Health Care Associated Infection
The next item of business is a debate on motion S3M-1621, in the name of Nicola Sturgeon, on the health care associated infection task force.
I am pleased to open the debate and to present our ambitious new plans for tackling health care associated infection in Scotland during the next three years and beyond.
It is important that we acknowledge that Scotland is a world leader in tackling HAI. During the past five years, our HAI task force has taken forward a high-quality programme of action to address infection and I take this opportunity to commend its work. On the amendment to our motion, I have no difficulty in recognising the previous Administration's contribution in setting up the task force and the Scottish National Party intends to support the amendment.
Although action that has been taken in recent years has stabilised rates of some infections and reduced rates of others, the overall rate of infection in our acute hospitals remains stubbornly high at 9.5 per cent, which is unacceptable. HAI takes a heavy financial toll—it costs the national health service nearly £200 million per year—and the threat of HAI erodes public confidence in the NHS. Many patients believe that, as a matter of course, they will catch an infection during their stay in hospital. We must work to recapture a sense of ownership and pride in our hospitals. NHS staff must embrace a culture in which keeping patients free from infection is not just their responsibility but everyone's responsibility.
In tackling HAI we must understand two important points. First, we will not eradicate all infection from our hospitals; what we can do is reduce infection and control it better. Robust and stringent infection control measures that are regularly applied in our health care environment will go a long way towards effectively tackling HAI.
Secondly, the NHS is not always to blame. Many infections are brought into hospitals from the community. That means that the public have a vital role to play, for example by washing their hands thoroughly, not sitting on beds and not touching drips and intravenous stands. However, it is essential that the NHS redoubles its efforts to drive down infection. A fresh and more targeted approach to HAI is needed if we are to ensure that the NHS delivers to the high standards that patients rightly expect.
Last November, I announced the largest ever investment in the fight against HAI in Scotland—£54 million over the next three years—to drive infection rates down from the rates that were published in July in the final report of the NHS Scotland national HAI prevalence survey. I also made it clear that the key elements of our patient safety and patient experience programmes will link with the HAI agenda to bring about a coherence of approach in the way the NHS in Scotland delivers its service.
It is also essential that we set NHS boards tough targets and hold them more firmly to account. A key example is the health improvement efficiency access and treatment target for all NHS boards to achieve a 30 per cent reduction in Staphylococcus aureus blood infections by 2010. We are at an early stage of monitoring progress, but the signs are good: seven mainland NHS boards already show signs of a downward trend. I am encouraged by that and I have asked the HAI task force to put in place stronger supporting mechanisms to assist boards in achieving the HEAT target.
Another core target is good hand hygiene compliance among NHS staff. Good hand hygiene is the single most effective way of cutting infection rates in hospitals and simply must become more embedded in everyday culture. The first Scottish national hand hygiene NHS campaign audit report, "Compliance with Hand Hygiene—Audit Report", which was published in December, showed that compliance had risen from 68 per cent in the first audit period, in February 2007, to 79 per cent in the second audit period, in September.
The increase in compliance is welcome, but there remains enormous scope for improvement. Patients rightly expect the highest standard of hand hygiene from staff, and a compliance rate of 79 per cent is not nearly good enough. I have set all NHS boards a target to achieve at least 90 per cent hand hygiene compliance by November. To help NHS boards to attain that target, Health Protection Scotland will step up its monitoring regime and publish quarterly audits from April this year. HPS will also take charge of a new look campaign that will be aimed primarily at NHS staff, patients and visitors.
Health Facilities Scotland has also been invited to raise the bar on hospital cleaning. It will overhaul the monitoring framework to ensure that it continues to set demanding and challenging standards for boards.
All those actions—and many more—are part of the new three-year HAI delivery plan that starts on 1 April. It aligns key action areas with the findings in the Scottish point prevalence survey and complements and co-ordinates the work being carried out on patient safety. The plan will be backed by £5 million of annual resources over the next three years.
I am making available £90,000 a year from the budget to allow the Scottish Commission for the Regulation of Care to recruit a nurse consultant for infection prevention and control. The nurse consultant's main target area will be to promote and increase higher standards of prevention and control of infection across the range of services that are regulated by the care commission, particularly those for the elderly. I know that that point is covered in the amendment to the motion.
I understand and stress how vital it is that we tackle all hospital infections, but the next matter that I want to touch on is our ambitious plan to tackle MRSA in our hospitals through the implementation of a national screening programme.
I have on previous occasions made clear my intention, subject to successful piloting, to roll out a national MRSA screening programme from April next year. That is in line with recommendations in the NHS Quality Improvement Scotland publication "The clinical and cost effectiveness of screening for meticillin-resistant Staphylococcus aureus (MRSA)", which was published in September 2007. To pave the way, and to ensure that we move ahead on the basis of robust evidence, we will invest £7 million this year in a screening pilot. NHS Ayrshire and Arran, NHS Grampian and NHS Western Isles will host the pilot as pathfinder boards from April this year. Those three boards together cover a population of almost a million people—a fifth of the Scottish population. They represent a diverse mix of urban, rural and island areas and include a range of hospitals from the very smallest to large teaching hospitals. The pilots will be an exhaustive test of the screening model and, crucially, will enable us to make informed decisions about the shape of the national programme that we intend to roll out from next year.
We should be under no illusion that MRSA screening is an ambitious undertaking, but I am proud that Scotland will lead the way with a planned, structured and deliverable national screening programme, which will help us to combat MRSA in our hospitals. I hope that the Parliament will give it enthusiastic support.
Closely linked to our work to tackle MRSA is our national initiative on improving the use of antibiotics. Earlier this month, I launched our new Scottish management of antimicrobial resistance action plan—ScotMARAP for short, which is perhaps not one of the NHS's better acronyms.
We have already invested £1.25 million in automated equipment to allow rapid standardised testing of antibiotic resistance in our laboratories. A new national forum will oversee implantation of the plan and will collate and disseminate information to help us to up our game in a key plank of the fight against infection in our hospitals.
I hope that in the short time that I have had today I have managed to convey to Parliament and to the public the priority that I personally, and the Government as a whole, have accorded to the fight against infection in our hospitals and other care settings.
My announcements today mark a new era of HAI action in Scotland. A multimillion pound investment is being made in Scotland to reduce HAI and I am setting a raft of demanding targets for NHS boards.
Allied to that, we will deliver a linked agenda with that on patient safety and patient experience to ensure a coherent approach. We will drive up standards, deliver more effective measures to minimise the spread of infection, lessen the number of ward closures and bring down HAI rates. We intend to deliver an NHS that is safer, more reliable, more anticipatory and more integrated. The effect of that will be to ensure that all those who are involved in the provision of NHS care in Scotland have a renewed sense of purpose to improve the quality of care that they provide.
Our new approach to tackling HAI means that health boards will have to adopt more flexible practices, develop new roles and design new ways of working. I will expect better motivation and support from senior NHS staff, to help individual staff members to understand why it is essential that they adopt safer and better practices. I assure members that I will expect NHS boards to deliver in this important area. Progress will be monitored closely. I look forward to reporting back to the Scottish Parliament on the progress that is being made on reducing infections in our hospitals.
I move,
That the Parliament notes the Scottish Government's commitment to bring infection rates down by investing £54 million to support a far more intensive and targeted three-year programme of healthcare associated infection (HAI) work from 1 April 2008; believes that the Scottish Government is right to introduce a one-year pilot MRSA screening programme to shape a planned, structured and deliverable national screening programme from 2009-10; welcomes the links that will be established between the Patient Safety and Patient Experience programmes and the HAI agenda to bring about a coherency of approach in the way that NHSScotland delivers its service to patients; welcomes the Scottish Government's continuation of the multi-agency HAI Task Force, and agrees with the challenging target that the Scottish Government has set for all staff of NHS boards to achieve at least 90% hand hygiene compliance by November 2008.
I emphasise how much we in the Labour Party welcome the debate. We acknowledge that our amendment will be accepted. I associate myself with many of the points that the Cabinet Secretary for Health and Wellbeing made about tackling the issue, which is a challenging policy area.
It is important to begin by giving some context and by appreciating the scale of concern that exists more broadly in Scotland about the human impact of the lack of control of infections and its consequences. I will begin with a story that is from south of the border but which illustrates the human dimension to the issues that we are discussing. In October 2003, Emma Lynch gave birth to her daughter, Daisy, at Derriford hospital in Plymouth. Within two weeks, Daisy began developing a cyst on her chest. That one cyst spread and soon cysts covered her entire body. Daisy and her mother fought the infection for the next three years. It turned out that the child was sick because of an antibiotic-resistant form of the MRSA infection. She developed the infection at a hospital, a place where, one would assume, children are supposed to be taken care of, especially in the early years. In all likelihood, the little girl developed that horrific and life-threatening infection because someone did not wash their hands.
