Labour has chosen this subject for debate this morning as the issue of effectively tackling health care associated infections is vital to ensuring patient confidence as well as patient safety. I particularly welcome Michelle Stewart and members of C Diff Justice Group and others who are in the public gallery.
I pay tribute to the families and members in all parties who have worked hard to raise awareness of the issue and ensure that it is taken seriously by the Scottish Government. I pay particular tribute to Jackie Baillie, who has campaigned tirelessly on behalf of her constituents who have been so deeply affected by the Clostridium difficile outbreak at the Vale of Leven hospital.
Our motion is designed to build on the consensus that was shown when Parliament voted to back calls for a public inquiry into events at the Vale of Leven. That was an important decision and, because Parliament has already decided to support that inquiry, we did not refer to it in our motion. However, we recognise why the Liberal Democrats have lodged an amendment to reinforce that position, and we therefore intend to support it.
We must look to the wider context. As the Health Protection Scotland report confirmed last year, the problem is not associated with only one hospital—indeed, it is not associated only with hospitals, as care in the home, primary care and care homes are all potentially involved. Although we recognise that the occurrence of HAIs is not new and might to some degree be inevitable in health care settings, there is no room for complacency. Indeed, as the British Medical Association has pointed out, the fact that we have an ageing population, combined with advances in medical technology and the ability to treat more severe and chronic disease, means that there are more patients who are potentially vulnerable.
In 2005, NHS Quality Improvement Scotland estimated that about 33,000 patients each year develop infections in hospitals alone. Research suggests that HAI is a major factor in around 450 deaths each year and contributes to around a
I know from hearing the Cabinet Secretary for Health and Wellbeing speak that she is personally aware of the impact that C diff can have on individuals and families. I hope that the debate and vote today will demonstrate that Parliament is united in its resolve to see further action taken to tackle the problem effectively.
We welcome the report of the expert team led by Professor Cairns Smith that was published earlier this week and which shows that progress has been made at the Vale of Leven. Vital refurbishment work is being carried out to ensure that infection control measures are effective. Impressive progress has been made on reducing the use of antibiotics, and the prescribing strategy is being carefully implemented and monitored—and, indeed, extended to primary care.
We acknowledge that steps are being taken to offer the public easy access to all published information on hospital infection rates and hand-hygiene compliance, although there are concerns with the validity of the some of the compliance data. We welcome the announcement in January that, after some pressure from Labour, a web portal on the Scottish Government's HAI task force website will include links to information from all national health service boards and hospitals. Hospital-by-hospital reporting, for which members from across the chamber have been calling for some time, is also a significant step forward.
However, we believe that there are areas in which we can make further progress, which is why we are seeking Parliament's support for the implementation of our 15-point action plan, which has been endorsed by Professors Hugh Pennington and Brian Toft. I do not have time to detail each of the 15 points, but it is important to highlight a number of key points. First, we believe that it is appropriate to set a target to reduce the rate of Clostridium difficile cases by 50 per cent by March 2011. The Scottish Government target of reducing C diff cases by 30 per cent over the next three years is welcome, but it is less than the reduction that the NHS in England has already achieved.
Provision of isolation facilities for all C diff or MRSA patients must be a priority. We recognise that that cannot happen overnight, but the Scottish Government must set out a clear timescale for it to be achieved across the NHS and ensure that the resources are in place to ensure that it happens. Similarly, we want a programme to be put in place that will provide temperature-controlled, sensor-
The Government's latest drive to improve hand hygiene among health care staff will result in members of staff who repeatedly fail to meet hand-hygiene requirements being disciplined. Although it is important that standards are met, the BMA and the Royal College of Nursing agree that that approach will work only if all the appropriate facilities to allow effective and timely hand hygiene are first put in place to enable staff to meet the requirements that are placed on them.
As identified in the report that was published on 10 February 2009, the Scottish Government needs to implement national NHS dress code guidance. We also need immediate guidance from the Crown Office and the chief medical officer to address the need for clear data on fatalities arising from health care associated infections.
I appreciate that there can be reluctance to introduce more tsars or commissioners into our system, but given the numbers of people who are involved in monitoring—I am sure that my colleague, Richard Simpson, will expand on that later—I believe that there is a need for one person, whom we have described as an HAI commissioner, to develop best practice, co-ordinate action and bring a sharper focus to what is recognised as the institutional clutter of the agencies that are responsible for tackling HAIs.
HAI is a vitally important and serious issue for our NHS, and I am not suggesting that our 15-point plan is the final word on what needs to be done. Others might suggest additional reasonable and practical measures. In light of that, we believe that it would be right and proper for the cabinet secretary to continue to formally report progress to Parliament.
The plan has been drawn up in consultation with two acknowledged experts, who have publicly backed it. It also has the backing of the families who are involved in the C Diff Justice Group. I believe that it commands support across a wide range of people, including the members here today, and I therefore commend it to Parliament.
That the Parliament welcomes the 15-point plan for tackling healthcare associated infections drawn up with the assistance of Professor Hugh Pennington and Professor Brian Toft and endorsed by the C.diff Justice Group, which represents the latest group of families to be affected by this problem; notes that the plan proposes a range of measures, including a revised target to reduce Clostridium difficile in hospitals by 50% by March 2011 compared with the current target of 30%; believes that comprehensive strategic action is required to tackle healthcare associated infections, and calls on the Cabinet Secretary for Health and Wellbeing to implement this plan alongside other measures to combat healthcare associated infections and
I welcome this debate as it allows me to reinforce further the importance that the Government places on driving down health care associated infection rates in our hospitals.
As members know, our comprehensive work programme is being overseen by the Scottish Government's HAI task force, whose expert members include people with clinical, scientific and education backgrounds as well as members of the public. It is also backed by record investment. We have increased investment by 260 per cent over a three-year period, which demonstrates the importance that the Government places on tackling infections.
It is vital that public confidence in the national health service is maintained. I am all too aware of the anxiety that patients and their families face in relation to the risk of infection when in hospital. That is why it is right that information about hospital performance on key indicators such as MRSA and C difficile rates, hand hygiene and environmental cleaning is published so that the public can understand how their local hospitals are performing.
