics is that that is particularly a prescribing issue, and also I think everybody should be in a position to challenge prescribing. Earlier I mentioned the role of pharmacists—absolutely key. We need to develop them far more, both in acute care and in the community. Pharmacists, as well as nurses, as well as doctors—we must all work together challenging each other, driving best practice, but, absolutely, all practice, from hand hygiene to how you insert a central line, how you manager a dialysis catheter, how you look after a neonate, or how you conduct yourself in your out-patient clinic—all of that must deliver infection prevention practice.

  Q568  Charlotte Atkins: The committee went to St Thomas' a couple of weeks ago and it was very clear as soon as we entered the room that we were expected to use the hand gel, and so on. I go to hospitals quite a lot, sadly, and that is not always expected. The canister is on the wall and if you feel you are going to be good you go and put it on, but it is not something where generally staff look at you and say, "You are coming in to visit a patient: use the gel"?

  Dr Holmes: I think this is why it is absolutely key about the senior buy-in—medical director, chief executive, key performance indicator, where they also identify what the professional group is that is not performing in hand hygiene and why hand hygiene monitoring should be up there as a regular indicator of quality.

  Q569  Charlotte Atkins: Do you think that the regulatory and the performance managing bodies are doing enough themselves to make this a top priority?

  Dr Holmes: I think there has been an awful lot done. I think what might be useful is if some activity is not duplicated. We need to find a balance between working within a framework of regulation and actually letting trusts develop good quality improvement within their own networks, so that they are not constantly duplicating activity and maybe needing to think about having extra people on their staff to deliver all that is required for external regulation rather than concentrating on local quality improvement initiatives.

  Q570  Charlotte Atkins: Maybe commissioning bodies have a part to play. Commissioning for Quality and Innovation by the Department of Health suggested that PCTs might be able to make payment to providers conditional on performance indicators for things like infection prevention and control; and I have to say that, if I was heading up a PCT and some of my patients had to stay in hospital an extra two or three weeks because of catching some sort of infection, I would want to ensure that my local provider hospital had a financial penalty for that. Instead, they have a financial advantage, because they are paid more for the patients that stay there longer.

  Dr Holmes: I think external reinforcement like that is valuable. However, I have a slight anxiety. I mentioned before about how critical it is, now that patient stays are getting shorter and shorter, that we really do need to look at `healthcare' acquired infection and antibiotic prescribing across the whole patient journey, and we are just beginning to work across that and look at it as a problem that is not either acute or primary but is something that we should approach together. I am slightly concerned that that may drive a wedge between some of the work we are trying to do about risk across acute and primary care boundaries. However, the quality initiative I completely support and the reinforcement being there is valuable, but I think we have to be mindful that actually we really do need to address this problem, not as a primary care and acute care issue but actually across the whole patient journey, if we really do want to do something about it.

  Q571  Charlotte Atkins: I appreciate that, obviously, many patients will enter a hospital already with infection, I appreciate those concerns, but where you have hospitals that warning, after warning, after warning their infection rates are much higher than acceptable, and anything is unacceptable but if they are very high, surely there has to be some sort of financial penalty: because it gets to the point where hospital managements can be in denial mode: "Oh well, it is everyone else's fault. It is the PCT's fault; it is the population we are having to serve", and it really has got to get to the point where if they are not performing there has to be some sort of penalty, and financial penalties seem to be the ones that actually have an impact on performance.

  Dr Holmes: I do think there are some lessons that can be learnt from the mandatory reporting of the MRSA bacteraemia and the actions that have been taken at trusts that have driven down numbers in the absence of financial consequences. I do not think I am in a position to comment any more about that. I completely value external reinforcement. In my job it makes it much easier to drive change when there is a level of external reinforcement, but I actually value working with my primary care colleagues to look at it as a comprehensive problem that we can work on together. That is my concern about that.

  Q572  Chairman: Could I say welcome to Professor Matt Griffiths, who has joined us. We are sorry about the delays; the weather is in nobody's control. You are the Visiting Professor of Prescribing and Medicines Management at Northampton University. I just want to put that on the record.

  Professor Griffiths: Yes.

  Chairman: We will come to you in a few minutes, but we are going to move on to Professor Esmail at the moment for some further questions.

  Q573  Stephen Hesford: Professor Esmail, there is a cross-over from the questions that have just been asked. Probably about 20% of my constituency population is elderly, 65 plus, and a significant proportion of those are in nursing homes. My local hospital's infection rates are low but they have a residual band that they basically cannot get rid of. They think that much of the infection is coming from the elderly coming in from nursing homes. Dealing with primary care, with that in mind, if that is at all representative of what happens elsewhere, there does not seem to be much hard evidence on patient safety in primary care. What can be done about that, either in the GP's practice or health centre or in other primary care settings?

