Aberdeen Royal Infirmary Health Care Environment Inspectorate Report
The next item of business is a statement by Nicola Sturgeon on the Aberdeen royal infirmary health care environment inspectorate report. The cabinet secretary will take questions at the end of her statement, so there should be no interruptions or interventions.
I welcome the opportunity to address the health care environment inspectorate's report following its announced inspection of Aberdeen royal infirmary on 13 October 2009.
There is no doubt whatever that the report makes difficult reading, but it vindicates absolutely the Government's decision to establish a tough and independent health inspectorate. When we debated hospital infections just last week, some members claimed that the inspectorate would not be tough enough. The report proves them wrong.
The inspectorate was established to provide rigorous and uncompromising scrutiny, to focus its attention on areas that need improvement, to agree action plans with NHS boards and to ensure that improvements happen. On the evidence so far, that is exactly what it is doing. The result will be higher standards in our hospitals and greater confidence among patients and the public in hospital cleanliness and in the quality and safety of the services that are delivered.
To that extent, I consider the health care environment inspectorate's establishment to be one of the most important steps that the Government has taken to drive up standards and drive down infection rates in our hospitals. The inspectorate's work will allow me and future health secretaries to stand in the Parliament and say not just that we are taking action that we hope will lead to higher standards but that those higher standards have been achieved.
I turn to the report on Aberdeen royal infirmary. The report's findings are unacceptable. Serious shortcomings have been identified, which are of the utmost concern to me and to the public. The key findings include a lack of awareness and communication of infection control policies at ward level; shortcomings in cleanliness, hand hygiene and facilities; a lack of risk assessment; a discrepancy between what the senior management believe is happening and what is actually happening at ward level; poor communication of health care associated infection issues and policies; and a lack of strategic responsibility for HAI education and training.
In the interests of balance, it is important to point out that some positive comments were made, such as the comments from patients on the hospital's cleanliness and from inspectors on antimicrobial prescribing—the inspection team was encouraged by the on-going work on that in the hospital.
NHS Grampian has accepted all the report's recommendations and is working to implement them urgently. The board has put in place an improvement plan to ensure implementation of all the recommendations. NHS Grampian has not only accepted all the recommendations and taken early actions to make improvements but made several changes at senior management level to ensure that the right leadership is in place to drive sustainable change. A director of acute services and a senior nurse have been appointed to focus immediately on the report's recommendations.
It is important to point out that the health care environment inspectorate undertook an unannounced follow-up inspection of Aberdeen royal infirmary on 16 November 2009, when the inspectorate found evidence that NHS Grampian had taken a great deal of action and that significant improvements had already been delivered. That is good news for patients and the wider public, and it is an illustration of the willingness of the NHS to learn, and to learn quickly, from this process. It provides the first hard evidence that the new inspection regime is working.
As I have already made clear, inspection was never going to be an easy or a comfortable process. We now have a patient's-eye view of what is happening in our hospitals on any given day, as well as a thorough review of the policies, practices and governance arrangements that NHS boards have in place.
Although the report focused on NHS Grampian and Aberdeen royal infirmary, I have instructed all NHS boards to give full and urgent consideration to all the issues and not to wait until they themselves are inspected. The findings raise substantive issues on which all NHS boards must reflect and take immediate action where required. The issues should be considered in the context of the range of strategic actions that are already in place to tackle health care associated infections and to improve the nature and quality of the care that is provided to patients.
One prominent feature that has emerged from the inspections to date is the importance of actions at the strategic and corporate level being linked to what is happening at operational level, in terms of both effective day-to-day management and clinical leadership, to ensure the delivery of high-quality care to patients. That means that priority must be given to the regular examination and discussion of the issues at board level; a careful examination of internal practices to reduce at all times the risk of outbreaks of health care associated infections; clear plans to ensure that actions at strategic level deliver improvements at operational level; and the use of all available tools to lead those improvements, including ensuring implementation of existing guidance, care governance and patient safety walk-rounds.
At national level, work will be continued to determine read-across from the health care environment inspectorate's reports to the progress that is being made by NHS boards against the HAI national action plan. I am convinced that the current policy framework for the prevention of health care associated infections across Scotland is appropriate and comprehensive—that is evidenced by the fact that rates of infection are falling—but we must continually up the pace on implementation.
Following publication of the report into the Aberdeen royal infirmary, the importance of addressing all these issues and making immediate improvements in the health care environment were underlined directly with NHS board chief executives on 18 November 2009 and NHS board chairs on 23 November 2009. On 23 November 2009, Dr Kevin Woods, the director general for health, wrote to all NHS board chairs and chief executives to underline that they must take all necessary steps to address the issues that have been raised in the health care environment inspectorate reports that have been published so far and to ensure that everything possible is being done to protect patients from the risk of health care associated infections. That means action in the boardroom, strong clinical leadership, knowing the local patch and delivering high-quality front-line care.