In January, we announced the introduction of a new national reporting template for that purpose. It will require NHS boards to publish hospital-by-hospital performance on HAI and to discuss that level of detail at board meetings. It will ensure that the link from ward to NHS board is made, and it will allow for greater transparency about levels of infection at both local and national level. The national HAI task force website has also been developed to act as a portal through which the public can access such information.
We have also set stretching targets for our NHS to reduce the levels of infection and improve standards of cleanliness and hand hygiene. I announced last year that a national target will be introduced to reduce C difficile rates by at least 30 per cent by March 2011—I stress that that is a minimum target. Delivery of that target has been underpinned by the provision of an additional £2 million to boards to ensure that local surveillance systems are further improved to track the progress that is being made.
We have also introduced a zero-tolerance approach to non-compliance with hand-hygiene policies. That is a cornerstone of the action plan, and all chief executives have received clear guidance on how it must be implemented at board level.
Our national approach to the monitoring of HAI performance at NHS board level will be further strengthened by establishment of the new care environment inspectorate. It will come into force from April 2009 and will ensure through a rolling programme that every acute hospital in Scotland is inspected when necessary on a random and unannounced basis. I will make a further announcement on the detail of the inspectorate and its leadership in due course.
As our consultation indicated, the care environment inspectorate will sit within NHS Quality Improvement Scotland, but further details on its governance and leadership will be announced shortly.
Other actions that we have taken include: implementation of a pilot MRSA screening programme and preparations for a national roll-out from next year; a requirement for all new-build hospitals to provide 100 per cent single-room accommodation for patients; integration of the cleanliness champions programme into nursing and medical undergraduate curricula; toughening up of cleaning standards; funding for antimicrobial pharmacists; and a new dress code and new national uniform for NHS Scotland from later this year.
There is no room for complacency, but our comprehensive programme is having an impact. MRSA rates are at their lowest since surveillance began and, although it is too early to determine any trends, C difficile rates are down by 17 per cent on the previous quarter and 2 per cent on the same quarter last year.
I am fully aware of the detail of the Labour Party's 15-point action plan. Much of what is in it is already happening in Scotland, but I have formally asked the HAI task force to review the detail of the plan and consider the adoption of any actions in it that it considers will add value to our existing work programme.
This issue is not about party politics: the combined efforts of everyone in this Parliament, as well as the entire Scottish population, are required if we are to succeed in reducing infection rates. That is why the Government has already agreed to carry out a study on the electronic bed management system, which is being piloted in NHS Grampian and is supported by the Scottish Conservative party, to ensure that lessons learned from its use are available to other NHS boards quickly. I will consider ideas about how better to tackle infection from wherever they come.
The outbreak of C diff at the Vale of Leven hospital brought into sharp focus the challenge of tackling infection. The independent review team that I established to look into the events at the Vale of Leven hospital produced a report containing seven key recommendations. Supported by family and patient representatives, the review team published its follow-up report on Tuesday. I was encouraged by its findings, which confirmed that progress had been made on all the recommendations. Building sustainability in each of the seven areas will be crucial to maintaining the significant progress that has been made.
It is essential that we learn lessons from the tragedy, and I fully understand why repeated demands for a public inquiry have been made. Let me make it clear again that I have not ruled out a public inquiry. However, the fact remains that there are on-going detailed and complex investigations by the procurator fiscal, police and the Health and Safety Executive that, unlike the report published this week, are about looking back at what went wrong. While those investigations are under way, there would be a real risk of prejudice to any possible criminal proceedings and a risk of inhibiting a public inquiry doing its work. However, as I have said before, I will return to the Parliament to make a statement on any further action as soon as the views of the Crown Office are known.
I hope that everyone in Parliament recognises the priority that this Government has given to tackling infection. It is a big and difficult challenge, but I am committed to ensuring that we succeed. I look forward to hearing other members' speeches and will consider any positive suggestions that they make.
I move amendment S3M-3428.2, to leave out from "welcomes" to end and insert:
"acknowledges the high priority that the Scottish Government is placing on tackling and driving down healthcare associated infection, backed by investment of £54 million; notes that a national action plan is in place and that a national reporting template has been introduced to ensure that NHS boards have the necessary policies and practices in place to drive forward improvements in areas such as governance, leadership and surveillance; further notes that NHS boards are now required to report publicly on hospital by hospital performance on MRSA and Clostridium difficile rates, environmental cleaning and the causes of adverse incidents; further acknowledges that a target of a minimum 30% reduction in Clostridium difficile rates by 2011 is in place and that there is a zero tolerance approach on hand hygiene; also notes that the Healthcare Associated Infection Task Force has been asked to consider implementation of the elements of the Labour Party's 15-point plan not already underway, and further notes that the Scottish Government has agreed to progress the electronic bed management system supported by the Conservative Party and that the Cabinet Secretary for Health and Wellbeing will report regularly to the Parliament on the progress being made on tackling healthcare associated infection."
This is certainly not the first time that the Parliament has addressed what is undoubtedly a crucial issue and one which the public rightly feels quite sore about. When someone goes to hospital there is a presumption that they will get well rather than acquire another infection, so there is a great deal of pressure on politicians to respond to the real and understandable public concern.
I welcome the work that the Labour Party has initiated and, in particular, the fact that it has used two experts to consider what might be required to bolster how we tackle HAI. It is particularly welcome that it added the name of Professor Pennington, who is well known to most people and is highly regarded in the field. The 15-point plan is a useful contribution: it leaves very few stones unturned and adds considerably to the debate. I am sure that the statement in the cabinet secretary's amendment that the HAI task force is considering how to implement the 15-point plan is genuine, and I hope that we can have a realistic expectation that this thought-out proposal—which as Cathy Jamieson said is not necessarily a party-political one but a plan that has been thought out by experts—will be taken on board and genuinely meshed in.
Although the 15-point plan makes a substantial contribution to the debate, it would be churlish of us not to acknowledge that the Government has set in train a number of measures that are contributing to the action to eliminate and eradicate the incidence of HAI across the health service in Scotland. There has been a substantial increase in the cash that has been allocated to address the problem over three years, which reflects the increase in the incidence of HAI infections across the health service. The initial report that came before us from the Smith inquiry indicated that there was a serious fault and a serious omission in monitoring and reporting and that that was one of the major problems behind the failure to identify the increasing incidence of the disease. Much of what is required has now been put in place.
