Improving patient care by reducing the risk of hospital acquired infection: A progress report (HC 1044-i) Public Accounts Committee 8 Sep 2004

Evidence given by Sir Nigel Crisp KCB, Permanent Secretary/NHS Chief Executive, Professor Sir Liam Donaldson KCB, Chief Medical Officer and Professor Brian Duerden, Inspector of Microbiology, Department of Health

Q44 Mr. Gerry Steinberg (City of Durham): : Sir Nigel, I have a lot of respect for you and I think you do a good job in the NHS but, frankly, the answers you have given this afternoon I am amazed at. I do not see it substantiates what The Sun said about you but, by gum, it is not far off, to be quite honest. If this had been the first report on hospital acquired infection then I could have understood some of the answers you are giving but, frankly, this is the second report, four years after the first report, and the answers you are giving would be the answers that one would have expected four years ago, not four years after the recommendations of this Committee. Quite frankly you just do not seem, you and Sir Liam, to have taken this problem very seriously at all otherwise we would not have the report we have today which, frankly, is a disgrace as far as I am concerned. I think it is one of the worst we ever had based on the fact we did it four years ago and the situation is now worse than it was then. You seem to have argued it is not, but you just have to read the report to see how many people have died since four years ago and how many people have acquired infection, and it is almost double. Frankly nothing has been done to change that. I want to read you, even if it takes me the next ten minutes, a quote that I used in a speech on the floor of the house three years ago in a PAC debate after the first report had been produced by the NAO and ourselves, so this quote I used is three years old. "Doctors campaign against filthy wards. GP takes action after hospital superbug kills his wife" - and I am going to quote extensively from the article because it sums up the tragedy that has occurred, and you have done nothing about it for four years to be quite honest. You can pontificate as much as you like but nothing has been done and twice as many people have died. The article said, "A retired GP has lost a campaign to improve hygiene in hospitals after his wife died from a superbug she picked up on a filthy ward while recovering from a routine operation. The retired GP in question was Dr Roger Arthur. His wife Patricia, 73, died in St Helier Hospital in Carshalton last month from the superbug MRSA, an infection which kills 5,000 hospital patients a year and is a factor in the deaths of 15,000 or more. Dr Arthur said that the real figure might be higher. The scale of the problem is highlighted in the fact that at the time of Mrs Arthur's death St Helier had dedicated an MRSA ward designed to keep infected patients in isolation, but it was full. She had gone to St Helier for surgery to remove a benign obstruction in her bowel. Her husband said the operation was a success but she died after eight or nine days. 'I noticed she had a bit of a cough but she seemed fine. However, when we got home she seemed to become ill and within ten hours I could see she was going downhill fast. We went back to the hospital and they did some tests. The doctor came back and told us it was MRSA'. Mrs Arthur died from the infection four days later. Dr Arthur from New Malden had little doubt how his wife become infected. He said 'The ward she was on was absolutely filthy. There were sweet papers, fluff, old bits of elastoplast, and the tops of disposable syringes behind the bed when we came in, and they were still there when we came out. I ran my finger down the windowsill by my wife's bed. There was a thick layer of dust and a vase of dead flowers. There were cleaners around but they all seemed to be cleaning the middle of the floor and not bother anywhere else. I was told there was a ward for MRSA patients but that was full so people with the infection were remaining in normal wards and infecting other patients'." We gave recommendations against that four years ago, I made this speech three years ago, and nothing has changed.

Sir Nigel Crisp: : I am sorry if I have given you the impression that we are not taking this seriously because we do indeed take this extremely seriously and I said to your Chairman at the beginning that every single case of the sort you are talking about is an absolute tragedy. A lot has happened. The fact that we started the first mandatory surveillance of the world the year after 2001; the fact that we have now got a changed accountability so we now have these new directors coming in; we have the handwashing campaign - which is not just an issue in England, the sort of issues --

Q45 Mr. Gerry Steinberg (City of Durham): : Sir Nigel, we sat here four years ago and said that people were dying or being infected because doctors, nurses and hospital staff were not cleaning their hands. We said it four years ago and I came back from holiday two weeks ago to see on television the amazing thing that nurses were now going to start washing their hands or cleaning their hands because there was going to be some stuff put on the bedside for them - four years later! How can you say you are not complacent if that has taken four years for people just to wash their hands?

Sir Nigel Crisp: : But if you go back and look at what we did this week it is based on what has been happening over the last eighteen months to two years when we have been piloting that in hospitals because what we know, and what this report says, is it is not that people are not washing their hands because they do not think it is important - there is a whole series of other reasons, so how do we make sure we get people to wash their hands? This is not just a problem in this country; that is why we piloted it in a limited number of hospitals and we are now running it out across the country. I understand that the argument is why could we not have done that two years earlier rather than starting it two years ago, and I take the point, but this is action that we have taken which is serious work.

Q46 Mr. Gerry Steinberg (City of Durham): : I do not want to mention any names because that would be unfair but I had a confrontation with a member from the House of Lords who I have a great deal of respect for and who I like a lot, and he is very influential in the medical service, and he fell out with me when I pursued the fact that one of the causes was that handwashing was not being done properly by his own profession. Now, if he, who is the one of the most prominent surgeons - perhaps I should not say that - in the country, can argue the case, what do you say to that? What do you say if the profession themselves will not accept that what they are not doing is causing MRSA?