  Professor Esmail: I think from the specific example you gave, we are only now beginning to understand that things like community acquired infections are a big problem; and we have not had systems in place to make sure that people are screened, for example, before they enter hospital sometimes, because you cannot do it when it happens as an acute emergency. I have noticed with of my own patients that people going in for very complex operations which are planned are now being routinely screened, for example. So we are beginning to understand this relationship between what happens in the community and what happens in hospital. Of course, it happens the other way round as well: people get discharged without being screened and we do not have any idea of that, and then they come in with persisting wound infections or become ill with pneumonia and the source might have come from the hospital; so we do not have that information either. I think we are beginning to understand that more and I think we have got to do a lot more work as we understand the epidemiology of these illnesses and how we have to have a whole systems approach to that. On the issue about evidence, it is not true to say that we have no evidence. We look at literature, we have done pilot studies, and we have looked at litigation databases; so we understand how big a problem it is. Of course, I think part of the problem is we have not concentrated on it enough. If you think that most people's contact with the NHS is through their general practitioner and you then imagine what must be happening, even if you talk about 50 incidents a day but you multiply it by the number of consultations that people have, you are talking about huge amounts of things that potentially can go wrong. So we recognise that it is a big problem, but we do not have a very good means of measuring or putting numbers to it, for example. We always talk about ranges and how big a problem it might be, but we do not have a specific number we can quote, saying, "This is how big a problem it is." Hospital people frequently talk about one in ten admissions or 10% of all admissions have adverse events. We cannot give you that figure for primary care, and that is a problem, but it should not prevent us from doing anything about it. This idea that we can only do something if we know that figure, I think, is misplaced. There is lots happening already and lots which can be done which does not have to be dependent on that idea.

  Q574  Stephen Hesford: I am slightly confused by that, because if there are no figures to know exactly what the problem is, I am not sure what the solution is to the problem that you do not really know what it is?

  Professor Esmail: Take an example of something which is widely happening in communities: warfarin prescribing. I cannot tell you at the moment how many adverse events occur in primary care because of warfarin prescribing.

  Q575  Stephen Hesford: Adverse events meaning?

  Professor Esmail: Let us say that the patients are getting medication repeatedly without having their level checked, or are getting too high a dose of warfarin so they are at risk of bleeding or having a haemorrhage, or something like that. I cannot tell you a precise figure as to what the problem is, but I do know, based on good practice, what should happen, and I can look at my processes in practice to say: is that happening or not? I know, for example, that before a patient gets a repeat prescription for warfarin someone needs to ask the question: "When were you last assessed? When was your last blood level taken and what was it? Is there a record of it? So that I know that I am giving you five milligrammes of warfarin, that is going to be within the accepted norm, or I am giving you too much and you need to cut back on that. So I do not need to know the exact number there; I just know that in good practice that is what should happen. I think a lot of general practice is like that. We know certain things that should happen but are not happening and we can focus on that, and that means a better understanding of processes. Of course I think that having the numbers helps, because if we want to put in very expensive intervention, something different or unusual, then we do need to be able to evaluate it. Again, we can focus on different areas and see if we can improve those, but I think we should not use that as an excuse to say we cannot do anything. That is the only point I am trying to make in that respect.

  Q576  Stephen Hesford: So would you agree with the statement that there is awareness at a fairly significant level that patient safety in primary care is an unaddressed problem?

  Dr Holmes: Yes, I think so, and I think all the big agencies, the National Patients Agency, the Government, even at a European level, are beginning to understand that there is a whole amount of work and understanding to be done in primary care and they are beginning to focus their attention on it. I am, for example, being asked increasingly to talk about areas in primary care, research money is becoming available to work in this area, so I think there is definitely a realisation now that there is a whole lot of work that needs to be done in primary care and think more effort and attention is being directed to that. In terms of awareness, I do not think there is a problem, because I think virtually every general practitioner. We did a study, for example, when we asked general practitioners over a three-month period to record things that should not have happened, and we were amazed, just in our small practice, how many incidents came up. We had instances where there was delayed diagnosis.

  Q577  Stephen Hesford: Were those anonymised?

  Professor Esmail: Yes, they were anonymised.

  Q578  Stephen Hesford: Otherwise you would not get anyone telling you.

  Professor Esmail: We had to do it that way. I made this point earlier before you arrived. Those sorts of issues still are not resolved in primary care, for example. Yes, there is the whole argument if we make them completely anonymised, we cannot find out the detail we want sometimes, but when we did our study, and we did it across Europe—

  Q579  Stephen Hesford: But it is a start?

  Professor Esmail: It is a start. That was crucially important because in some ways general practitioners were able to unburden themselves of something, and we do this now in our practice every year. We have a four-week time when we say, "All right; we are all going to report things now for a four-week period", because we know that is sustainable. Our research evidence shows, wherever we have done it, that after about three months it begins to fall completely and people do not do it, so we have a one-month campaign and we say, "Let us report." We have reminders and everyone is doing it, and then we collect the information and we the use it as a feedback, and we plan to do it at different times of the year so we will get a range of things going wrong and be able to investigate what happened.

6   Further information supplied by witness: Holmes A, Dore« CJ, Saraswatula A, Bamford KB, Richards MS, Coello R, Modi N. Risk factors and recommendations for rate stratification for surveillance of neonatal healthcare-associated bloodstream infection. J Hosp Inf. 2007 Oct 15; 66-72; Back

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