That story exemplifies how crucial the issue of health care associated infections is. As has been said, the number of such infections is on the rise. In the United Kingdom, the number of cases of infections that cause meningitis, pneumonia and toxic shock has increased by up to 100 per cent since 2002. The rate of MRSA infection has increased by 6 per cent and that for E coli infection has risen by 48 per cent. I acknowledge the cabinet secretary's focus on MRSA, but our amendment mentions the significance of tackling other infections.
As has been said, Scotland seems to have limited the spread of MRSA infection. According to a Scottish surveillance quarterly report, incidents of MRSA infections as well as the number of deaths resulting from them have remained largely stable since 2003. On the other hand, Clostridium difficile has been on the rise in certain areas in Scotland. In NHS Highland, the number of documented cases of C difficile rose to 120 in 2006, whereas there were only 50 in 2005. We have a problem with the spread of such infections in Scotland. We need to stay ahead of the rest of the UK on combating the spread of health care associated infections.
The fact that we have controlled infections such as MRSA is in large part a result of work by the previous Labour-led Executive. In England, emphasis has been put on investing in tackling such infections. I hope that Scotland will maintain the progress that we made in the past. We produced the first health care associated infections action plan, in 2002, and established a ministerial task force in 2003 that had the explicit goal of tackling issues such as the decontamination of medical instruments and antibiotic prescribing. The task force has established numerous initiatives, such as the promotion of alcohol-based hand rubs, the national cleaning services specification for hand hygiene and the cleanliness champions programme, which is an education initiative.
The task force has recognised risk management methodologies and model infection-control policies, and it has promoted the innovative "NHSScotland Code of Practice for the Local Management of Hygiene and Healthcare Associated Infection (HAI)". As I said earlier, it is important that Scotland continues to lead the way in fighting all health care associated infections. We will no doubt debate that again and again in the Parliament.
The Government's commitment to more funding to address the potential spread of infections is welcome—it is representative of our approach when we were in government. We welcome the investment as a necessary step in ensuring that Scotland remains at the forefront of medical advances in the field, and in ensuring that health care associated infections are addressed. As I have said, there are more cases of C difficile in the UK than cases of MRSA. I hope that the cabinet secretary will address that issue in the near future.
As the cabinet secretary said, it is important that we focus on—and provide funds for—tackling the issue of antibiotic resistance. That, too, will be a continuation of work that has gone on in the past. The 2005 prescribing policy established recommendations for proper practice in acute hospitals; increased NHS boards' accountability; promoted training and education in prescribing; and defined the minimum requirements for collecting information, auditing, and developing performance indicators. It is proper that the priority given to tackling the unnecessary prescribing of antibiotics is continued. It will undoubtedly be a crucial part of fighting the spread of health care associated infections.
One of the most important points that the cabinet secretary made was that we have to focus on the importance of promoting hand hygiene—a significant and effective way of stopping the spread of health care associated infections. I am persuaded that full hand hygiene compliance is essential in health care facilities if we are ever to control such infections. Health care workers must be trained in proper hand hygiene. It can be difficult to grasp that doctors, nurses and other members of staff need to be trained in hand hygiene. Knowledge of hand hygiene should be common to all, but the prevalence of health care associated infections shows that it is not. That must remain a priority.
Patients need to feel confident about speaking up if they think that a health care worker has not used proper hand hygiene measures when treating them or other patients. We need to let people know that they have the right to speak up. That will be imperative in addressing the problem of high rates of infection.
I note that the Government has set what seems to be an aggressive target of achieving 90 per cent hand hygiene compliance by November 2008. The quarterly statistics will help us to measure that. The Health Protection Scotland report shows us how and where the problem of a lack of hand hygiene compliance is most severe. I understand that some NHS boards, such as NHS Forth Valley and NHS Orkney, as well as the national waiting times centre, already have compliance rates of over 90 per cent. They should be congratulated on that. However, in some areas, compliance is below 70 per cent and, in others, it is below 60 per cent. It is vital that we continue to address the problem.
It is imperative that the Government focus on care homes, as we suggest in our amendment. The previous Executive made important strides in that area and we need to ensure that that work is continued.
In 2005, the care commission published "A Review of Cleanliness, Hygiene and Infection Control in Care Homes for Older People". I note what the minister has said today, but it is vital that older people in care homes can be promised a clean and secure environment. They have to be protected from infection.
It is vital that funding levels are maintained in order to match those in England. I hope that the minister will reassure us on that.
I hope that I can reassure Margaret Curran that the investment that we have set aside for the next three years is 260 per cent higher than the investment over the past three years. I hope that Margaret Curran will take that as an assurance of our commitment to the right kind of investment in this issue.
I will take that—graciously, I hope—as an indication of the cabinet secretary's commitment. However, as I understand it, England has prioritised the issue, and we need to ensure that Scotland matches that.
We support the pilot screening programme. It is vital that it is introduced, but it will have to be assessed properly. The full conclusions of the pilot will have to be brought to Parliament, because there is some debate over the effectiveness of the screening programme. However, it is clearly one prong in the attack on infections.
I hope that we can continue this debate and that we can assure the people of Scotland that we can master the challenge of tackling continuing infections.
I move amendment S3M-1621.1, to insert at end:
"commends the progress made by the previous Labour-led government in establishing the HAI Task Force and ensuring that Scotland was a model for tackling healthcare associated infections and should continue to be so; asks the Scottish Government to commit to tackling all healthcare associated infections, not just MRSA; notes the importance of combating infections in care homes, and calls for a specific plan of action to do so."
It is always good to follow the gracious Margaret Curran.
The Conservatives welcome the debate on health care associated infection. We also welcome the investment of £54 million in the targeted three-year programme of action on health care associated infection from April this year alongside the one-year MRSA screening pilot. However, we do not know whether £54 million is enough and I did not know until I came to the chamber exactly what outcomes we could expect from the programme and how they would be measured.
I also want to be gracious in welcoming the quarterly audits. It will be helpful to see not only what the outcomes are and where the money is invested, but how effective the investment is.
I acknowledge the target of 90 per cent hand hygiene compliance by November. My colleague Nanette Milne will say more on that. We note the previous Government's work on the issue. Although the measures that it took had a negligible effect on the number of infections, we can only assume that the situation would have been much worse had that action not been taken. We can all safely assume that the detection and recording of infections are also much better thanks to the measures that have been put in place.
However, while I was preparing for the debate, I came upon some interesting statistics and information. I ask the Minister for Public Health to consider responding to one or two of the points in her closing speech.
First, I notice that, in response to a written question from Margaret Mitchell in July last year, the cabinet secretary confirmed:
"Recording of MRSA infection on death certificates is based on the clinical judgement of each doctor."—[Official Report, Written Answers, 13 July 2007; S3W-1495.]
Given the £54 million investment, should we not insist on a standardised method of recording MRSA and other health care associated infections when they are significant contributory factors to death? Unless the information is recorded consistently, we will never know the true extent of the problem. Moreover, in 2002, hospital-acquired infections were not notifiable causes of death. Has that changed in the past six years? I trust that the minister will respond to that in her closing speech.
We need guidelines on the provision of proper changing facilities for staff to combat the possibilities of cross-infection. All members have probably had letters from constituents asking whether it is all right that their doctor walks round Tesco with his uniform on or that nurses walk their dogs with their uniforms on. I do not know the answer, but Brian Adam posed that question in 2006, and the British Medical Association confirmed that research has shown that pathogenic micro-organisms, including—I hope that I pronounce this right—S aureus and C difficile are frequently carried on clothes, which represents a potential source of infection in the clinical setting. Are there clear guidelines on wearing the same clothes in hospital and outside? Unless the basic facts about how health care associated infections spread are made known to staff, we are unlikely to be able to prevent them and treat them early.
Many hospital patients now fear a hospital-acquired infection more than surgery. The cost to the health service is significant: £186 million a year. Hospital-acquired infections also mean that patients take longer to recover and have longer hospital stays, which reduces bed nights for other patients and delays admissions and discharges. There is also the cost of closing wards to prevent the spread of infection.
I welcome what the health secretary said about the care commission recruiting a nurse consultant to address standards in care homes—the point about care homes is well made in the Labour amendment. The delivery plan states that care home surveillance will be explored in March 2009. I would like more information about that. I welcome the recruitment of the nurse consultant, but we must wait another year before there is proper care home surveillance.
There is another interesting set of figures relating to MRSA rates for large, medium, small and very small hospitals. I noted that the very small hospitals fared the best, whereas the large hospitals fared the worst by far. There could be many and various reasons for that, which I hope will be investigated during the period of the delivery plan. However, it is concerning that the training package for infection control teams relating to ventilation and water systems has no stated target completion date in the delivery plan. Once again, I ask the minister to address that in her summing-up speech.