I am glad that, in addition to acknowledging the 15-point plan, the cabinet secretary acknowledges in her amendment the proposals from the Conservative party on dealing with electronic bed management. I am also pleased that the reporting standard that she has set is on a hospital-by-hospital basis. All too often—on a range of issues—members have felt frustrated when figures have been aggregated on a health board basis, which masks the situation and makes it almost impossible to track down where the real problems are and where solutions are required.
As the cabinet secretary indicated, we continue to agree to disagree on the need for a public inquiry. If Professor Cairns Smith can continue both to monitor progress and to make recommendations that entail finding fault—finding things that need to be improved—I find it increasingly difficult to accept that a thorough review should not be carried out by a public inquiry, in the public glare and open to public scrutiny. Although the families have welcomed Cairns Smith's findings, how those are arrived at and determined is not open to public view.
I know that the cabinet secretary is strongly of the view that holding a public inquiry would imperil any further police inquiry. I repeat what I said when the issue was last debated: if at any point the Lord Advocate indicated to a public inquiry that its continuance was putting in peril a proper legal proceeding, the inquiry would be sisted. I stand by that position.
I move amendment S3M-3428.1, to insert at end:
"and, given that the cabinet secretary has deemed the publication of the report of the independent review team on Clostridium difficile at Vale of Leven Hospital as not being prejudicial to the police inquiry, calls on the Scottish Government to establish a public inquiry immediately."
Scottish Conservatives want a health service in Scotland where patients and their families do not fear hospital admission due to health care acquired infections, which not only add to a patient's stay in hospital and suffering but, as we all know, can be fatal. Patients throughout Scotland should have confidence in the hygiene and cleanliness standards in our hospitals. They also need to understand why there should be a reduction in the prescribing of antibiotics.
We welcome as a major contribution to tackling hospital-acquired infections the 15-point plan that has been drawn up by Professors Pennington and Toft, which is mentioned in the Labour motion. We endorse the proposal to raise the target for the reduction of C diff in hospitals to 50 per cent, compared with the current minimum target of 30 per cent, and we therefore support the Labour motion. However, the measures that we are addressing today come against the background of an ageing population, more patients and more severe and chronic diseases being treated, higher bed occupancy and more patients vulnerable to infections, alongside a higher turnover of patients and, in some health care settings, inadequate standards of hygiene.
The British Medical Association briefing on health care associated infections highlights the need to inform and manage patient expectations
"Complacency, poor prescribing practice and misuse of antibiotics are major factors in the emergence of drug resistant infections."
I make that point today, as it is often lost in debates on hospital infections.
As Cathy Jamieson said, the 15-point plan is not exclusive, and neither do we want to give the impression that only the Vale of Leven hospital needs to address the issue of hospital-acquired infections. Lessons that have been learned need to be applied throughout Scotland. The Scottish Conservative bed management and hospital-acquired infection information technology system would be of enormous benefit in tackling infections; we thank the Scottish Government for its budget commitment to the issue.
In the best of Scottish traditions, where there is a problem, there are innovations. A small company in Inverness has developed an MRSA home testing kit, which saves time, travel to hospital and delays to surgery—in my opinion, it ticks all the boxes. I have sent a copy of a paper on the kit to the cabinet secretary.
I welcome the guidance on death and the procurator fiscal that the Crown Office and Procurator Fiscal Service has issued to medical practitioners. It includes guidance on any hospital-acquired infection, and I look forward to further clarification from the Crown Office. Many families have been fully aware that a hospital infection was either the direct cause of or a significant contributory factor in their relatives' deaths, but in recent years the NHS seems to have been reluctant to include any mention of such infections on death certificates. We welcome further clarity on the issue, as well as the other measures that have been announced. In the longer term, I hope that we will look at the design of our hospitals, including air conditioning and heating systems. The debate has been diverted on to the issue of private contracting, but it is for the NHS to ensure that standards set are standards met.
Today we will support the Government amendment but not the Liberal amendment, as we have already debated and voted on the issue of a public inquiry.
How can I refuse that invitation, Presiding Officer?
I welcome to the public gallery families from the C Diff Justice Group and representatives of many other families that have been affected by Clostridium difficile in hospitals across Scotland. I join other members in welcoming Hugh Pennington, emeritus professor of microbiology. I owe Professor Pennington and Professor Brian Toft, one of the United Kingdom's leading authorities on patient safety, an enormous debt of gratitude, because they gave up their time over Christmas to shape the 15-point action plan that is before the chamber today. The plan was also endorsed by the C Diff Justice Group.
I commend the plan to Parliament. It is not intended to be the final word on health care acquired infections. New microbes are evolving in real time, and all of us need to be open to new ideas in our constant battle against infection. Although the incidence of C diff may be constant, the number of cases has risen by 10 per cent over the past year, and new, more toxic strains are emerging.
It is just over a year since the outbreak of C diff started at the Vale of Leven hospital. Mary Scanlon was right to say that health care acquired infection affects not just that hospital but hospitals throughout Scotland, but the families cannot wait any longer. I call on members today to make 2009 the year in which we in Scotland get serious about tackling all health care acquired infections.
At the heart of the plan is a 50 per cent reduction in C diff cases by March 2011, rather than the Government target of 30 per cent over the same period. I will tell the chamber why. In England, the target has already been exceeded—cases of C diff are down by 38 per cent. In Maidstone and Tunbridge Wells, where there were significant outbreaks of C diff, the local target is to wipe out MRSA completely and to reduce C diff infections by 55 per cent by April 2011. Our target applies only to people over 65; in England, the target applies to everyone, from the age of two upwards. We need to be more ambitious. Raising the target will signal the seriousness of our intentions and drive change, if it is backed by a range of actions and resources.