Sir Nigel Crisp: : This report again says that getting people to wash their hands is not as simple a thing as we have just said, for cultural reasons, for habit reasons - for a whole series of different reasons --

Q47 Mr. Gerry Steinberg (City of Durham): : That is not good enough, is it? It is just not good enough as an answer to say that for cultural reasons or for habit reasons or whatever people in the Health Service are not washing their hands? It is such a basic thing, and yet it has taken four years to do something about it.

Sir Nigel Crisp: : I agree but how do you get everyone to do it because it is not quite as simple as it sounds.

Professor Sir Liam Donaldson: Sir Nigel is right, this is a problem world-wide. The World Health Organisation have pointed out that compliance with those basic practices is a problem in many countries of the world. One of the reasons is that if there was a sink by every patient's bedside to which the doctor or nurse could go every time they had contact with the patient life would be a lot simpler, but there is not -

Q48 Mr. Gerry Steinberg (City of Durham): : To put it down to the fact that there is no washbasin beside every bed therefore they cannot wash their hands is, to me, just making excuses.

Professor Sir Liam Donaldson: If I could ask you to let me finish my answer -

Q49 Mr. Gerry Steinberg (City of Durham): : If the answer was worth listening to, I would listen to it. Go on, then. Let's hear it.

Professor Sir Liam Donaldson: But sometimes very busy staff could be dealing with 30, 40, 50 different patients in the course of a morning and they are moving quickly, often doing life-saving procedures, so we do have to make life easier for them -

Q50 Mr. Gerry Steinberg (City of Durham): : So they save somebody's life on one bed but kill the next one in the next bed because they have not washed their hands?

Professor Sir Liam Donaldson: - so the way we tackle this is to bring in alcohol rubs which can be applied in 20 seconds, they can be at the end of every bedside, or on a doctor or nurse's belt.

Q51 Mr. Gerry Steinberg (City of Durham): : Fantastic, but it has taken four years to do it?

Professor Sir Liam Donaldson: Well, it was not a widely used practice four years ago. It has been researched over time, been shown to be beneficial, and it is not a panacea because the cause of MRSA is not dirty or unhygienic hands alone, although it is an important contributory factor - something like 20% of cases have probably contributed to that - but this is a technique which has now been properly evaluated and can be introduced comprehensively, which it is being.

Mr. Gerry Steinberg (City of Durham): : Just to finish I think that there is a certain amount of arrogance in the way that you treat things and the way you deal with things. You say that there needed to be pilot schemes and God knows what else that has taken four years, but the truth of the matter is I do not think you have been listening to people. This report clearly shows that where people have listened to what has been said, for example in Denmark, they have got their rates down to something like 0.6 while ours is 42.9 in terms of resistance to MRSA, because they took advice and they carried that advice out. I understand in Scotland, for example, in their Health Service they give antibiotics - for some reason you do not do that - during an operation. Apparently it has been proved in Scotland that this works but in England we do not do it. There is another one, the Pan Celtic collaboration. The English are so arrogant they are not going to take part in this because they want to do it their own way. You just do not listen, you do not take advice, you just go your own way and then four years later you come back and there is no improvement whatsoever - in fact, the figure is worse.

Q52 Chairman: To complete that question for the sake of the record, the reference to Denmark is in paragraph 4.38 and Appendix 3, page 50, Sir Liam, and what Mr. Steinberg was putting to you was that they have been very successful in Holland and Denmark in their "search and destroy" approach which apparently you have not been able to implement so successfully here, if at all?

Professor Sir Liam Donaldson: They start from a lower baseline, they have been at it for ten, fifteen years to get to the position they are in -

Q53 Chairman: Which, of course, begs the question?

Professor Sir Liam Donaldson: - and they do so obviously by good hygiene but also a very strong part of their policy is based on having a high proportion of isolation beds in the hospital, isolating people who are infected immediately, swabbing them on admission, creating a cohort of nursing staff especially to look after those patients --

Q54 Mr. Gerry Steinberg (City of Durham): : So why do you not do it?

Professor Sir Liam Donaldson: Because we have been treating a greatly increased number of patients in the NHS and to rein back and deny patients treatment whilst we create more spare capacity is quite a difficult thing to do. It has to be introduced over time. We do not at this stage have hospitals with high levels of single rooms and cubicles, but that is being introduced into the NHS building plan so we will get there with some of these structural changes. We do not yet have what we need compared to the Netherlands, which I have visited recently, and some of the other Scandinavian countries, but we will be able to get there when we do have those facilities available.

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Mr. Gerry Steinberg (City of Durham): : It seems to me that you did not listen and seem to take advice, so what I want to know is why, after our report in 2000 when, as a result of that, you introduced a national manual, that that manual has totally disappeared and been ignored? Why? Who took any information from it and used it, and who ignored it? If you want to write to us on that one, you can. The other important point is that apparently the only thing that the Health Service employees thought was worthwhile that you have done over the last four years was to introduce the infection control insurance standards. The report tells us that 90% of the NHS who were involved thought it was a good idea - and you scrapped it. Since the report came out the Committee received a letter from a Bob May, who presumably you must know, who was the manager of the NHS national control insurance project for the Department of Health. He has written all members a letter in which he asks some very pertinent questions. Presumably, you have not seen the letter. I would ask that the Chairman allow you to see the letter and respond to it on the point that he makes.

This is an uncorrected transcript of evidence taken in public and reported to the House. The transcript has been placed on the internet on the authority of the Committee. Neither witnesses nor Members have had the opportunity to correct the record. The transcript is not yet an approved formal record of these proceedings.