I do not discern—and I suspect that, by the end of the debate, I will not discern—any disagreement with the proposition that, because health care associated infections continue to pose such a significant problem, as the cabinet secretary pointed out, it is vital for the Government, supported by all of us in the chamber, to continue to support the HAI programme and bear down on the problem. There is no great surprise about that.
It is therefore difficult, if not impossible, to disagree with the thrust of the motion—save only for one small point, which I hope is a typing error. I do not necessarily approve of the Americanisation of our language, therefore I find the noun "coherency" not to be preferable to the word "coherence". I hope that that proves that I read the motion, and I hope that there is not an undesirable trend in the language that is used in the chamber.
I am pleased to intervene on that very serious point. I hope that the member will take some reassurance from my pronunciation of "coherence" during my speech. The word "coherency" in the motion is nothing more than a typing error. I know that the member will rest easy tonight, knowing that.
I am greatly comforted. We must maintain standards in the chamber.
Health care associated infection is a serious issue, and I welcome the debate. Margaret Curran is right to point out the previous Government's important role in recognising the problem and in establishing the HAI task force—although, without wishing to be picky again this afternoon, I notice the amendment's reference to "the previous Labour-led government". I comfort myself, however, with the knowledge that the radical thrust, and indeed the majority for everything that was passed, was provided by the Liberal Democrats.
The amendment refers to
"tackling all healthcare associated infections, not just MRSA",
with which I am sure we all agree. It was my understanding that the health targets for 2007-08 included reducing by 30 per cent the incidence of all Staphylococcus aureus—including MRSA—bacteraemia by 2010. Like Mary Scanlon, I have difficulty with the pronunciation. I would be grateful if the minister clarified that, as it is quite important in relation to the amendment. We obviously will support the amendment: it adds to the motion.
We welcome the Government's positive approach and its building on the work of the previous Government. Although the problem has not proved intractable, the figures remain extremely worrying. As the cabinet secretary suggested, we now have more evidence on the nature of HAI, and it is clear from the epidemiology that resources must be targeted at those people who are identified as being most susceptible to the infections that we are trying to address.
I mention targeting because it will be useful as we examine the issue in greater depth. The Dutch have developed much tighter controls on the use of antibiotics and have much higher standards of general hygiene in their hospitals, but they put their ability to control infection down to targeting, thus they restrict testing to all patients from high-risk groups. That is an extremely important point, to which I think the cabinet secretary alluded in her opening remarks. We welcome the establishment of further means to address those high-risk groups and we welcome the establishment of the screening pilot and the whole thrust of trying to tackle MRSA in particular.
We have an assurance that the situation will be monitored. Margaret Curran was right that an assessment will be brought to the Parliament. Although, on the face of it, the proposals appear to be a better way of ensuring that we get to the high-risk groups, we need evidence for that. The establishment of the MRSA screening pilot and of the C difficile reference library will go a long way to ensuring not just that we identify the disease but that we get results from testing to our hospitals much quicker than before.
I trust that the commendable resources that the Government is allocating will involve not just provision but capacity in hospitals, because there could be problems if we start to identify other difficulties.
I share some of Mary Scanlon's concerns. I hope that, in the next few weeks and months, the minister will help us to understand where we have got to with the action plan that was developed. The plan contained five clear headings under which we needed to develop where we were going—I accept that the previous Government did not complete the work. We need to get from the minister, at a fairly early stage, a statement that does not just reiterate the five broad areas—patient safety, education, surveillance, guidance and standards, and physical environment—but sets out the targets and where we are in meeting them. That is extremely important.
Finally, there is the issue of the public themselves. I welcome the emphasis on hand hygiene, but we must also deploy the work that the Food Standards Agency did in getting the general public to be much more aware of hand hygiene and engaging them in understanding and tackling the very difficult problem of HAI.
We have heard a lot—and I am confident that we will hear a lot more as the debate progresses—about the virtues of cleanliness in preventing health care associated infections. That is right, because methicillin-resistant Staphylococcus aureus and, to an even greater extent, Clostridium difficile are easily spread as a result of poor hygiene—I yield to my Latin-usage adviser, Ross Finnie, as to the correct pronunciation of difficile.
Initiatives ranging from the deep cleaning of hospital wards to a simple insistence on regular hand washing to a wear-nothing-below-the-elbow policy all have their place in prevention, although I assure the chamber that the wear-nothing-below-the-elbow policy refers to the arms and not the rest of the body.
Moves that the cabinet secretary has announced, such as implementing a screening programme for MRSA in three pathfinder boards, are welcome. However, there is more to HAI than that. I want to break away from the cosy consensus that has pervaded the chamber and consider another factor in the genesis of HAI: the pressure on clinical staff to treat more and more patients under circumstances that are less than ideal. Part of the problem is that there are two measures of a hospital's efficiency. First, there is the financial or accountancy yardstick, in which bed occupancy is a measure of success. By that measure, the ideal outcome is 100 per cent bed occupancy 365 days a year. That is recognised in hospital private finance initiative contracts, where the number of beds is reduced to achieve that so-called efficiency. Here in Edinburgh, to achieve affordable unitary charge payments under the PFI contract for the new royal infirmary, there had to be a 24 per cent reduction in acute hospital bed numbers throughout Lothian.
Apologists for that sort of draconian reduction, which is not confined to Lothian, claim that a reduction in the number of acute beds is justified because more people are treated in the community, and even in their own homes. Although it is true that many people with medical problems such as asthma can now receive satisfactory treatment without involving a hospital, the same is not the case for surgical conditions. Several years ago, I happily excised cysts or removed toenails in my health centre treatment room, and one of my colleagues had a regular vasectomy list. However, all of that has now stopped. My old health centre, like the majority of general practitioner premises around the country, cannot be modified to suit the requirements of the Glennie report, which was aimed at preventing the transmission of new variant CJD, and such operations now have to take place in hospitals.
It can be argued, rightly, that minor operations rarely end up with admissions to a hospital bed, but they add to HAI risk, because they occupy hospital staff's time and expertise. Further, they introduce patients into an environment that is more likely to be populated by antibiotic-resistant pathogens.
What is the result of the policy of shrinking the number of available beds so that 100 per cent occupancy rates can be achieved? I mention in passing that, for many weeks over the past few months, GPs in Lothian have received a message informing them of the red status of Edinburgh royal infirmary, which states:
"Capacity on site is at present challenged. Any deferrals or alternatives to admission would be appreciated."
GPs are being asked not to send to hospital patients whom they feel unhappy about treating at home. That certainly involves a health risk, but not a cause of infection.
The real threat of infection comes from the so-called hot bedding that needs to take place so that treatment can continue. Patients lying on trolleys in accident and emergency wards have to be found a bed somewhere. In some hospitals, patients having operations such as hip joint replacements, in relation to which wound infection is a disaster, end up in inappropriate wards because they must go where a bed is available. Further, the shorter the time between one patient leaving a bed and another filling it, the greater the chance that the cleaning process will be inadequate.
I mentioned that there are two measures of a hospital's efficiency. The second is a clinical measure. It does not mind a proportion of empty beds; it requires a bed in an appropriate ward at an appropriate time. It requires staff who are not rushed off their feet. Perhaps we should examine the effect of some of our waiting list targets on that measure. It also requires an environment that is conducive to care, not speed. Unless and until we can return to those basic clinical principles—well known to Florence Nightingale—fighting HAI will be an uphill struggle.
I agree with Ross Finnie's suggestion that there is likely to be near unanimity on this vital issue.
I welcome the cabinet secretary's announcements about the multimillion pound investments and wish her well. However, I am having some difficulty in keeping track of the various amounts of money that she is investing. Perhaps she will provide us with an overview of the investments when she winds up the debate.
I am sure that all politicians in the land will share the collective ambition that we express today.
In the time that I have been an MSP, my most harrowing and challenging case has involved one of my elderly constituents whose family has been decimated in four years. First, his wife died from MRSA, then his son died from the lack of appropriate mental health support and then his other son died of a heart condition. All of those deaths could have been avoided, but he has been left alone without anyone in the world. As if that were not bad enough, my constituent has had to cope with the withdrawal of all his advocacy support because of failures over the period in which he tried to complain and have his concerns addressed.
At a time when patients are vulnerable because they have just been diagnosed with a serious illness, the last thing that they should be doing is fretting. They need to have complete trust in the hospital where they are being treated and in the people who are delivering their care. However, one thing that causes patients great concern is the fear that their recovery will be hampered because their admission to hospital will lead them to contract a life-threatening superbug infection. Having had two major operations, I know that it is more than enough to have to cope with the worry of the surgery, without having to worry about further infection challenges. The Cabinet's commitment to screening is to be warmly welcomed.