The Royal College of Nursing was right to point out to the Health and Sport Committee and in a briefing to members that the sum of £54 million over three years that has been allocated to deal with HAIs is unchanged from the original spending review figure of 2007. I acknowledge that money and welcome it, but not one penny extra has been made available, despite the fact that 2008
I will deal briefly with a couple of issues, starting with hand hygiene. The cabinet secretary reports compliance rates of 93 per cent, but we are not measuring like with like across health boards. The number of observations varies in different hospitals and health boards. Our approach must be more rigorous than simply relying on self-assessment by clipboard. We need temperature-controlled, sensor-operated washing facilities in all hospitals. It is embarrassing that there are better facilities in our airports than in our hospitals.
The cabinet secretary announced that all new hospitals will have single rooms, to help to reduce infections. I welcome that, but there is no timescale or outline of resources for the programme. It will take more than a generation to cover the whole NHS estate, but we need a crash programme now—isolation facilities must be available in every hospital. Our proposal is proportionate, targeted and, therefore, more deliverable.
Turning to the Liberal amendment, the Parliament has already voted to support a public inquiry and, two weeks ago, the Public Petitions Committee unanimously agreed on the need for a public inquiry without further delay. The committee did not consider that on-going proceedings would be prejudiced, which is welcome.
Today, we have a chance to move the agenda on. We need a comprehensive strategy, not a piecemeal approach. Yesterday, the Tories and the Liberals supported the Labour motion that is before us today. Support for the Scottish National Party amendment would remove the support for implementing the 15-point plan. The Parliament will not be forgiven if we allow that to happen.
First, I extend my condolences to the families and friends of those who have died at the Vale of Leven hospital and elsewhere as a result of C difficile infection and other hospital-acquired infections. One death in which hospital-acquired infection is the main cause is one death too many.
In the period from May to August 2007, a link was established between the deaths at the Vale of Leven and C difficile. I, too, do not wish to politicise what should be a consensual debate. Families, especially those with elderly relatives in hospital, deserve better from the Parliament. It is undeniable, however, that between 2001 and 2006 the number of cases in which C difficile was mentioned as the underlying cause of death or as contributing to death rose from 170 to 417—a 145 per cent increase. That said, I commend Jackie
Historically, the Vale of Leven hospital has been under threat of closure, which must have contributed to the hospital's decline and to falling morale among its staff. The independent report disclosed that surveillance systems were inadequate and that, in clinical and patient toilet areas, there was a serious lack of dedicated hygiene practices and equipment.
As is sometimes the case in our world, it took a particular tragedy—in this case concerning the failure of basic hygiene at the Vale of Leven—to shine a harsh light on an issue that many of us were already aware of anecdotally. I remember visiting my late mother when she was terminally ill in hospital some time ago. The walls were dirty. The family worked on a rota system to check that she was being properly cared for and kept clean when she was unable to move. It is a story that others have heard, too.
The cabinet secretary spoke about the action that is being taken and the £54 million that is being spent over three years to tackle hospital-acquired infection. That is a 260 per cent increase in spending. I think that members throughout the chamber recognise that, whoever is in government, the issue has to be taken very seriously and funding has to be provided.
I recognise the simple measures that the cabinet secretary is taking, which will assist with the situation. In particular, there is to be no more privatisation of cleaning. I know that it was not privatised at the Vale of Leven, but there is no doubt that when cleaners, porters, nurses and others feel that they are part of a team in a hospital, they work together and take pride in what they do. People who come through on contract work do not have the same engagement with the hospital.
I am content to acknowledge that. My point—and the member is perhaps agreeing with me—is that when all the staff in a hospital are part of a team, there is a different kind of morale and a certain kind of commitment.
Among the other measures that the cabinet secretary has announced today that I welcome are those concerning nurses' uniforms. It is not appropriate for nurses to take their uniforms home to be cleaned or to travel on buses while wearing them.
Let us consider some of the new hospitals that have been built under public-private partnerships. The design of the royal infirmary of Edinburgh is appalling. There are carpets right up to the doors of the wards—that is a hobbyhorse of mine—and they are not even very clean carpets. Going into the RIE, we might think that we are entering an airport terminal. There are restaurants and cafes—food is being eaten all over the place. That cannot be appropriate for our hospitals. There are unlimited visiting hours on communal wards. Heaven help someone who is feeling very ill when there are lots of families bouncing about. Children bounce about on beds with their dirty little feet from the dirty little streets. Outdoor clothing carries unseen germs. We carry them around with us and we take them into the wards that house the ill and the vulnerable.
How I remember the days—I am saying this because I am so old—when the hospital matron would allow two people in for only two yours. Heaven forfend if a visitor sat on the end of the bed rather than on one of the wipe-down chairs. Practices must change.
I very much welcome the cabinet secretary's remarks. I say to the families concerned that their pain and loss will continue but, as with all bereavements, it will ease with time—it will not go, but it will ease. However, I know that their anger will be assuaged only when we get to the bottom of the matter and get the full facts, and when we make Scotland's hospital wards and care homes safe and clean places for the people we put into them.
A number of colleagues are probably aware that I underwent surgery some months ago. Of course, I was aware of the debate around hospital-acquired infection, but I admit that that was the last thing on my mind as I cleared my desk and cancelled appointments. I wanted to get into hospital, have the surgery and recover as quickly as I could. It was only an e-mail exchange with a local general practitioner with whom I was working on a campaign that reminded me that avoiding infection was something else that I might have to contend with. The GP told me not to allow anyone—nurse or doctor—to examine me without first washing and gelling their hands and putting on gloves. She told me that they should change their aprons every time they approached a patient and every time
I remember wondering whether I would remember all those rules if I happened to be feeling particularly unwell. Would I have the courage to ask someone on whom I was relying for care to please wash their hands? I was fortunate, in that those who were caring for me were scrupulous in that and every other regard. However, on one occasion, I heard a young nurse reprimand a consultant who approached the patient in the bed next to me and told him in no uncertain terms that, although she was aware that the person was his patient, if he did not put gloves on he would not be examining any patient in that ward. The other patients in the ward resisted the temptation to applaud at that point. Should patients have to think like that, though? What of those patients who are too ill or too elderly, or who have problems communicating? Who will look out for them?
