Meeting of the Parliament

Meeting date: Tuesday, February 26, 2019

Official Report 924KB pdf

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National Health Service (Patient Safety)

The next item of business is a statement by Jeane Freeman on patient safety in the NHS in Scotland. The cabinet secretary will take questions at the end of her statement, so I encourage all members who wish to ask a question to press their request-to-speak buttons as soon as possible.

14:20  

The recent loss of life in which a healthcare associated infection was a contributory factor is a stark reminder of how vital infection prevention and control measures are. I am sure that I speak for everyone in the chamber when I offer my sincere sympathies and condolences to the families and friends who have lost loved ones.

I know from speaking with NHS staff that they, too, are profoundly affected by the loss of their patients. Every day, our front-line NHS staff work to prevent and control, as much as is possible, healthcare associated infections. They have my thanks—and the thanks, I am sure, of everyone in the chamber—for the vital role that they play and the responsibility that they take.

The step change in the approach to managing infections in Scotland stems from the Clostridium difficile outbreak in 2007-08 at the Vale of Leven hospital. At that time, C diff and MRSA were the biggest infection threats to patients. Identification of the outbreak did not happen quickly enough to stop the spread of infection, and many of the cases were only identified as being part of a major outbreak through retrospective analysis. The subsequent inquiry and efforts of the Scottish Government and the NHS led to the introduction of a national inspection and scrutiny programme of healthcare facilities, and the development of a national infection prevention and control manual, with clear and wide-ranging procedures for healthcare professionals to follow. We also set up the world-leading Scottish patient safety programme, which has contributed to significant and sustained improvement in a range of areas, including healthcare associated infection.

Those approaches have delivered real results. In people who are the most at risk—those who are over the age of 65—C diff infections have reduced by 85 per cent, from 6,325 cases in 2008 to 917 cases in 2017. However, although infection incidents on the scale of the Vale of Leven are now markedly rarer, it remains vital that we continue to learn from them and take whatever further steps are necessary to make sure that our NHS is as safe as possible.

Last year, there was a water contamination incident in the Royal hospital for children in Glasgow. The previous cabinet secretary asked Health Protection Scotland to examine the issues and I published its report, “Summary of Incident and Findings of the NHS Greater Glasgow and Clyde: Queen Elizabeth University Hospital/Royal Hospital for Children water contamination incident and recommendations for NHS Scotland” on Friday. The report makes a number of recommendations, and today I give members my commitment that the recommendations will be addressed.

The report will be passed to the independent review group for it to consider as part of its work to review the design, commissioning, construction, handover and maintenance of the Queen Elizabeth university hospital and how such matters contribute to effective infection prevention and control. My officials are in the concluding stage of appointing two co-chairs of the review. The potential co-chairs have asked for time to consider what would be required of them, in order to ensure that they can fulfil their responsibilities.

I fully appreciate that members will be keen to see the work begin as a matter of urgency—I am, too. However, I am also adamant that we take the time that we need to appoint the right clinical experts to lead this critically important work. The focus is on the Queen Elizabeth university hospital, but the lessons are for NHS Scotland. We need to ensure that our physical infrastructure is designed, built and maintained to maximise infection prevention and control. I expect to be able to advise Parliament shortly on the review’s co-chairs, and then its remit and membership, in line with Professor Britton’s recommendations.

Since the water contamination incident, NHS Greater Glasgow and Clyde has given notification of a number of other infection outbreaks. Such notifications happen as a result of the clear procedures that were agreed after the Vale of Leven tragedy and set out in the “National Infection Control and Prevention Manual”, which is evidence of a monitoring and control system that acts much earlier to identify and control infection and protect patient safety.

Some infections, such as the Staphylococcus aureus bloodstream infections at the Princess Royal maternity unit, are common in the general population but can impact acutely on patients who are very unwell and likely to have a lower immunity. Other infections, such as the Stenotrophomonas maltophilia infection at the Royal Alexandra hospital, are rare. However, no matter whether the infection is rare or not, it is crucial that staff identify it early, deal with it and prevent it from spreading. In all infection outbreaks, immediate additional measures are put in place to ensure that hygiene and infection prevention is absolutely as good as we need it to be.