NHS Quality Improvement Scotland raised many issues in the work that it undertook in 2003, the most important of which were about the inadequacy of monitoring, reviewing and evaluating policies on hospital-acquired infections. That thread applies throughout a number of health boards. Perhaps the cabinet secretary will discuss that issue further with NHS QIS and encourage it to revisit its 2003 investigations and update its work on this vital matter.
I was going to raise a number of other points, but I will not do so, because Ian McKee covered them adequately.
I share Ross Finnie's view. International experts paid tribute to the previous Labour and Liberal Democrat coalition when it produced its model for tackling hospital-acquired infections with a task force in 2003. At that time, an expert said:
"I am very impressed by the work of the HAI Task Force which is addressing this problem in a comprehensive manner … Reducing the levels of infection, including MRSA, is a major challenge for all countries. As Scotland points out, infection control is everybody's business, and the strategy followed by Scotland is an excellent model for others to look to."
That was said by Professor Didier Pittet. I say to Ross Finnie that I hope that I got the pronunciation right; I apologise if I did not. Professor Pittet is the World Health Organization's leading expert on MRSA, and those were his comments on the approach of Labour and the Liberal Democrats to controlling hospital-acquired infections.
I urge Nicola Sturgeon to take on board Ian McKee's points. Instead of repeating them, I will make some points that he might have missed. We can perhaps learn some lessons by looking south. In February 2008, a new antibiotics campaign was launched to remind the public, general practitioners and other doctors about the use of antibiotics. I do not remember whether the cabinet secretary mentioned that. If she did, I apologise, but it is important.
I am always happy to consider lessons from elsewhere, and I appreciate Helen Eadie's point, but I remind her that I mentioned our policy, which I launched earlier this month, on dealing with antibiotic prescribing. Perhaps she would like to take this opportunity to congratulate the Scottish Government on making resources available for MRSA screening, which is something that the Government south of the border has not yet done.
I am sorry that the cabinet secretary feels aggrieved, but if she had been listening she would know that I congratulated the Government on its screening initiative and apologised if she had already mentioned antibiotics.
I urge the cabinet secretary to pick up on an important point that was made by Scotland's leading microbiologist, Professor Pennington, who believes that we need to consider death certification, because there is significant underreporting of MRSA and Clostridium difficile. He said:
"The whole process of death certification is basically flawed … I would not be surprised if we did a proper study of all deaths in a hospital that we would find the actual number involving MRSA was ten times higher."
Finally, we need to ensure that we support the calls from trade unions throughout Scotland and take hospital cleaning back in house where it is not already provided in house, because the matter is of serious concern.
I welcome the Cabinet Secretary for Health and Wellbeing's statement. In the spirit of consensus, I acknowledge the work that the previous Labour and Liberal Democrat Executive did to tackle HAI. However, despite the inception of the HAI task force in 2003, patients are still being exposed to avoidable infections. The overall rate in acute hospitals remains high: the cabinet secretary stated that it is in the region of 9.5 per cent. I was interested to note that hospital-acquired infections contributed to 422 deaths in Scotland last year, which represents a 5 per cent increase compared with 2005. Some 13 per cent of deaths are now associated with infections that are acquired after surgery. There is clearly a deep-running problem in our hospitals and health service if so many people suffer from hospital-acquired infections and, tragically, so many lives continue to be lost because of them.
I welcome the fact that, soon after she took up her portfolio, the cabinet secretary made it clear that tackling hospital-acquired infections was a priority not just for the Government but for her personally. In November last year, she announced £54 million to be invested in the coming three years to drive down hospital infections. Those resources underscore the Government's commitment to ensuring that preventing people from acquiring infections when they receive health care continues to be a priority in our health service.
A considerable part of the cabinet secretary's speech focused on MRSA. The problems associated with MRSA in the NHS are not new; they have been around for many years. I can remember in my previous career dealing with many patients who had MRSA, which extended their period in hospital and, sadly, for some resulted in their passing away.
I was interested to note that 51 deaths were attributed to MRSA in 2006, which was 38 up on the previous year. I suspect that the sudden jump is due to greater recording on death certificates. As we have already heard from Mary Scanlon and Helen Eadie, there is an issue about recording deaths caused by MRSA. Professor Hugh Pennington has stated that the real number of deaths linked to MRSA could be 10 times greater than the official statistics, which depend on recording the cause of death on the death certificate. If we are to tackle what the cabinet secretary correctly described as a stubborn problem with MRSA, we must ensure that we have the right data on which to base our judgments, which means that deaths must be properly recorded.
I welcome the delivery plan to deal with the problem more effectively, and the screening programme, which will be introduced in pilots. I am disappointed that my health board—Forth Valley NHS Board—was not selected as a pathfinder board, although I am reassured that, if the screening programme is successful and proves worth while, Forth Valley will be in a position to implement it in 2009-10. The additional funding for the pathfinder boards is welcome in trying to deal with infections.
The cabinet secretary accepted that hospitals will never be sanitised, infection-free places and that control in tackling the problem is the way forward. I agree. She also highlighted the importance of hand hygiene. All the moves proposed in the delivery plan, including more auditing and ensuring compliance, are to be welcomed, but a more consistent approach is needed throughout different hospitals. In the past six months, I have been in four different hospitals, all of which have a different approach to ensuring that staff and visitors clean their hands properly when entering wards, visiting bed units or leaving. There is a need to ensure greater consistency because, as Ross Finnie said, we must get people on board—the patients and the people who visit hospital. I hope that, as part of the delivery programme, there will be greater focus on ensuring more consistency in how hospitals get the message across to people about when they should clean their hands.
My final point is on the design of some of our hospitals, because it is clear that some designs contribute to the problem. For example, a patient in a single bed unit who has an intravenous drip and is being barrier nursed and who does not have a toilet in their unit must leave the unit to use the toilet outside the ward, which compromises infection control. In the long term, we will need to ensure that patients who are barrier nursed in single bed units in some of our older hospital estate buildings have integrated toilet facilities. In this day and age, it is unacceptable to expect people to use commodes when they could use toilets.
Patients, the public and staff must be united in tackling the problem. I hope that, through the additional resources, we will start to drive down the number of hospital-acquired infections rather than stabilise it, as at present. By reducing such infections, we will ensure that patients have more faith that, when they go into hospital, they will not contract an infection.
I welcome the commitment that the cabinet secretary has made and the opportunity that the debate gives us to consider how we can reduce the risk of contracting hospital-acquired infection. It is clear that members across the parties are willing to debate the matter constructively.
I will talk about one of the most at-risk groups: the frail elderly. The key issue is that acquired infection is, in the main, preventable. Hand washing and good hygiene are obvious and cheap yet, for many years, we as a society did not do enough to promote them. Progress is now being made.
An important principle is the presumption against admission. For elderly people—and particularly those with dementia—hospital can be a risky place. I am sure that every member knows of an elderly person who was admitted to hospital for a minor ailment but who at best ended up as a delayed discharge or at worst acquired C diff or a fracture because their resistance was lower and their vulnerability to adverse incidents was higher.
To state the obvious, we need to ask whether the balance of risk for an elderly person is greater at home or in hospital. Ian McKee touched on that. Too many elderly people are admitted to hospital not for an operation or a blood transfusion—for something major or serious—but for diagnostic testing. Improving access to diagnostic testing could play a major role in decreasing the number of admissions and therefore the number of hospital-acquired infections. The Forth Valley project on care pathways for people with dementia has taken an innovative approach that ensures that accident and emergency staff are fully trained in dealing with dementia and encourages them to ask whether an admission is absolutely necessary and where the balance of risk lies.
In relation to admission to hospital, I will talk about closed wards. I found out only recently that patients are not allowed into or out of a closed ward but a visitor can visit freely without a gown, mask, gloves or even an information leaflet about why the ward is closed. Relatives need to be provided with information. If a ward is closed but visiting is allowed—that appears to be the case occasionally—relatives must be required to undertake basic barrier precautions. I emphasise that that is not a matter for clinical staff; a top-down management decision needs to be taken. I would welcome the minister clarifying in her summing-up whether some of the resources that have been announced could be allocated to addressing that issue.
That leads me to contaminated laundry. Mary Scanlon made the important point that viruses can be transmitted on clothing. I was surprised to learn that when a patient is in a closed ward—even when there is vomiting or diarrhoea—relatives are expected to take home contaminated personal laundry for washing. Given what Mary Scanlon said about bugs being transmitted on clothing, that issue is serious. I ask the minister to consider how we can ensure that, when wards are closed for good reason, in-house provision is made for laundering contaminated clothing.