My treatment contrasted sharply with that received by an elderly constituent of mine. The lady in question went into hospital for a relatively minor operation and, having been discharged and readmitted, and discharged and readmitted again, she was eventually diagnosed as being infected with Clostridium difficile. Her family informed me that, unfortunately, they were never told that she had a C diff infection, nor were they aware that any particular infection controls were being used. A close family friend, herself a health professional, once had occasion to complain about the way in which sharps were being disposed of by a doctor, as well as about the attitude of staff who were asked about the patient's progress.
Unfortunately, the lady passed away. Some months later, because of the complaint that her family made, the death certificate is to be amended to show that Clostridium difficile was in fact a contributory factor. The family has received reassurance that the issues that they raised are being addressed in the hospital in question. In the meantime, however, a family has had to deal with anxiety for a wife and mother, and with a feeling of disbelief that our NHS could allow her to suffer in that way when she was vulnerable and afraid.
I posed the question earlier: what of the patients who are too ill or too elderly to help themselves? How are they to be protected? Their first defence must be the hospital or other health care staff, but we must give those staff the resources to allow them to do their job. Staff need to have information about how infections are caught and spread, and about the different ways of dealing with them. They need to know about the latest infection control methods, and they need the confidence to challenge others when they fail to follow the rules.
As I am sure we all agree, much has been done in recent years to tackle health care acquired infections but, if we are really serious about it, we have to adopt the 15-point plan and be flexible in the years ahead. Only through having a comprehensive plan for prevention and treatment will we ever be able to tackle the problem properly.
Reducing the number of cases of health care acquired infection needs to be our next big crusade. It should unite the chamber, not divide it. It should be tackled with the determination that previous generations brought to their efforts to control the spread of tuberculosis.
The problem of how to deal with health care associated infections is one of the most intractable issues facing the health service. Since the turn of the century, the escalating figures for deaths from this cause show that it is a long-standing problem and not just one for the SNP Government. As the prefix "health care" suggests, HAI does not just affect hospital in-patients but extends its tentacles into the community, as thousands of women who get thrush after antibiotic treatment for urinary tract infections can readily testify.
During the years that I was in general practice, I frequently performed minor operations on my patients. I removed toenails, cysts, and lipomata, and I incised abscesses. Colleagues with more extensive surgical experience performed more exotic surgery. Rarely was there a wound infection, waiting lists were measured in weeks rather than months or years, and, with policy favouring a shift of care from the hospital to the community, we were all convinced that more surgery would be undertaken in the community.
What happened? Fear of the transmission of new variant Creutzfeldt-Jakob disease led to the Glennie report, which laid down strict guidelines for the facilities that were to be provided before surgery could be undertaken. Those guidelines were impossible to satisfy in many doctors' surgeries. Today, almost all people who would have undergone procedures locally are now referred to hospital, but in 2008 there was only one death from vCJD in the United Kingdom and five from CJD caused by health-related procedures. Patients who were formerly dealt with in the community to everyone's satisfaction are now being operated on in the accident and emergency departments of Scottish hospitals that, between July and September of last year alone, experienced 522 cases of MRSA infection, a condition that can be transmitted in accident and emergency departments as well as among in-patients. The law of unintended consequences strikes again.
Today's motion strongly emphasises Clostridium difficile infection as a source of HAI. Labour's 15-point action plan, although a little late on the scene from those who were in government when the number of Scottish deaths from C diff trebled, is an effort to get to grips with the problem. I do not decry that effort, although many of the suggestions are already being implemented. However, it is futile to have a target of a 50 per cent reduction in Clostridium difficile infection by 2011 unless a clear indication of how to reach that target is given. Although cleaner hospitals, better sterilisation procedures and a greater emphasis on hand washing can go some way towards meeting the target, the ability of C diff to form resistant spores means that those procedures are not always as effective as they would be for other HAIs.
Given that many of the elderly patients who contract C difficile have difficulty with faecal continence, does the member agree that using containment measures to prevent soiling of bed linen and so on is an important factor in controlling infection?
Absolutely. The point I am trying to make is that cleansing methods are not the whole answer in dealing with C diff, because it is a very resistant bacterium.
A 2008 article in the Journal of Antimicrobial Chemotherapy showed that increased usage of alcohol-based hand wipes in hospitals significantly diminished the incidence of MRSA but had no effect on the incidence of C diff. According to the Association of Medical Microbiologists, the sensible use of antibiotics in hospital is the key to the prevention and control of C diff, as Mary Scanlon has already told us. However, there is little mention of that in Labour's action plan. A broad-spectrum antibiotic may be used to control or prevent infection for one reason or another, but it might interfere with the normal bacterial flora of the gut, allowing C diff a space to multiply. Using antibiotics less in primary and secondary care, and using bacteria-specific rather than broad-spectrum antibiotics, should do a lot to reduce the incidence of C diff. Will that increase morbidity and mortality among those who are denied the antibiotics that traditionally have been used in their treatment? The truth is that we do not know, but it might. If it does, Opposition MSPs, whichever party they are in, will have another stick with which to beat the Government of the day. HAIs are not susceptible to easy solutions, so let us not pretend that they are.
I apologise to members for missing one or two of
I welcome the opportunity to contribute to the debate, and am glad that we all agree that this is one of the most serious challenges facing the public. Everywhere I go, people agree that there is a crisis of confidence among the wider public on the issue that Patricia Ferguson spoke about so eloquently. We have seen the deaths in the Vale of Leven hospital, and the 90 deaths in Maidstone and Tunbridge Wells, where there were significant outbreaks. Following those outbreaks, the NHS on the south-east coast of England published the goals and priorities that it wants to deliver by April 2011. It pledges to have wiped out hospital-acquired MRSA by 2011 and reduced Clostridium difficile by 55 per cent.
We ask the Scottish Government to demonstrate a similar commitment in tackling health care acquired infections. The spin that accompanied the previous set of figures, which went against what Health Protection Scotland said, serves only to undermine public confidence in the figures. It is true to say that there was a fall in cases during the previous quarter, but there was an annual increase.
I am happy to join Jackie Baillie in thanking our academic professionals, whose diligence and commitment has shone a light on this vital issue for everyone in Scotland. I agree with others that we should pay tribute to Jackie Baillie, whose dogged determination has made such a mark in Scotland.
