Examination of Witnesses (Question 560-579)
DR ALISON
HOLMES, PROFESSOR
MATT GRIFFITHS
AND PROFESSOR
ANEEZ ESMAIL
5 FEBRUARY 2009
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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