I turn briefly to the care home sector. I was surprised to read in the Scottish Commission for the Regulation of Care's report on cleanliness, hygiene and infection control for older people that there have been a higher number of outbreaks of the norovirus—the winter vomiting bug—in care homes than in hospitals. The regulations relating to, and the monitoring of, acquired infection are much more rigorous in the acute sector than in care homes and there are more resources in that sector. I welcome the additional resources that the minister said will be available, but it is vital that those resources ensure that there is appropriate monitoring and surveillance—Mary Scanlon made that point—and that care home staff are adequately trained. Currently, too many staff in care homes go to work when they are unwell because they are low paid and do not receive sick pay. A culture change is needed, as there has been with hand washing. Staff who are ill must be encouraged not to go to work and so place frail elderly people at risk.
Having clearer procedures for closed wards where such procedures are necessary, dealing with contaminated laundry and—most important—raising standards in hospitals and care homes for the elderly could help to reduce acquired infections. It is no longer acceptable that some of the most frail and vulnerable people in our society, who have no voice, should be treated in such a way. Let us say that we are on their side, that we are their voice, and that we will work tirelessly in the Parliament to raise standards for them.
I support the amendment in Margaret Curran's name.
This debate on dealing with health care associated infections is extremely important. However, I cannot help feeling sad that the reputation of a health service that has achieved so much for so many patients has been blighted by a problem that, to a large degree, is preventable. There have always been patients who have developed wound infections following surgery, and cross-infection has always been an issue. However, many people now live into frail and advanced old age; large numbers of patients are on treatments that impair their immunity; many more invasive procedures are routinely carried out in a variety of clinical settings; and many people expect to be given antibiotics for the most minor of ailments, whether or not there is a proven scientific need for them. As a result, it is hardly surprising that HAIs have become a significant problem.
As infecting organisms increasingly develop resistance to antibiotics, it is important to try to prevent infections in the first place. Such attempts will be successful only if people work together and constantly bear in mind the need to avoid passing infections on from person to person. There must be awareness of how to prevent infections at all levels of health care and in all clinical settings.
Almost all health professionals of my vintage bemoan the informality and apparent lack of discipline in today's NHS compared with what happened when we started our careers. We all have tales of belligerent ward sisters whose eyes were everywhere and who would pick up the slightest infringement of the strict disciplinary code of the ward—a code of efficiency and cleanliness. In those days, no pieces of fluff were seen under beds or in corridors and bedpans and urine bottles were disposed of immediately. Any visitor or doctor who sat on a patient's bed could expect an explosion of wrath and visitors were strictly kept to their visiting hours. No more than two visitors were allowed around a bed unless the patient was close to death. White coats and uniforms were for wearing inside hospitals; we never saw nurses, physiotherapists, radiographers and suchlike in uniform in buses or shops. There was constant polishing and cleaning, and there was obsessive tidiness in general. Perhaps such an approach is old-fashioned, but it seemed to work. I will be honest: I do not recall huge emphasis being put on hand hygiene then, except, of course, when people were preparing for invasive procedures, when they were thorough and meticulous. However, MRSA was not endemic in the population then and few organisms were resistant to antibiotics.
As Ian McKee highlighted, life in the NHS was less pressurised in those days. Managers did not breathe down people's necks to push more and more patients more rapidly through the system, and the turnover of beds was slower. Time was taken to clean and fumigate all equipment thoroughly between patients' use of it. Things have now changed and it is even more important to run a tight ship, with rigid control of hygiene at institutional and personal level. Therefore, infection prevention and control activities must be everyday practice and applied consistently across the board, with all health care professionals sharing responsibility for them. The BMA's guidelines on health care associated infection must be heeded by all staff, including—perhaps especially—the more senior staff, who are role models for their juniors.
Antibiotic prescribing should be done responsibly to reduce the development of organism resistance. That can be difficult for a busy clinician, especially in primary care where patients demand treatment for minor ailments that would get better if left alone, although they might last a day or two longer. I must say that I am concerned about what will happen once prescription charges are dropped. Many patients nowadays think that they know it all—they browse the internet; they watch health programmes on television; they think that they know best—but they lack the years of training that go into making a competent health professional. Somehow, such patients must be educated to accept that a doctor who says that treatment is unnecessary is usually right, that viruses such as the common cold do not respond to antibiotic treatment and that, in normal people with normal immune systems, nature can often be an effective healer without the need for adjuvant drug therapy.
I think it sad that we need an HAI task force within the NHS, but I agree that, unfortunately, such a body is now needed if we are to be effective in combating such infections. I also think that the Government is right to pilot MRSA screening, and I very much welcome the cabinet secretary's announcement that three health boards will be involved. I will take a particularly keen interest in the pilot in the NHS Grampian area.
I accept that there must be a coherent approach to NHS service delivery, with links between patient safety and experience programmes and the HAI agenda. However, although I accept that a 90 per cent hand hygiene compliance target across Scotland may be reasonable and is right for this year, I think that we should nonetheless aim higher by seeking 100 per cent compliance as soon as possible thereafter. I am old-fashioned enough to recognise that that will be achieved only through stringent local enforcement by those who are responsible for the behaviour of staff, patients and their visitors—the old-fashioned ward sister, if you like—so that junior staff become so inured to good practice that it soon goes against their nature ever to breach the hygiene code and so that patients and visitors are constantly supervised to achieve the same result. I have seen that work effectively in a transplant unit, where infection control is, of course, vital. I see no reason why such enforcement should not work throughout the entire NHS.
I commend the cabinet secretary for her announcement this afternoon. I wish the Government every success in its endeavours to overcome HAIs and I hope that it will soon be able to report a very much reduced incidence of such infections in all health care settings.
I welcome the opportunity to take part in this afternoon's debate on health care associated infections. I endorse the cabinet secretary's announcement and, obviously, I support the Labour amendment.
There is no doubt that HAIs are a serious issue. The human impact of such infections, which Margaret Curran mentioned, was driven home to me earlier this week when I read an obituary in The Herald for Drummond Hart, who was a hospital consultant. I did not know anything about Drummond Hart beforehand but he was clearly an active man who was successful professionally and had many interests in life. Sadly, in his last five years, he was wheelchair bound after he contracted MRSA while in hospital for an operation on his spine. That shows the indiscriminate nature of MRSA and how it can strike innocent people. People enter hospital looking to be cured of their illnesses; they do not expect to leave with an illness that they did not have when they went in. That shows the seriousness of the task that the Government faces.
The cabinet secretary spoke about the costs and strains that MRSA imposes on the health budget. This year's health budget of £10.25 billion is targeted mainly at heart disease, cancer and strokes. However, MRSA results in more people being admitted to hospitals, which imposes greater strain on the health service and its budget and diverts resources from the main health issues that the Government and the service are trying to tackle. Addressing health care associated infection is not only right but, hopefully, will lead in the long run to a healthier Scotland and more efficient use of the health budget.
I support the publication of the delivery plan and many of the measures that it contains, which build on the work of the previous Executive. Like other members, I welcome the publication of the MRSA screening programme. Much can be done to track the programme and lessons can be learned from it, to ensure that we have in place an effective plan to combat MRSA.
I reiterate the comments that many members have made about hand hygiene. It seems basic, but poor hand hygiene is one of the major causes of the spread of infection in hospitals. I agree with Michael Matheson that we need to put across a consistent message throughout the country, in all health boards, to ensure that people take hand hygiene seriously and that we meet the hand hygiene compliance target of 90 per cent that has been set. Audits can be an effective way of measuring progress towards the target and of learning positive lessons.
Local campaigns are also important. The NHS is a big organisation; even boards cover large areas. It is important that we get down to the grass roots of the NHS, through local campaigns to put across the key messages in tackling the spread of infection. Education is important in that regard. The necessary staff must be in place in boards and we must work closely with the trade unions and patient groups such as the Scottish patient safety alliance.
I reiterate my colleague Helen Eadie's comments on the importance of in-house cleaning services. We should work towards establishing a presumption in favour of such services.
The Labour amendment refers to care homes, about which Mary Scanlon and Irene Oldfather made good points. I pay tribute to both members for their excellent record of promoting investment in care homes. Patients in such homes are less able than patients in other parts of the NHS to look after themselves, so they are potentially more vulnerable to the spread of diseases such as MRSA. I welcome the positive announcements that the cabinet secretary has made on the issue.
This has been a good debate, although it has not evoked much interest in the press gallery, which is empty. Parliament has an important role to play on the issue. As Ross Finnie said, it is important that there should be accountability on both the delivery plan and the action plan. I look forward to the cabinet secretary giving us regular updates on those.
Health care associated infection is a serious problem that affects communities and families throughout Scotland. Today there has been much agreement on the issue across the chamber. I am sure that Scotland will watch closely as we seek to continue to make progress towards making our hospitals and care homes free from infection.
The cabinet secretary is to be congratulated on this initiative. As the Labour amendment states, the previous Government is to be commended for the establishment of the HAI task force. The additional money that the cabinet secretary announced today and previously will be greatly significant in targeting not only MRSA but other virulent infections.