In our debate last week on Clostridium difficile, I said that I imagined that the inspectorate's reports would be used to attack the Government. So be it: a health secretary who was worried about that would not have set up the inspectorate in the first place. I set it up because my priority—and I know that it is a priority that is shared by members across the chamber—is to see improving care for patients, regardless of how uncomfortable it might be on occasions to find out where improvements are necessary. We established the health care environment inspectorate to root out problems—problems that matter to patients and front-line staff—and to ensure that action is taken. That is exactly what the inspectorate is doing.
The inspectorate has already secured improvements in the NHS. I welcome that, and I believe that members throughout the chamber will also welcome that. The public and NHS staff will welcome it, too, when they see that our determination is making things better for them and—crucially—when they see the continuation in that downward trend in hospital infections that we have already delivered.
The cabinet secretary will take questions on issues that were raised in her statement. We have until exactly 25 past 3, and not one second longer. I ask members to keep questions and answers as brief as possible.
I thank the cabinet secretary for providing me with an advance copy of her statement. It may come as a surprise to her, but I regret the fact that we are considering the inspectorate's report on Aberdeen royal infirmary, because it demonstrates graphically that lessons have not been learned. There is no doubt about the seriousness of the inspectorate's findings. Equally, I am sure that the cabinet secretary will acknowledge that the Vale of Leven families affected by C diff pressed her to establish the inspectorate. I know that they welcome the rigour that was applied to the inspection.
The cabinet secretary may recall her written response to me that identified Aberdeen royal infirmary as having the highest incidence of C diff of any hospital in Scotland—438 cases in one year. I have no doubt that the failings identified in the inspection contributed to that figure.
Does the cabinet secretary agree that no fault lies at the door of the hard-working domestic and nursing staff and that, rather, they need to have adequate time, resources and equipment to do their jobs? The cabinet secretary may be aware that there was a lack of clarity, which was never resolved, about whether senior charge nurses had authority over domestic staff in NHS Grampian. She may also be aware that senior charge nurses asked for more sinks to be installed but that that was not done until after the inspection; I am sure that she shares my disappointment at that. Finally, will she put senior charge nurses in Scotland in the driving seat and give them direct responsibility for the management of cleaning on their wards and a small budget to enable the changes at ward level, such as the installation of sinks, that we know can make a difference?
We all regret that we are debating this report today, for no other reason than that we should not have to do so. Standards at Aberdeen royal infirmary should not have been such as to give rise to the report; no one will disagree with that. I hope that Jackie Baillie will accept from my statement that, like her, I do not question or doubt the seriousness of the matter.
Lessons are being learned. Some of those lessons are difficult and, unfortunately, take time to implement properly in an organisation the size of the NHS. One key lesson that has been learned is that we must establish a system of robust, independent inspections of our hospitals.
Jackie Baillie was right to highlight the contribution of the families of the people who died of C difficile at the Vale of Leven. At one of my meetings with them, they made the point that, although many of the measures that we were discussing sounded good, they as patients needed to have confidence that those measures were being implemented. That was one of many things that were said to me in the wake of the Vale of Leven outbreak that struck me forcefully and powerfully. It is why I took the decision to set up the inspectorate.
Some people said that the inspectorate would not be tough and would not do the job that it was required to do; I hope that, having read the report, they will reflect on their position and accept that, for the first time ever in Scotland, we have in place a tough, independent inspection regime that can shine a light on areas of weakness and ensure that improvements happen. That should give all of us confidence.
I agree that no blame attaches to members of staff. I never blame staff for what goes wrong in the NHS. We all have a duty to support staff in the crucial job that they do and, in the main, staff in the NHS do that job exceptionally well. We should support them not just morally but in practical ways. That is what the Government is doing.
I will make two points in response to Jackie Baillie's questions about charge nurses. First, the senior charge nurse review is precisely about giving charge nurses leadership and responsibility at ward level. I am sure that Jackie Baillie has read the HAI action plan, one of the actions in which is the devolving of budgets to the front line so that quick improvements can be made when front-line clinical staff think that they are necessary. Those actions are in place and are the right actions. Secondly, I refer the member to part 4 of the NHS Grampian improvement plan in response to the inspectorate's report, which contains a range of extremely important recommendations to empower charge nurses to lead in the ward.
Does the cabinet secretary agree that patients are not interested in whether cleaning contracts are in-house or private and that they just want high standards of infection control? The question is pertinent because Aberdeen royal infirmary had an in-house contract that did not meet the quality mark.
Does the cabinet secretary acknowledge the disappointment in the report findings and the need for Government to instruct NHS boards to look at internal communication, practices, plans and implementation of existing guidance, all of which they should have been doing already? Are NHS targets and financial challenges potentially compromising infection control? After every infection outbreak and report, we are given assurances that action will be taken. How can we be assured that the action outlined today will be sustained in the long term?