Later today, I will meet a number of my constituents who are following this debate, and we will talk about their reaction to it. I have worked with a number of them in recent times, and they or their relatives and loved ones have all been affected by hospital-acquired infections. Like members, they have raised the importance of what is recorded on death certificates. I have written to the cabinet secretary about that, and she has responded that she agrees that there is an issue and she plans to take action to address it. I look forward to seeing how that progresses.
I have also been in contact with a family that raised significant concerns about patient transfers. How can a patient leave one hospital, such as the Queen Margaret, where they have been told that they do not have a hospital-acquired infection, yet be told within an hour of arriving at another hospital, such as the Cameron hospital, that tests show they have C Difficile? That situation raises extreme concerns in families. The two brothers and sister who will be with me this morning have expressed profound concern about how one hospital can say that there is no infection while the other says that there is within one hour of the patient transferring.
Nanette Milne talked about hygiene and washing, which have been raised by a number of my constituents. When they arrive to take a patient's washing home, they are given it without being advised whether there is an outbreak on the wards. That is a matter of serious concern. Such washing should not be taken home; it should be washed properly within the hospital environment.
I welcome the submissions from various people across Scotland who have expressed their concerns. The Royal College of Nursing said that it has serious concerns about investment in the workforce, which needs to be increased. In preparing the budget in the past year, we saw a proposal to reduce the money for training, a point that I raised with the Health and Sport Committee and the cabinet secretary. In real terms, that money has gone down. Health boards need to employ more nurse epidemiologists, who provide expert advice on organisms that cause hospital-acquired infections and how to prevent them.
The resources that are available to the Scottish national reference laboratories should be assessed to establish whether they can analyse and monitor hospital-acquired infections in a timely manner that benefits patients. There might be new organisms that cause HAIs in future. The laboratories need to be equipped to deal with that, so resources should not be cut. More resources should be targeted at improving hospital isolation facilities to allow HAIs to be treated more effectively and to help prevent their spread.
I warmly welcome the consensus in the debate. I am tempted to support the Liberal Democrat amendment. As Jackie Baillie said, the Public Petitions Committee's unanimous view is that there should be a public inquiry into the outbreak at the Vale of Leven hospital. I understand that public inquiries are expensive but, in this instance, it is vital that we have one.
The tone of the debate has suggested that members do not doubt one another's sincerity on the need to tackle hospital-acquired infections. In that spirit, I commend the motives behind Cathy Jamieson's motion. Many members will have relatives or constituents who have been affected by hospital-acquired infections—I can think of some harrowing examples. However, in supporting the amendment in the name of the cabinet secretary, I bring to the Parliament's attention the work that NHS staff are already doing to tackle the problems. Nobody should underestimate the size of the task ahead, but neither should we overlook the work that is being done.
The Western Isles are, in every respect, a beacon, and I am happy to commend that particular example.
As I said, we should recognise the work that is being done. Nurses, doctors, health managers and, perhaps most important, cleaners have already made great progress. As Christine Grahame pointed out, between 2001 and 2006, the number of deaths in which C difficile was an underlying or contributory factor soared from 170 to 417. Such a massive increase requires dramatic action, and action is being taken that is paying dividends. The tragedy of a single death from a hospital-acquired infection renders all statistics redundant, but we should pay tribute to the health service in Scotland for reducing rates of hospital superbug infections to their lowest levels since records began in 2003.
Perhaps the most significant change of emphasis has been on the simple matter of hand hygiene. We have come a long way in the 100 years since an instruction went out to all doctors, particularly those dealing with infectious patients, to wash their hands before delivering a baby. It seems scarcely believable that such a reminder was required. No doubt it was resisted by some doctors at the time as an undue interference that called into question their clinical judgment. Patricia Ferguson's story about a consultant leaps to mind when I say that. That single measure 100 years ago resulted in a staggering decrease in mortalities among mothers and babies. Today, we cannot overestimate the enormous significance of improving the hand washing regime in hospitals in tackling superbugs. A zero-tolerance policy on hand hygiene has been announced and compliance is at the highest rate since records began—93 per cent, which exceeds the Government's targets.
That is one of the many ways in which the health service is already doing much of what the 15-point plan that is mentioned in the Labour motion calls for. I welcome the consensus that has emerged. Other measures include the HAI reporting template, which gives the public instant access to information on infection rates, and the plans for a care environment inspectorate. Further, there is the welcome news that all new-build hospitals will have 100 per cent single-room accommodation.
No one pretends that the entire hospital estate can be rebuilt overnight, but the Government has made it clear that we are moving towards 50 per cent provision in existing hospitals. Everyone accepts that, in the longer term, single rooms are the way forward.
Nobody underestimates the scale of the task, which is why the Scottish Government has released £3 million to promote further development of local surveillance systems and to prepare for the roll-out of the national MRSA screening programme. Perhaps one of the most significant changes will be the ending of the privatisation of cleaning services in hospitals. I hope that, once more, cleaning staff will begin to feel as though they are the valued workforce that they deserve to be and that they will be able to play their vital role in the fight against infection without forever having to look over their shoulder at a contracting system that has, in the past, worked against those very ends.
I acknowledge the evident sincerity with which all the speeches have been made. There is no doubt that the Parliament is united in the opinion that health care acquired infection must be tackled. Cathy Jamieson, for the Labour Party, spoke of patient confidence and patient safety—which are my themes, as they were for Ross Finnie—and how they also apply to care in the home, care homes and nursing homes. That is the extent of the problem. She correctly reminded us that the HAI task force was started by the previous Government and she mentioned the importance of isolation facilities.
The cabinet secretary, Nicola Sturgeon, spoke of addressing patient anxiety, which echoed Cathy Jamieson. She mentioned the role of the new care environment inspectorate, which should make a difference; the pilot MRSA screening programme; and the proposals to have only single rooms in new-build hospitals to provide isolation. She also mentioned Grampian NHS Board's electronic bed management scheme. It is important that we roll that out.