The incidence of MRSA has risen steadily over the years, as my colleague Michael Matheson and other members said. There are numerous reasons for that increase, but I will concentrate on just a few of them. A number of members spoke about the increase in drug-resistant infections, which has been brought about by the overprescribing of antibiotics. Nanette Milne targeted that point very well in her contribution. I welcome the cabinet secretary's announcement on how we will monitor and tackle that problem. People have been used to going to the doctor and receiving antibiotics because of a perceived need. That has led to antibiotics no longer working and our being left with virulent infections.
Another area that gives cause for concern is the movement of patients between hospitals and wards. Not so long ago, it was much less common for patients to be moved from hospital to hospital or even between beds. Unfortunately, it is much more common now, which has something to do with the spread of infectious diseases.
Helen Eadie and Irene Oldfather mentioned the contracting out of hospital cleaning services, which has had a direct effect on the spread of infectious diseases. Staff are now paid less and less time is allocated to cleaning wards. It is certain that those circumstances have contributed to HAI. I hope that the cabinet secretary, or perhaps the task force, will look at that area. The one-year screening programme pilot will have positive results, but only as part of a coherent and integrated approach to overall hygiene in hospitals. That point was mentioned in the motion and recognised by the cabinet secretary.
I know that the cabinet secretary is aware of the different views about screening. I offer two examples. In Geneva, 3,000 patients were screened for MRSA and the conclusion was that there was no benefit in such a programme. However, three hospitals in America used screening for MRSA and the conclusion was that screening did work. That is why it is beneficial for us to run the screening pilot, which must be monitored and audited after a year, as was mentioned. The pilot scheme is most welcome.
The cabinet secretary spoke in her opening remarks about the appointment of nurse consultants. Could that role be enhanced to include targeted cleaning pilots? Ross Finnie raised that point, as did the HAI task force, which I think referred to the housekeeping monitoring group. Combined targeted cleaning, which would entail the cleaning of clinical equipment and the patient environment, including lockers and bedframes, would be extremely beneficial. If it is not possible to extend the role of the nurse consultant in that way, will the cabinet secretary consider a pilot of targeted hospital cleaning?
Nanette Milne and others spoke about the role of former matrons. We know that we cannot go back to those days, but it is important that hospitals are clean not only for patients and visitors, who are encouraged to wash their hands; the hospital environment must be considered too. Michael Matheson mentioned that services vary in hospitals. In a letter to The Herald yesterday, I think, a lady said that she went to visit her mother in hospital and was appalled to see blood on the handrails of her mother's bed. That is totally unacceptable. Although it is up to the hospital management to deal with the problem, a targeted cleaning pilot would tackle such situations and they would not be allowed to happen. Over time, it would become the norm for hospitals to reach that high standard of cleanliness.
Everyone here agrees that patients must come first. They must have faith in the health service. The MRSA screening programme and additional money that the cabinet secretary announced today will bring benefits not just to this generation but to many generations to come.
Many members have talked about consensus, but consensus does not make the debate any less important—we should debate such issues.
The cabinet secretary mentioned the Western Isles hospital and I am pleased to have heard her announcement that it will form part of the screening pilot. The ethos at the Western Isles hospital is about infection control. When a person walks into the hospital, they hear a recorded message telling them to wash their hands if they have not already done so. They find hand-cleaning lotion for their use at the entrance to the ward and to the patient's room, and inside it at the foot of the bed, beside the patient notes, and by the wash-hand basin. The hospital strongly emphasises hand washing and informs patients, visitors and staff that they, too, should emphasise it. As I said, I am pleased that the Western Isles hospital is involved in the pilot. That demonstrates the effectiveness of the course of action that the hospital has taken. The pilot will also show any improvement that results from patients being screened before coming into hospital.
In many cases, it is too late to wait until someone has walked into a hospital to educate them on infection control. Patients are worried about their condition and what lies in store for them. Relatives, too, worry about what is happening to family members. That said, notices advising people to wash their hands are important. The Western Isles hospital displays them prominently. Other hospitals could learn from its example.
Hospitals have notices telling people not to sit on a patient's bed, but they do not tell people why they should not do that. We need a system that informs people about infection control long before they walk into a hospital, when they are feeling stressed because of what lies ahead for them, or their loved one.
Hand washing used to be taught in all schools. It then became part of community education, with notices posted in public places telling people to wash their hands. We need to return to those first principles on hand hygiene. We should mount a public information campaign to tell people why the rules have been put in place. People need to know about the importance of not sitting on a patient's bed, but on a chair, and of washing their hands before they visit the ward. Indeed, if someone is visiting more than one patient, they should be told about the importance of washing their hands between visits.
Advertising campaigns should be used to do that, given that they have been successful in the past. We also need to use the popular media. I am thinking of television programmes that highlight the health services, such as "Casualty" and Holby City" that have been used to put across good and important messages. We need to be told that it is everybody's responsibility to cut down on infection—staff, patients and visitors.
More public information is needed on the use of antibiotics, as many members have said. General practitioners are often pushed for time; they can come under a huge amount of pressure to prescribe antibiotics. Before patients go to their GP, it is important for them to be well informed about the ill effects of antibiotics on their health and that of others. We need to stop the over-prescribing of antibiotics, and responsibility for that lies not only with GPs but patients. Work also needs to be done on use of antibiotics in treating animals and, more generally, in farming. The impact of such use is not fully known, and it is an important source of antibiotic resistance.
We need also to counteract some of the scare stories that appear in the press on hospital-acquired infection. As other members have said, people can be reluctant to go into hospital because of the fear of catching an infection. It is also important that people understand the nature of the infections and where they arise. Hospital-acquired infections are obviously acquired in hospitals, but they do not always arise there; they can be brought into hospital.
We need to work with staff. I was interested to read the BMA briefing for the debate, which raised the importance of work clothing being designed with short sleeves and no ties. Perhaps it is time for us to look at the provision of uniforms for all staff. It is important for us to do so, given that the BMA has highlighted the issue. In the hospital pecking order, some staff wear uniforms and others do not.
Rhoda Grant makes an important point. It may be of interest to her and other members to know that we are working with the trade unions on a national uniform specification. We will outline our plans in due course. I hope that that reassures her.
Yes. I am grateful to the cabinet secretary for that information. The BMA position shows that doctors have the will and wish to see the proposal progressed.
We can use patients to reinforce the message about hand washing. It is important that we empower patients by giving them a role in telling people to wash their hands. Hand washing is part of nurse training, but what about the staff who qualified before it was included in the programme? Is hand washing included in training for other NHS staff? It is important that such matters be considered and that hand washing training becomes part of continuous professional development.
We must consider all other aspects of health care in the community. Members have mentioned nursing homes. Reducing infection is everyone's responsibility—staff, patients and visitors. We must all take our share of the fight against infection.
I agree with nearly everything that has been said in this worthwhile debate. The unanimity of the message will be encouraging to patients and health professionals.
Nicola Sturgeon pointed out that Scotland is a world leader in tackling health care associated infection. However, she also said that the infection rate in acute hospitals is 9.5 per cent and HAI costs us £200 million per annum. She was right to say that staff must have ownership of, and take pride in, hospitals. She made two important points. First, she said that eradicating infection is simply not possible—anyone who knows anything about science will realise that—but control of infection is possible and must be achieved. She mentioned funding of £54 million over the next three years. Members questioned whether that is enough money, but the proof of the pudding will be in the eating. Secondly, she talked about targeting health boards.
MRSA, which I think stands for methicillin-resistant Staphylococcus aureus—the cabinet secretary is nodding—is upon us. Indeed, a member of my family has suffered from MRSA. Luckily they made a complete recovery.
Margaret Curran welcomed the acceptance of the amendment and told us a harrowing tale, as did James Kelly, who referred to a recent obituary. Margaret Curran also made a good point about older people in care homes.
Mary Scanlon welcomed the quarterly audits and got into interesting territory about death certificates when she quoted from the response to a written question. That relates to Michael Matheson's point about whether the perceived rise in deaths from MRSA is related to recording methods. We are interested to know whether that is the case.
My colleague Ross Finnie emphasised that there is no disagreement in Parliament and made two important points. First, he said that resources must be targeted at the infections that we are trying to tackle. If we do not point the weapon at the right target we will be failing. He made play of the interesting and groundbreaking targeting work that the Dutch are doing, in particular in testing all patients in high-risk groups, so that audit can be as accurate as possible. Secondly, he was probably the first member to highlight the importance of the public. Many members subsequently made that point.
Reference was made to the pressure on clinical staff to have 100 per cent occupancy and to treat more and more patients—I think that the expression is "hot-bedding".