Since previous outbreaks, action has been taken. As I said to Jackie Baillie, one of the most important actions taken following the Vale of Leven outbreak was the establishment of the health care environment inspectorate. It is because we established the inspectorate that we have the report that we are talking about today. We know the problems that were identified at Aberdeen royal infirmary, and action is being taken to put them right.
In direct answer to Mary Scanlon's question, I give the assurance that all hospitals will be inspected on an on-going basis, with both announced and unannounced inspections. For the first time, we will know whether there are problems such as those in Aberdeen because the independent inspectorate will go into hospitals, root out those problems and ensure that they are addressed. Above all else, that is what will give confidence to people—not just those in the chamber but throughout Scotland.
Patients say to me regularly that they believe that the contracting out of cleaning services over the years has undermined standards and that it is better to have cleaners and domestic staff within the NHS family. In and of itself, that does not deliver the standards that we need to see, which is why we have cleaning standards that have been monitored by self-assessment and are now monitored by the independent inspectorate. I agree absolutely with Mary Scanlon that standards are extremely important. At the heart of the report is the point that existing guidance was not being implemented properly, and that is what must be addressed.
The NHS north and south of the border faces financial challenges, but this year the NHS has more money than it had last year, and next year it will have more money than it has this year. Financial challenges are not an excuse for not meeting the highest standards of hygiene and cleanliness. I make no apology for setting ambitious targets to reduce health care associated infections in our hospitals.
The cabinet secretary outlined several major problems; I want to focus on one major contributory factor, which is the management of NHS Grampian and the Aberdeen royal infirmary. She mentioned in her statement the discrepancy between what senior management believed was happening and what was actually happening. That is a management function—they are not there to run the hospital day to day; they are there to set the strategy and make sure that it is carried out.
The management knew that, in March and April 2008, there was a serious spike in the figures for C diff. How could any senior management worth their salt reach a position of receiving such an inspection report having known about that earlier C diff outbreak? The cabinet secretary said in her statement that in future strong clinical leadership will be required in the boardroom. I ask her how we can have any confidence in that boardroom given its present composition. I invite her to admit that the senior management, both at board and hospital levels, have failed and that there must be changes to restore public confidence.
I agree absolutely that senior management have to take responsibility for ensuring that what requires to be done is done and that that must feed from board level right down to the wards.
The senior management at NHS Grampian now have an absolute responsibility to implement urgently all the recommendations in the report. They will be monitored and inspected against the recommendations, and they have already been subject to a further unannounced inspection from which there is evidence of improvement. The health care environment inspectorate will continue to monitor the implementation of the recommendations.
I do not entirely disagree with Ross Finnie's general point. If the health care environment inspectorate inspects a hospital but improvements are not made, ultimately I have the power to make changes in the boardroom and to give instructions to NHS boards. If as the process evolves we do not see the changes that it is intended to drive, I do not rule out taking such steps in any health board area.
Eight members want to ask a question, but we have less than 10 minutes. Members probably get the message.
In the light of what Ross Finnie said, would the cabinet secretary care to give us some of the counterbalancing aspects of NHS Grampian's overall performance?
The report was comprehensively bad in the context of what NHS Grampian was being inspected against. I mentioned that positive comments were made in the report: the inspectorate commended the board on its antimicrobial prescribing policies and some patients had commented positively on the cleanliness of the hospital. However, those comments rather fade against the criticisms that were made. It is right that we and NHS Grampian focus on the criticisms and it is right that the board is focusing on putting right those problems. That is what the board is required to do, what it will be monitored and inspected against, and what it will be judged on.
As the constituency member, I emphasise the dedication of all grades of staff at Aberdeen royal infirmary to the care and safety of patients. Will the cabinet secretary ensure that staff have the time that they need to do their jobs and that NHS Grampian has the resources that it needs to protect patients from health care acquired infections?
I acknowledge Lewis Macdonald's interest as member for the constituency that includes Aberdeen royal infirmary. His points are absolutely valid. As I said to Mary Scanlon, we live in a time of tight public resources—that applies to the NHS and all parts of the public sector, not just in Scotland—but I repeat that NHS Grampian's budget went up this year and is going up next year. NHS Grampian has the resources to ensure that the problems are rectified. As I said, no health board should ever use resources as an excuse for not ensuring the highest standards.
Time for staff is fundamental, and many of the report's recommendations to do with, for example, senior charge nurses are about ensuring that there is a clinical focus at the front line that allows staff to do their jobs properly. A positive step that has been taken is the appointment of a senior nurse and a director of acute services, to ensure that changes happen and have the desired effect.