Given the serious nature of these incidents, my officials have daily phone calls with Health Protection Scotland so that I can be updated, and the healthcare incident infection assessment tool—HIIAT—reports are delivered following multidisciplinary incident management team updates.

As members know, following the Cryptococcus infection at the Queen Elizabeth university hospital, I asked the healthcare environment inspectorate to undertake an unannounced inspection of the hospital. The report on that inspection will be published by Healthcare Improvement Scotland on 8 March. We will publish our response to it at that time, and it, too, will feed into the work of the expert review.

All those steps are important and it matters that, while the independent review undertakes its work, we make any immediate improvements that are necessary and identified by the reports. I want to make sure that the clinical voice is heard with regard to clinicians’ work environment, so that they can continue to deliver safe, effective and person-centred care to their patients.

The Health and Care (Staffing) (Scotland) Bill, which will reach stage 3 in the chamber in the coming months, follows Lord MacLean’s recommendation from the Vale of Leven inquiry that we should act to ensure that the staffing and skills mix is appropriate for each ward and that, where that is not the case, an escalation process is in place to respond. The bill provides an opportunity to enable a rigorous evidence-based approach to decision making on staffing, taking account of service users’ health needs, including in infection prevention and control.

It is important, too, that we recognise the role and voice of all our front-line staff in NHS Scotland. Porters, domestic and housekeeping staff, catering staff, receptionists and maintenance staff all have a critical role to play in effective patient safety. I will be giving further thought to how we can ensure that, across all our health boards, the voices and expertise of those staff members are integral to the work on infection prevention and control.

Scotland’s response to healthcare associated infections is wide ranging, and a number of expert agencies are involved. Health protection Scotland is responsible for undertaking surveillance and horizon scanning for emerging threats and seeking advice from United Kingdom and international organisations where required. When HPS is made aware of threats, it produces guidance for NHS Scotland to prevent on-going transmission of infections. The Healthcare environment inspectorate leads on independent inspections of every NHS acute and community hospital in Scotland. Since 2009, HEI has published 261 hospital inspections as well as thematic inspections of theatres and invasive devices.

The Scottish Government has underpinned those efforts by launching the mandatory national infection prevention and control manual in 2012, using a once-for-Scotland approach. The manual provides a framework for staff to apply effective infection prevention and control practice and it sets out the process that health boards must follow to manage incidents and outbreaks. We have led the world with the national infection prevention and control approach. It has been adopted by NHS Wales and there are calls for it to be adopted across the UK.

In the past decade, Scotland has made significant progress on infection prevention and control. Spurred by the tragedy of the loss of 34 lives in the Vale of Leven, where C diff was a contributory factor, NHS Scotland is now in a position to identify incidents and outbreaks much earlier and take immediate action.

Infections are present in everyday life. We cannot avoid all infections, but we must ensure that our systems include horizon scanning for emerging infection threats and ensuring preparedness and resilience. I assure Parliament and, through members, the public that a culture of improvement and safety is woven through our national health service and that I am committed to ensuring that our hospitals remain some of the safest healthcare facilities in the world.

I thank the cabinet secretary for advance sight of her statement. We pass on the thoughts of members on the Conservative benches to the families involved.

Public confidence has been shaken in the light of recent events in Glasgow. It is now critical that we see leadership and action to ensure that our hospital estate is safe and that all measures are put in place to meet the best infection control standards. I agree that the review will suggest lessons and recommendations for other hospitals—including the new Edinburgh sick kids hospital—on infection control measures and building standards that go above and beyond those that are currently in place.

How will ministers make sure that health boards take forward any and all recommendations, and will the cabinet secretary commit to the publication of any interim findings and recommendations?