Helen Eadie and other members, including Rhoda Grant, Nanette Milne and Sandra White, talked about antibiotics, which is a big issue. I stand to be corrected on this by Dr Simpson or Dr McKee after the debate, but in my experience GPs and health professionals are now much less inclined to prescribe antibiotics and the regime is much stricter, which is a welcome step in the right direction. My mother, who is known to Mary Scanlon, Rob Gibson and other members, has a wee medicine cupboard, which is full of half-used antibiotic prescriptions, which seems to her to make eminent sense. How dangerous is that? I assure members that whenever I get the opportunity the antibiotics go straight into the bin.
Michael Matheson made an interesting reference to different approaches in hospitals and to hospital design. If I may turn, with the Deputy Presiding Officer's indulgence, to my constituency, the point has been made that big hospitals differ from little hospitals. That is not always accurate, but it is a general trend. Two small hospitals in my constituency are the Caithness general hospital and the Lawson Memorial hospital. Everything that the cabinet secretary and others have said is borne out by their experience: it is about environmental cleanliness and a hand-cleaning regime. The Lawson Memorial hospital asks visitors to maintain a hand-cleaning regime. As other members have said, there is no uniform approach—it varies from hospital to hospital. The regime that I have outlined is one of the factors that makes at least two hospitals in my constituency relatively successful.
I return to the points that were made by Ross Finnie. We must target resources. The minister and all members know—if we are honest about it—that resources are limited; we cannot throw endless money at the problem, so targeting is crucial. I flag up the Dutch example as one form of very good practice.
I conclude on the most positive aspect of the debate. As Ross Finnie and others said, the unanimity of contributions to the debate must surely give great encouragement to people who are potentially at risk of acquiring such infection, and to health professionals. It is an example of Parliament's being able to speak with one voice in a constructive way.
We welcome all that Nicola Sturgeon has said today in her speech and her interventions, including the MRSA pilot that she announced, in what has been a useful debate on a matter on which there is often more fresh heat than fresh thought. This is one of those problems for which there is a commonsense remedy that is all too often absent, or the message is in danger of becoming overcomplicated in its delivery.
My experience of being a hospital patient is relatively recent, as an accident and emergency admission within the NHS with what turned out to be a fairly routinely diagnosed complaint of gall stones one year and kidney stones the next. After treatment had helped alleviate the immediate discomfort, I found it fascinating just to watch. So much is made of the experience of patients by politicians that—admittedly, this is almost a perverse logic—it was almost a privilege to be a politician who was also the patient.
It was fascinating to watch the endless stream of individuals who strolled through the men's general surgical ward. There were committed public servants going about their business and there were patients and their families. The newspaper trolley man was astonished and unable to oblige when I requested The Herald—he ensured that the ward was made aware of the special delivery for "the professor" the next day to my bed in a window corner. There was the self-evident suspicion of fellow patients at the various baskets and bowls of spring bulbs that were delivered to the same corner—it was seemingly further evidence of, at the very least, some extravagant erudition.
There was the delight of the man opposite me, whose colostomy bag burst frequently in the night, or of the Irishman in the bed next to me, who did a runner because, as he confided to me, "The Southern general makes a much better job of drilling open a seized rear end." He was replaced by a young gentleman substantially the worse for wear after a Scotland match, whose excessively noisy comeuppance through the night was less than endearing. The hospital porters arrived, like buses, all at once—sometimes to ferry patients who had blocked a bed throughout the day and night for a routine X-ray, after which they could be discharged, but who as a result of lack of organisation lingered on, so other patients could not be admitted.
The staff—nurses, doctors, consultants, deliverers of meals and cleaning staff—were all doing their best, and the other patients were an on-going delight. There was the disembodied conversation heard over the partitions between an elderly man, who asked, "When did you get in, son?" and a recent arrival, who responded, "Just the day, big man, and no for long. And yersel?" "1952", came the reply. There was a daily procession of visitors, family and friends.
Not once, on either admission, did I hear anyone being challenged, or asked, to wash or sterilise their hands or not sit on the beds, nor was I ever savaged by a tie—the poor defenceless tie, around which now can be heard the clamour of indignant outrage as it is identified as the source of all infection. Ties, if worn, were tucked away within a coat or a jersey.
It seems to me that the most obvious action is the one that is least applied—washing or sterilising hands. In part, that seemed to me to be because there was no dragon enforcing the rule. I know that Conservatives have in the past called for matron, and I hope and believe that that has been for practical reasons and not just to fantasise about the swish of uniformed authority—I look over my shoulder, but no, she is not here. What is needed is a figure who has both the authority and confidence to bawl at anyone—patient, visitor, visiting politician, nurse, doctor or consultant—that they should wash or sterilise their hands and not sit on the beds. It appears that there are currently too many different chimney stacks of employee accountability and that in this grievance-rich age no one is able or prepared to take the risk of assuming overall command.
In saying all that, I accept that developments in medicine now keep us on the go until a greater age, often when hospitalised and with longer recovery times, and that our potential exposure in wards for longer and in a weakened state is a consequence of that. Therefore, when the BMA tells us that
"compliance with hand hygiene among professionals varies as a result of a lack of understanding of the associated risks and a lack of knowledge of the basic guidelines",
I cannot help but feel that there is considerable window dressing of a perfectly simple and straightforward concept: people should wash or sterilise their hands regularly and thoroughly. For hospital professionals, doing that and addressing the associated issues that Irene Oldfather raised should be as routine as is putting on a seatbelt for the driver of a car.
I have sympathy with the BMA's concern about inappropriate prescribing of antibiotics. I read its briefing on that subject and instantly recognised my mother, who—like Jamie Stone's mother—is a serial attendee of her local general practitioner, with an unshakeable belief that an antibiotic is the cure for all ills, from something genuinely serious to a blocked kitchen sink. There is a widespread belief that, even if an antibiotic is inappropriate, no harm can be done, yet those who prescribe them must know that harm is being done, as resistances are diminished. Again, public education is important, but the resolve of the medical profession in the face of what sometimes amounts to badgering is necessary, too.
In general, we believe the Government to be sincere in its objectives and we will support it today and will watch with interest the emerging outcomes. If the measures are successful, they will be a considerable achievement that will benefit the NHS hugely. I started by saying that common sense ought to be the rule but, as I have observed before, the problem with common sense is that it is not very common. The challenge for the Government is to make it so.
I hope that I have not made light of the subject. My sister-in-law—a mother of three in her 40s—is in the later stages of facing the cruel fate of the complications arising from untreatable breast cancer. Her journey has been made all the more stressful and grim by a hospital-acquired infection along the way. For that reason alone, I hope that the Government's announcements have a successful outcome.
As all other members who have spoken have said, the debate has been consensual, informed and of a high standard. As Jamie Stone said, that should give comfort to people out there. The problem is not new—it used to be called hospital-acquired infection. More than a century ago, Semmelweis solved some of the problems of puerperal deaths by getting people to wash between practising anatomy on cadavers and attending women in childbirth. That simple approach saved many lives. Jackson Carlaw is right that some of what we need to achieve is simple, or appears to be simple, yet it has been hard to achieve.
The first step in dealing with any such matter is to recognise the problem. I thank the cabinet secretary for her courtesy in accepting our amendment. I pay tribute to the 2002 action plan and the establishment of the ministerial task force, which, led by the chief medical officer and chief nursing officer, has been instrumental in setting up a model that has been praised as being excellent. However, despite that work, levels of MRSA have remained stubbornly high and consistent in the past few years.
Members mentioned some of the factors in that. Ian McKee referred to overoccupancy, although I must say that, despite the references that he made, the number of acute beds per capita in Scotland is still substantially greater than in England. However, it is true that overoccupancy rates of more than 90 per cent are associated with increased rates of infection. Delayed discharges were a major problem, because they increased the occupancy problem. The target that was set to eliminate delayed discharges by March 2008 has freed up more than 3,000 beds, which is a massive contribution to tackling the occupancy problem, as well as to tackling the problem of people who are kept in beds for a long time in hospital being more likely to contract a condition. Important changes have been made.
The rapid throughput of patients is another contributory factor, as has been said. Another factor that contributes to the problem is boarding out—rather than hot-bedding—which is the movement of patients between wards to allow more acute patients into the appropriate wards. Several members referred to those pressures.
Members have also referred to antibiotics—their type and their appropriate use. Such issues are of great importance, as Sandra White, Ross Finnie and others said. Not only must we have a public education programme on the appropriate use of antibiotics, but we must have antibiotic pharmacists in every trust, who can teach junior doctors and ensure that prescribing is appropriate, stating which antibiotic should be used, when and for how long. That will help to reduce rates of resistance. The national guidance that the cabinet secretary mentioned is indeed welcome.
Michael Matheson and other members referred to the physical environment. Redesign of some of the less appropriate elements will be important. Another important issue is decluttering—removing from wards items that do not need to be there. A more pristine environment can help.