During my 20 years working at ARI, ward sisters had tight control over their wards, including over domestic and cleaning staff. I note what the cabinet secretary said in response to Jackie Baillie about senior charge nurses being given a leadership role at ward level, but do charge nurses have the authority to ensure that their wards are properly cleaned?
Did the cabinet secretary have any indication that there were still problems with cleanliness at ward level at the time of the recent annual review of NHS Grampian?
If I had had any indication of the kind of criticisms that are in the inspectorate's report, action would have been taken. Now that we know, through the inspectorate that we set up, that problems exist, action will be taken.
Nanette Milne is right to say that it is not enough to ask senior charge nurses to have the ability to lead—although I am not suggesting that that is all we do. They must have the ability to challenge and to enforce standards in wards. I am sure that, like Jackie Baillie, Nanette Milne will be interested in the ARI improvement action plan, section 4 of which details improvements that NHS Grampian has been asked to make in relation to charge nurses. In recommendation 4.8, the board is asked to ensure that charge nurses have a process in place to challenge people, to ensure that the highest standards are maintained in their wards. That is exactly the intention that is behind the senior charge nurse review, and we must ensure that the process works, not just in ARI but in all hospitals.
I acknowledge the importance of inspections and I thank Nicola Sturgeon for her statement. I well remember the early inspections by Her Majesty's Inspectorate of Education that led to negative reports on individual education authorities when I was an education minister, and I recall getting directly involved in urgent follow-up action.
What action has the cabinet secretary personally taken since the publication of the report? Has she met the chair and chief executive of NHS Grampian formally to discuss the damning recommendations? Has she written to communicate her dismay at the report's findings? Has she commissioned a detailed action plan for recovery with appropriate follow-up monitoring and inspection? Will she agree to visit the hospital in due course to emphasise her concern? In short, will she guarantee—as I think she did in her reply to Ross Finnie—to do everything necessary within her significant powers to ensure that the failings are never repeated at Aberdeen royal infirmary or any other Scottish hospital?
I recognise Nicol Stephen's local interest. I saw the chair of NHS Grampian on Monday this week—the day that the report was published. I detailed in my statement the letter that has gone not only to NHS Grampian but to all the chairs and chief executives of NHS boards to draw their attention to the recommendations in the report. I stressed strongly to NHS boards that, although they will all be inspected, they should not sit back and wait to be inspected but examine other reports to ensure that any lessons that they can learn from them are learned.
I have in my hand the detailed action plan for improvement that has been agreed between the inspectorate and NHS Grampian. It is on the NHS Grampian website, and the board will provide updates on the implementation of the recommendations. It will be closely monitored by the inspectorate, my department and me, because I am determined to see the problems that are identified in the report resolved and rectified for all time.
As the work of the health care environment inspectorate is now in full swing, will the cabinet secretary give us a picture of general trends throughout the country that are now being acted on? Will she also reassure us and, especially, patients in the north-east that the environment in Aberdeen royal infirmary is safe and relatively risk free now?
On the second part of Brian Adam's question, I refer to the follow-up inspection of Aberdeen royal infirmary. Patients and the public are right to be concerned at what they have read or seen reported about the inspectorate's findings, but they should also be assured about the follow-up inspection and the fact that improvements are already being made.
The first part of Brian Adam's question concerned trends throughout the country. The health care environment inspectorate will inspect every acute hospital, and all acute hospitals will receive at least one announced and one unannounced inspection in every three-year period. That will allow us to shine a light on any problems that are identified.
However, as I said in response to Nicol Stephen and others, all health boards must ensure that they analyse fully all the inspectorate's reports—not only those for their own hospitals or boards—and learn any lessons from them. I hope that, if that happens, the reports that we receive from the inspectorate from now on will show a very different picture.
Why do lessons appear not to have been learned in NHS Grampian not only from experiences in other health boards but from its own experiences in Woodend hospital and Dr Gray's hospital? What continuing contact will the cabinet secretary have with NHS Grampian to ensure that the necessary changes are put in place, and how will the public be informed of that progress?
I possibly partially answered Richard Baker's questions in my response to Nicol Stephen. I will not defend anything about the report. It is comprehensively bad from NHS Grampian's point of view, and the board requires to address that comprehensively.
As I said to Nicol Stephen, the improvement action plan is in place. In the health care environment inspectorate's opinion, some of the recommendations have been implemented already, which was reflected in the inspectorate's unannounced follow-up visit. We will continue to monitor the improvements that are made as a result of the action plan. The plan is published on the NHS Grampian website, and information on progress against it will also be published there. I assure Richard Baker that it will continue to be the subject of close discussion among me, my officials and NHS Grampian for some time to come.
I am afraid that I must draw that item of business to a conclusion. I apologise to the two doctors for being unable to call them, but we must now move to the next item of business.
Resumed debate.