I understand that public confidence has been shaken, which, in part, is why I made the statement. I wanted to remind us all of the significant improvements that have been made in infection prevention and control across Scotland, and the steps that have already been taken to ensure that we do not repeat what happened at the Vale of Leven hospital, so that we do not have any outbreak that is not identified until it has progressed quite considerably.

That said, I am not suggesting, by any stretch of the imagination, that therefore everything is fine. When there are infection outbreaks, that suggests to me that there is more that we need to do. I completely commit making public the interim recommendations—if there are any—and our response to them. We will also publish not only the HEI report but my response to it and the actions that I will take on Cryptococcus. I cannot give the details of the overarching review until we appoint the co-chairs, because it will be for them to determine how long they think that it might take. However, I hope that they will agree a remit, a timeframe and an approach that we can publish, within which we will be able to see where there might be milestones and where recommendations will come forward that we can act on. I will certainly share that information with the Health and Sport Committee, but I am also happy to share it more widely with members when we get to that point.

I thank the cabinet secretary for advance sight of her statement. The thoughts of Scottish Labour remain with the families of the patients who have died.

What has occurred is no reflection on the hardworking staff in the hospitals affected by these infections. However, it is clear that NHS Greater Glasgow and Clyde has suffered reputational damage. A culture of secrecy has clouded the health board’s communications and I think that we all agree that that has had an impact on public confidence. Staff and patients who raised concerns about cleanliness, infection control, building maintenance, workforce pressures and more felt that their concerns were not acted on, which is bitterly disappointing.

In the interests of transparency, will the cabinet secretary update Parliament on how many patients have been affected by the infections referred to in her statement or any other rare infections, how many patients have died, how many have received treatment, and how many cases relating to hospital-acquired infections have been referred to the procurator fiscal in the past 12 months?

In order to be absolutely certain that I provide Monica Lennon with the accurate detail, if she and other members are content, I will write to her later today with the answers to all those specific questions, including the PF question—as far as we know that information. I will make sure that that detail is shared with the other party spokespersons on health, so that they have that information too.

Ms Lennon knows that, in previous statements in the Parliament, I have recognised that our health board communications across NHS Scotland are at times not as good as I want them to be. I take the view that if we have information we should give it to people and that there is nothing worse than a vacuum that people fill with their understandable worries and anxieties. That is not an approach that I want our health boards to adopt.

We are working with our health boards to ensure that communications are as transparent and detailed as they can make them, bearing in mind that they have an absolute duty under their Caldicott guardian and other responsibilities not to release any information that could lead to the identification of individual patients. That duty curtails the boards to some extent, but it might not always curtail them to the extent to which they believe themselves to be curtailed.

I am also aware of concerns that have been raised in the past in NHS Greater Glasgow and Clyde. I now have information on some of those concerns, which I will ensure is passed on to the independent review. I know that the individuals who have raised such matters with me will make sure of that, too. I have given a commitment that I will make sure that that information is passed on so that the review has the benefit of historical information as well as the evidence that it may choose to take.

In her statement, the cabinet secretary recognised that all NHS staff, from clinicians to those who are involved in catering and maintenance, have a critical role to play in effective patient safety. I appreciate that she said that she will give thought to how we can make sure that all those voices are heard, but given the pressure on staff who work in the NHS, what assurances can she provide that staff will be given sufficient time for the expert training and mentoring that they need, so that we can ensure patient safety?

That issue will be dealt with partly through the Health and Care (Staffing) (Scotland) Bill, which is working its way through the Parliament. We are very keen to ensure that that bill is also applicable in our social care settings, where safety and infection prevention and control are as important as they are in our acute settings.

I want to make sure that, as part of the standard work that a board should undertake on infection prevention and control, which includes all the processes that I outlined, we are assured that important voices such as those of maintenance, housekeeping and catering staff are integral to the overall approach that a board takes in a hospital setting and elsewhere to infection prevention and control. Rather than being seen as additional, their involvement should be considered to be as central as the involvement of nursing and medical staff. That is a case of making sure that the individuals who would be part of those discussions have the time to bring to bear the expertise that they bring from the roles that they play. When additional training or support is needed, I will expect boards to make that available.