Effective control of sterilisation of instruments is needed, and that issue has been tackled effectively. Irene Oldfather spoke about cleaning of soiled clothes, and that issue should be investigated. It would be useful if the task force could comment on whether the issue is important.
Helen Eadie, Ian McKee and others also spoke about clothing. Jackson Carlaw wittily but seriously discussed the clothing of all staff. It is important that people's clothing is right, so I welcome the cabinet secretary's announcement of a national clothing specification. The BMA would say, "Ditch the tie." In Ian McKee's early days and mine, if a doctor turned up without a tie, he was not allowed on the ward, but now he must turn up without a tie or he will not be allowed on the ward. That, I suppose, is progress.
Helen Eadie referred to cleaning of wards. I take issue with Nanette Milne about one issue among her reminiscences about the good old days. It was the Conservatives who, in effect, privatised cleaning services in hospitals; but it was the Labour Party, when it came to power with its Liberal colleagues in 1999, which said that there would be a presumption that the services would be taken back in-house. Cleaners are a very important part of the care system.
My point was that it does not matter who actually does the cleaning. What is important is the supervision of a high standard of cleaning.
I hate to say this, but I could tell Nanette Milne numerous stories of when contract cleaners have come in, done their bit and gone away, leaving the question of who would clean up the mess in the toilet when someone was sick. Senior nurses end up having to do that. That is fine—we all have to muck in and do the job—but because the cleaners are not part of the team, they are not there all the time. Taking the services back in-house is important.
Important too are the overall staff structures. When she responds to the debate, I would like the Minister for Public Health to address the December 2007 report "National Hand Hygiene NHS Campaign". Under the heading "Next Steps", the report says that funding to allow local health board co-ordinator posts should
"continue for at least two years".
Such work should be mainstreamed. I assume that that can be dealt with using the new funding. We need the whole team to be in place.
I welcome the cabinet secretary's announcement of a nurse consultant for the care commission, but I agree with Mary Scanlon that progress must be made on care homes. Irene Oldfather reminded us that inability to provide home care on a day-case basis can lead to unnecessary hospital admissions, which adds to the pressures.
I welcome the screening programme that has been announced and the funding for it, although I would correct one thing that the cabinet secretary said. Alan Johnson has announced the introduction of screening for all elective patients by March 2009 and for emergency patients as soon as possible over the next three years. He has announced £130 million of funding to achieve that. He has praised the Dutch programme to which Ross Finnie and Jamie Stone referred. The Dutch call it the "search and destroy" system. That programme—Sandra White referred to two other research programmes—will have to be considered carefully. Before any pilots are established, I hope that the monitoring or evaluation group will have a chance to comment on how they are being run.
I have not covered hand hygiene to any great extent. The variation in compliance rates in the two audit periods is alarming. The range in compliance is 50 per cent to 94 per cent in the first audit period and increases to only 59 per cent to 94 per cent in the second audit period, so the 90 per cent target, which I welcome—it is also the World Health Organization's target—is entirely appropriate. It is a challenging target, and we will need a partnership between different groups to achieve it. As Margaret Curran and James Kelly indicated, it is important that patients be encouraged to say to doctors—who are the worst-performing group in the monitoring figures—that they must wash their hands when they move from one patient to another. The Scottish patient safety alliance should be asked to help in that regard.
The audit is obviously important. We are making good progress, but there needs to be a full partnership between health care staff, patients and visitors. We also need to share experience with our colleagues in England, who are introducing substantial programmes, so that we do not develop different methods. The funding in England is huge—£270 million annually by 2011—so I wonder whether we will have enough funding to tackle the issue in the way that the cabinet secretary clearly wants to.
I have listened with interest to this constructive, stimulating and wide-ranging debate, which has served as a stark reminder that the Scottish Government and the NHS have a range of complex issues to tackle.
I will respond to as many of the issues that have been raised as I can. First, I want to underline some of the key points on our commitment to tackling HAI that the cabinet secretary outlined. The publication of the Scottish point prevalence survey came when we were new to government, but we reacted swiftly and made it clear that we simply would not tolerate a situation in which 9.5 per cent of patients in our acute hospitals suffer from some form of health care associated infection, with some of our elderly patients caught up in a seemingly endless cycle of infection and treatment.
Our investment of £54 million over three years is 260 per cent higher than the previous budget. It is a thorough and more robust HAI programme, which will bring about a number of benefits and make huge inroads into reducing the estimated £180 million that it costs the NHS in Scotland every year to treat patients with health care associated infections.
We have set a number of challenging targets for NHS boards to deliver on, not least the target to achieve a 30 per cent reduction in S aureus blood infections by 2010. The target of reaching at least 90 per cent hand hygiene compliance by November 2008 is another major challenge for boards, but we have made it clear that they will be given all the help that they need from infection control managers, local health board hand hygiene co-ordinators and Health Protection Scotland.
Our £7 million MRSA screening programme, which will be implemented by pathfinder boards next year, will take us a step further towards ensuring that each and every pre-admission patient is not unnecessarily exposed to an avoidable infection. We are convinced that, taken together, the measures in our coherent HAI delivery plan will make huge inroads into achieving our long-term goal of substantially reducing the rate of HAI in Scotland.
The debate has raised a number of interesting points, to which I have listened carefully. I will do my best to respond to them and I apologise if I do not cover them all. Margaret Curran and, I think, Rhoda Grant referred to the training of cleanliness champions. I remind members that all undergraduate nurses and doctors undergo cleanliness champion training. Nearly 4,500 have now completed that training programme.
Mary Scanlon, Michael Matheson and, I think, Helen Eadie mentioned MRSA being recorded on death certificates. Our quality control measure of MRSA instance is the national surveillance programme for blood infections. Those data give us a hard measure of the problem, whereas ascribing the cause of death can often be a subjective judgment. Having said that, I recognise the concerns that have been raised in the debate and we will consider the issue further.
Ross Finnie talked about the need to measure all HAIs, not just MRSA. We know from the point prevalence survey that MRSA and MSSA are a good proxy for HAI rates in general. It is not necessary to measure all types to know that we are winning the fight against infection.
Helen Eadie asked us to revisit the Quality Improvement Scotland review of NHS boards' HAI policies. QIS has just published a revised set of HAI standards, against which boards will be assessed in 2009.
Michael Matheson spoke about the design of hospitals contributing to infections. We acknowledge that, and we have national guidance on hospital construction specifically for reducing infection risks. We are considering specifying single-room provision in hospitals, which, in future, will have many more en suite single rooms—up to 100 per cent where appropriate. The existing estate is more challenging, and we need to make progress on that.
Michael Matheson also talked about getting across the message about good hand hygiene to patients and visitors. A lot of work has gone into that. We had the six-week television and radio campaign at the beginning of the year, and a new campaign—aimed at members of the public who visit hospitals—is scheduled to begin later this year. That marks a shift in emphasis, which I am sure that many members, having raised the matter in the debate, will welcome.
Sandra White spoke about targeted hospital cleaning. As was indicated in the cabinet secretary's speech, the cleaning monitoring tool is being revised to ensure that improved, modern and rigorous standards apply in all NHS board areas.
Jackson Carlaw and Nanette Milne spoke about the nurse in charge—the matron, as I think Jackson Carlaw said. We are concluding a fundamental review of the role of the ward sister and charge nurse, which we will publish in the spring. That review makes it clear that the central responsibility of the ward sister lies in compliance with standards. I hope that that reassures those members.
Much of our new delivery plan will bring about quick results and improve patient care straight away. Care bundles will bring significant benefits to patients, who will receive consistent provision of care in many areas of hospital practice. However, there are other issues that we will not be able to solve so quickly. For example, it will take until 2010 for health boards to achieve our target of a 30 per cent reduction in S aureus blood infections, and it will be April 2009 before the national MRSA screening programme can be rolled out.
If we are to deliver our ultimate goal of a safer, cleaner and more efficient health service, I ask for members' patience. There are no quick or easy solutions, and we need everyone to play their part. We want to get it absolutely right, so that everyone in Scotland can once again be proud of our NHS and the service that it provides.
We have set out our stall today, and a huge amount of action will take place over the coming months and years to tackle HAI. We aim to bring about significant change in attitudes and behaviour across the NHS, and we will make a number of changes to the way in which services are delivered, so that patients can once again be confident that they will be safe and cared for while they are in hospital. We are instilling a sense of pride, progress and direction. However, as the cabinet secretary and I have both said, action on HAI must be taken over the longer term and across a wide range of fronts if we are to succeed.
It is clear from today's debate that HAI is an issue on which there is wide, cross-party support, as well as broad engagement from a wide variety of agencies, which are actively and enthusiastically tackling the problem. With the Parliament's support, the Scottish Government and the multi-agency HAI task force will do all that they can to reduce the rate of infections in our hospitals and other health care environments. I thank all members who contributed to this important debate.