My colleague Ross Finnie said that the public feel quite sore about HAIs. He said that people want to go to hospital knowing that they are going to get well, not get worse. Like Ross Finnie, I acknowledge the work of the Labour Party in producing the 15-point plan, which is an extremely useful contribution. However, in the same breath, I
Mary Scanlon made the hugely important point, on which I have commented previously in the Parliament, that patient pressure is linked to the prescribing of antibiotics. I have humorously referred to my dear mother, who keeps drugs long beyond the time that they should be kept. That is precisely the sort of issue that we are talking about. Jackie Baillie, on a chill note that was nevertheless accurate and true, reminded us that, as more toxic strains of Clostridium difficile and other superbugs come to the fore, the fight will be extremely difficult. Christine Grahame referred to dirty little children with their dirty little feet and to the issue of uniforms. Those matters are important. We must ensure that carpets in hospitals go only as far as they should go. I commend Patricia Ferguson for bringing her personal experience to the debate, which reminded us of the sheer importance of the issue. I acknowledge the contributions of Ian McKee, Helen Eadie and Alasdair Allan.
Our amendment states:
"given that the cabinet secretary has deemed the publication of the report of the independent review team on Clostridium difficile at Vale of Leven Hospital as not being prejudicial to the police inquiry, calls on the Scottish Government to establish a public inquiry immediately."
When I referred to Cathy Jamieson and the cabinet secretary, I talked about patient confidence and patient anxiety. The Liberal Democrats' point is that, if we are to maximise the patient confidence to which Ross Finnie referred, so that people know that they will get better and not worse by going into hospital, there must be public confidence in the light of proper examination of what went wrong. If the Lord Advocate tells us that a public inquiry would be prejudicial, we will heed that, but we have no evidence of that at this stage, so I ask members to support the amendment in Ross Finnie's name.
I will start with a short story. Someone known to me recently underwent a third invasive procedure for a minor outpatient operation. When she was called back to hospital for the second procedure, under the national health service, she was somewhat
For her third operation, the woman chose to use the independent sector. The point that surprised me and her was that she was asked to go to hospital in advance of the operation because she was told that, having been treated in the NHS, there was a presumption that she would carry MRSA and they needed to establish whether that was the case. That is something that ought to give us all considerable cause for concern.
The Vale of Leven case, if it has done nothing else, has reinforced in the wider public consciousness a concern about health care acquired infection in the NHS that, if allowed to take root and become part of the common currency of people's concerns, will be very damaging to the long-term reputation of the NHS. Decisive action is being taken, but it must be effective.
I say to Jackie Baillie in particular, if I may, that the political cynic in me, if I can call it that, made me perhaps somewhat sour and ungracious in my initial reaction to the 15-point plan that the Labour Party introduced a few weeks ago. I was cornered by Jackie Baillie, who told me that if I did that again I was to be advised that she was coming for me. Colleagues on this side of the chamber told me that that was a threat or a challenge that I ought to take very seriously. My staff were encouraging me and were very excited at the prospect, but the measured and serious way in which Cathy Jamieson addressed the 15-point plan in her speech has allayed many of my concerns. However, I will state for the record what they were.
I would almost have been better convinced by a plan that had 14 or 19 points. The 15 points led me to think that the plan was somewhat contrived in its construction—partly because, earlier this week, the leader of the Labour Party had a 15-point plan for the economy, too. I was just slightly anxious about Labour having 15-point plans for everything, but that may have been an unreasonable attitude.
I also felt that there was no prioritisation in the 15-point plan. It seemed to me that some points had more substance than others and that it would have helped if they had been prioritised. I would also have welcomed it if the plan had spent a bit of time analysing the contribution that the Government has made in advancing a number of points in the plan and saying what progress has been made against them.
I think that I have done that. I accept that this is not a subject that any one party in the Parliament, conscious of the fact that there is now widespread public concern, is trying to address as a monopoly concern of its alone. Every party has a contribution to make. We have made a contribution in respect of the hospital bed management and acquired infection software, which is being piloted in Aberdeen—the health care acquired infection element is being done in Belford hospital. The software allows clinical staff, who have been involved in its design, to see exactly where outbreaks of infection have taken place and to ensure that they are properly monitored and that beds are cleaned thereafter.
Part of the problem with the current system is that a patient leaves a bed and it is sometimes established only post mortem that they had C diff, by which time nobody can remember which bed they were in and another patient has been put in it who subsequently becomes infected. The software will address that.
Our intention is to support the Scottish National Party amendment, which refers to the programme that we are progressing. Were that amendment not to succeed, we would be minded to support the Labour motion. We have a difficulty with the Liberal Democrats' amendment because we do not at this time support having a public inquiry.
This has been a far-reaching debate on an issue that impacts on us all. I am very grateful indeed for the constructive contributions that have been made on all sides of the chamber, which shows the seriousness with which the whole Parliament treats this important issue.
The cabinet secretary took some time in her opening speech to set out the actions that we are taking across the NHS in Scotland and I want to use a little bit of my time to restate the significance of those actions and how they impact across the NHS. NHS boards now have better local surveillance systems in place, which are more transparent, robust, sensitive and reliable in identifying situations that require further investigation. A far better understanding of the different C diff strains is emerging through the work of the C diff national reference laboratory, a more robust reporting regime is in place and there is a zero tolerance approach to non-compliance with hand hygiene standards.
I was struck, as I think other members in the chamber were, by Patricia Ferguson's description of the nurse pulling up the doctor. I think that that is absolutely right; it should be understood throughout the NHS that it is everybody's responsibility, no matter how senior the person who breaches the guidelines, to speak out. I say well done to the nurse who did that.
It is important to reiterate that we are investing record levels of resources in tackling HAI and increasing spend by £39 million over three years, which is a 260 per cent increase. We have announced a target, from April 2009, for NHS boards to reduce C diff rates by at least 30 per cent by March 2011, but we will ask boards to set themselves a more challenging target for reducing C diff year on year.
There has been talk this morning about the Government agreeing to mesh the 15-point action plan in. Will the Government agree to implement all of the 15-point action plan? Specifically, will the Government commit to a target of a 50 per cent reduction in C diff by March 2011 for all ages from two upwards?
I will come on to Jackie Baillie's specific point if she just gives me a chance to do so.