As Ms Johnstone knows, I regularly meet the chairs of our health boards to seek their assurance on the areas that I consider to be of the utmost importance, and there can be nothing of higher importance than patient safety. In addition, the chief executive of NHS Scotland regularly meets the board chief executives. All those discussions are aligned with the Government’s key priorities. We regularly have the opportunity to get such assurances and to act when we believe that what needs to be done is not being done.

The investigation into the water contamination incident at the Royal hospital for children in Glasgow was instructed by the cabinet secretary’s predecessor on 20 March last year in response to a question from Anas Sarwar. The report on the investigation was concluded and given to the Government in December, but the Government released it only this weekend. What was the reason for the delay? Why did the investigation take so long? Why did the Government choose not to release that information to the Parliament and the general public until two months after it received it? If there are learning points for all of us and we are to work together to combat and control infection, surely time is of the essence.

I am grateful to Mr Cole-Hamilton for that question. If he has read the report, I am sure that he will understand that it took time for HPS to identify the exact source of the water contamination and to take the necessary steps to address that in what was an ever-changing situation in the hospital. HPS had to do that before it could produce conclusions and recommendations that it was confident about and could be assured that it had looked widely for expert advice and support on to allow it to get to that point.

There were two parts to my decision to publish the report last week although I had been made aware of it on 21 December. I took the view that publishing the report in the week before Christmas was not necessarily the most helpful thing to do and would be considered in a critical light. I then took the view that I had to be sure that HPS could see how the report fitted into the work of the wider independent review. There was no intention not to publish it; it was about making sure that the report could be aligned with the independent review. I am sure that members understand that I had hoped to be able to say today who would lead the expert independent review into Queen Elizabeth university hospital. However, for the reasons that I outlined, I am not able to do that.

All those reasons contributed to the reasons why we took longer than we would otherwise have wanted to take to publish the report. There was no intention to conceal anything, as is evidenced by the fact that we have published the report and the fact that I have committed to implement its recommendations, notwithstanding the independent review. It is important that the information is available, understood and acted on.

I am conscious that the minister is giving detailed answers. I welcome that, but we have 10 more questions to get through.

Will the cabinet secretary confirm how the Scottish Government’s approach to safe staffing will ensure patient safety as well as the delivery of high-quality, safe care across our hospitals and emergency services?

The legislation on safe staffing is designed to ensure that there is a consistent approach across Scotland to understanding the workload demands of meeting the healthcare needs of any patient cohort at any time and the skills mix that is required to address those demands. Inside that is infection prevention and control, which, as Ms Harper knows from her own experience, varies between different patient cohorts depending on the presenting healthcare need.

Notwithstanding the fact that colleagues will have identified ways in which the legislation could be improved, we all agree that it will provide consistency of assurance and methodology, so that workload is understood in the context of the presenting healthcare needs of patients and the skills mix is understood so that we have the right staff in the right place and a way of escalating if staff feel that they require additional support that is not being delivered to them.

Health Improvement Scotland has no regulatory powers to enforce the implementation of recommendations. For the confidence of staff and patients, and given the seriousness of the situation, will the cabinet secretary commit the Scottish Government to implementing all the HIS recommendations when it publishes the HIS report?

Yes, I will. The question of regulatory powers and the various bodies involved—health facilities Scotland, HPS and HEI—will be part of the review. As I said, the focus is on the Queen Elizabeth university hospital, but the lessons are for NHS Scotland on what more we might do to ensure that there is a more joined-up approach to what needs to happen. It will be for the review to determine whether more regulatory powers are needed. If they are, the review will produce recommendations.

The cabinet secretary mentioned the Scottish patient safety programme, which is helping to reduce hospital mortality and reduce avoidable harm at every stage of care. Will the cabinet secretary provide an update on hospital standardised mortality ratio figures for Scotland?

The hospital standardised mortality ratio has shown a significant decline, decreasing by 13.2 per cent in the four years from January to March 2014 to July to September 2018. That is all helped by the Scottish patient safety programme, which is one of the key drivers of that reduction. We need to continue the improvement in the ratio, which has been in a steady decline since the introduction of the measures that I outlined.

What lessons have been learned about patient safety with regard to new-build hospitals, specifically concerning the handover and maintenance of buildings?

Some lessons are immediate—some, in the HPS report that was published last week, have already been picked up by NHS Lothian for the new children’s hospital for Lothian—and others are being worked through by our directors of estates with the chief executive of NHS Scotland, together with health protection Scotland and health facilities Scotland, to see what more can be drawn at this point from the HPS report and whether there is anything further to draw from the HEI report. That is what I meant when I said that, although the independent review is very important and its work will be of significance, there are recommendations that we can take forward at this point. Once the HEI report has been published, I will be happy to set out those recommendations that are specifically for buildings, so that members can see what we are doing to act on them.

The Scottish patient safety programme has contributed to a significant reduction in harm and mortality in our NHS. Will the cabinet secretary outline how that internationally renowned programme can continue to provide public assurance about the quality and safety of care that the public expects?

Healthcare Improvement Scotland is the primary driver of the Scottish patient safety programme. It provides assurance with regard to its inspections and reviews, which are reported and published, and can be used and seen by others. Some of the data that we produce about overall general infection rates are also reassuring about the continuing decline of Clostridium difficile, MRSA and so on. Members can see, for their individual health boards, other work that we discuss with Health Improvement Scotland, including on surgical site infections and other aspects of the Scottish patient safety programme, but there might be merit in pulling that together for the health service across Scotland. Again, I will be happy to look at whether that is worth doing.

As the cabinet secretary has pointed out, front-line staff have a critical role to play in patient safety. Despite that, figures show that there was an 11.5 per cent cut in maintenance and estate workers across Scotland in the two years to September 2018. In NHS Greater Glasgow and Clyde, the numbers have reduced by nearly 19 per cent since 2009. What action will be taken to address that drastic reduction?

Ms Wells is correct about the level of vacancies that are being carried in maintenance and, in some instances, in domestic staff. I am very alert to that and have already asked for explanations from boards about what exactly they are doing.

Annie Wells will know that boards are required, in addition, to produce an annual operating plan that shows how they will use their resource. This year, that will be within an overall three-year financial planning cycle, but there will be more detail in the first year. We have been really clear about how we will sign off that annual operating plan, and I will be looking to ensure that capacity—by which I mean staffing—is not being reduced in areas that are critical to infection prevention and control, in which I include all the areas that I have mentioned. Once the plans signed off, they will be published, so the member will be able to see what specific action we are taking.

I am sure that, across the chamber, we agree that all staff are essential to ensuring patient safety. What impact could a no-deal Brexit have on NHS staffing levels and patient safety?

Ruth Maguire will know that our current estimate is that just under 6 per cent of the current health and social care workforce are non-United Kingdom European Union nationals, and that we have a significant number of non-UK EU nationals in our health service. The figures are greater than that in some parts of the country and in some job roles. Our planning for our workforce needs in areas that Ms Wells identified and other areas has to take account of the fact that we might not, in the current climate of uncertainty, be able to retain all of that workforce.

There are practical steps that we can take, which we hope to be able to set out soon for members in order that we can make good on our words, the intentions of which are genuine. We value all those staff very much and we want them to stay.

An additional issue is how we can attract into our health service people from EU countries from which people have traditionally come here to work. Ruth Maguire will be aware of the 80 per cent reduction this year from last year in the number of nurses from the European Union coming to work in the UK: non-UK EU nationals are not registering.