Much of what is in the 15-point plan is already in place in Scotland in the 57-point action plan that is being actioned by the national HAI task force, which has been asked to review the detail and consider what actions would further enhance our already extensive HAI work programme. I can tell Jackie Baillie that it is on the agenda for the next meeting of the HAI task force on 24 February to take that work forward, so it is happening very quickly. I hope that that assures members across the chamber that the HAI task force will act on that very quickly indeed, as is quite right and proper.
It is also important to say that our rates of MRSA are now at their lowest since surveillance reporting began: C diff rates are down by 17 per cent on the previous quarter and by 2 per cent on the same quarter last year; and, of course, despite concerns that have been raised in the chamber about hand hygiene compliance, it is at its highest level—93 per cent—since reporting began, so that message is getting through to front-line staff in our health service. It is clear that only by continually improving and redoubling our efforts to tackle HAIs will we see those trends continue, so there is no room for complacency. Only by doing that will we
I thought that I had made it clear that the task force will consider all elements of the 15-point plan. None is excluded. The task force will look at the 15 points and advise what further progress needs to be made, including in relation to the target in the 15-point plan. I can give the member that reassurance.
Finally, members can be assured that our HAI work programme will continue to engage with a wide variety of agencies through the national task force, which is responsible for overseeing actions on reducing infection rates in Scotland. I am sure that members will welcome the fact that we are also engaging with many linked sources, including the patient safety and patient experience programmes.
This has been a good debate, so let me begin with some positives. We welcome the follow-up report to the independent review of the Vale of Leven outbreak, which makes it clear that substantial progress has been made. We welcome the changes to the HAI task force programme that the cabinet secretary has announced, particularly the hospital-by-hospital reporting and the new web portal.
Let me be clear that we in no way doubt the Government's concern about making progress on HAI generally. Indeed, we welcome the undoubted progress on MRSA that NHS staff have achieved even before the pilots have reported. Despite what Dr McKee implied, we do not suggest that it might be possible in future to eliminate all health care associated infections. Such a suggestion would be foolish, as that will not be possible. MRSA, C difficile, norovirus and vancomycin-resistant enterococci—which is another new infection on the horizon—will be with us, so they will need to be tackled effectively.
Our concern is that the current situation is not advancing quickly enough. For example, the cabinet secretary reminded us—quite rightly—of the substantial increase in funding that the Government has put into tackling HAIs, but that is mainly for the MRSA pilots, which will swallow a huge amount of the funding.
The recent Audit Scotland report highlighted a £512 million backlog in maintenance, which we need to deal with to tackle HAI infection. Hospitals with maintenance problems are more likely to have HAIs. Audit Scotland reported that PPP hospitals are well maintained, but all those other facilities need to be dealt with. For example, temperature-controlled and automatic washing basins are vital. Further to Alasdair Allan's comments, I point out that if people turn on the taps to wash their hands thoroughly and then need to turn the taps off, they will transfer the bacteria that they had put on the taps back on to their hands. We need modern facilities urgently.
Labour recognised that MRSA and C difficile were growing problems, as Christine Grahame mentioned. C difficile hardly existed 10 years ago. Previously, it was a commensal, largely non-symptomatic, organism. We recognised that C difficile had increased and, as it were, had come up on the rails, so we tried to draw together all the work on the issue by setting up a HAI task force in 2006, but items that were on the agenda of the task force's first meeting—the minutes of which I have read thoroughly—are still on the agenda today. For example, the dress code that is now being implemented was on the very first agenda. The Cairns Smith report identifies
"implementation of the NHS Dress Code" as one of the issues that are still outstanding.
Christine Grahame has not listened to the point I have been making. We set up the HAI task force, which has been continued and has produced 56 points. Revised information and guidance on death associated with C difficile has been issued to medical practitioners. That was not an issue eight years ago, but it is an issue now.
Implementation of the outcome that we all want to achieve, which the HAI task force plan indicates, seems to be rather leisurely and slow in some places. The issue has not had the impetus
As my colleagues mentioned, the health service in England has met the target of a 30 per cent reduction in C difficile. In the south-east and in other regions, targets of 50 and 55 per cent are now being set. We need to revise our targets and to make progress.
I ask the cabinet secretary to be cautious in interpreting the statistics that are reported. In England, the health service has met its target of a reduction in C difficile on the whole of the previous year of 2007. In Scotland, we have not achieved a reduction in the rate of C difficile associated disease in the rate per bed occupancy, which is Health Protection Scotland's preferred measure. The rate increased in the two winter quarters but decreased in the two summer quarters. HPS said that that was a "seasonal variation", but the cabinet secretary's press releases said that the reduction was a trend. That might be the case, but there is no way of telling. Given that public confidence was undermined by the Vale of Leven situation, I urge the cabinet secretary to be cautious in interpreting the statistics.
I accept that entirely, but the cabinet secretary's press release called it a reduction. I just urge caution.
Do I have one minute left, cabinet secretary—I mean Presiding Officer—to conclude? [Laughter.] Sorry, all the promotions of the past week are getting to me.
I will finish by making a couple of serious points. First, we have an alphabet soup of organisations and systems. Their functions might be clear to the organisations themselves, but I can say as a doctor that it has taken me many days of work and many meetings with the individual organisations even to begin to comprehend their function and role. How can the public have clarity? We have HPS and HFS—health facilities Scotland—as well as NHS QIS, the care commission, health and safety at work, statistical process control, the SPORS reporting system, hand hygiene surveillance and even Audit Scotland. The system is too complex, so it needs to be simplified and focused. That is why we have recommended a single leader to help us achieve that focus. The Cairns Smith report that was published this week states:
"Restructuring ... has produced a much clearer and simpler structure, with clear lines of responsibility and accountability."
We need that nationally.
Presiding Officer, I realise that I should probably close now. This has been a good debate; members have drawn together a lot of serious issues and given some very good examples of their personal experiences and those of their constituents. Unless we draw together all the issues—hand washing, the environment, antibiotic policy, testing of toxins and death certification—and ensure that guidance is clear and standardised, we will not secure the public confidence that we all seek. I hope that the 15-point plan that we have produced will be seen as building on and complementing the 57 points that the HAI task force suggested. I hope that we will achieve that.
Let me make one last point. The public must be seen as our partners in this. Public involvement is taking place at a number of levels. In NHS Forth Valley, we now have members of the public on the team walking the wards—