There are serious issues relating to Brexit, and serious uncertainty and anxiety are being experienced by people who work in our health and social care services. We are doing what we can to reassure them that they continue to be welcomed and valued in our service.

Last week, the cabinet secretary responded to a question from my colleague Neil Bibby on infection control at the Royal Alexandra hospital in Paisley. She said that she shared his concerns about gaps in the domestic cleaning rotas. In light of that case and other tragic cases in NHS Greater Glasgow and Clyde, does the cabinet secretary have any plans to review and update the “National Infection Prevention and Control Manual”, which was published in 2012? If so, when?

That matter will be part of what the independent review will consider. The review will consider our existing measures, including that mandatory manual. In addition, I have asked our national clinical director and HIS to review our current measures to see whether we can make other improvements to particular steps, in the light of current knowledge.

I do not yet know the answer to the question. I am mindful of the point that Mary Fee has made about domestic staff, which Mr Bibby has made and which Ms Wells made again. I do not think that I need anything to be reviewed before I can act to make it clear to boards that I do not think that it is acceptable to carry such levels of vacancies in maintenance, domestic and housekeeping staff. Those staff are central—as central as any other bit of the workforce—to infection prevention and control. We can act on that now, while we consider whether our current procedures require updating and review as a consequence of our recent experience.

Can the cabinet secretary confirm whether measures are in place to ensure that health boards promptly and effectively implement recommendations that are made by independent reviews?

When a review is undertaken by Healthcare Improvement Scotland, it has in place a process for going back and checking that its recommendations and associated actions are completed. HIS also takes a view on whether actions that a board suggests it should take are adequate to meet the recommendations that HIS has made.

If a review is external and the recommendations are to the Scottish Government, obviously members have a means by which they can check the Government’s responses to those recommendations and how we are taking them forward. In addition, we have, as I said earlier, regular meetings with board chief executives, directors of estates, directors of human resources and directors of finance. I also meet chairs of health boards in order to pursue specific recommendations board by board or across the whole health service.

I welcome the cabinet secretary’s comments. However, clinicians and patients have expressed concerns about NHS Greater Glasgow and Clyde’s statement that was issued on Friday, in which it seemed to imply that the cabinet secretary’s independent review had limited scope and in which it announced three reviews of its own.

Will the cabinet secretary please confirm that the review that she announced has a broad scope that will include the Queen Elizabeth university hospital’s maintenance and upkeep since it opened? Will she outline what the three reviews that NHS Greater Glasgow and Clyde proposes to undertake will cover? Will she guarantee that they will not undercut the work of her independent review?

I am grateful to Mr Sarwar for raising the issue. It is disappointing that the board does not appear to have understood what I have—exceptionally clearly—said. I repeat and absolutely confirm that the scope of the independent review that I have commissioned is exactly as was described in the answer to a written question that was lodged. The review will go back to the design and take us right through.

To comply with the Britton report’s recommendations, it will be for the review’s independent chairs to work the scope that I have commissioned into a remit, and to decide where they will bring in expert advice, whom they will seek evidence from, how they will seek evidence, how long that will take and whether—on the basis of their work plan—there is an opportunity to make interim recommendations. I will ask the chairs to give permission for all that to be made public. I have no doubt that they will be happy to do that. I take that responsibility.

My understanding—I will make a point of double checking, so that I can confirm it to Mr Sarwar and others who are interested—is that one of NHS Greater Glasgow and Clyde’s immediate reviews is of whether it should take additional maintenance and infection prevention and control measures now, at its estate at the Queen Elizabeth university hospital. Another review is about ensuring that infection prevention and control steps are being taken in the right places as people flow through the hospital. As I said, I will ensure that we have the clear detail on that, which I will pass to Mr Sarwar and Opposition spokespeople so that they are clear on the subject.

NHS Greater Glasgow and Clyde’s reviews absolutely should not undercut the independent review: they should feed into it. The independent review can take a view on the board’s reviews and their conclusions.