Ms S Ramsey:

If there are three cases of what?

Mr Compton:

If there are three cases in any one area in the South Eastern Health and Social Care Trust, we carry out a deep environmental clean. I am sure that the same thing happens elsewhere.

Ms S Ramsey:

Does that apply to any hospital-acquired infection?

Mr Compton:

I am sure that the same thing happens elsewhere, because we all operate to the same environmental cleanliness standards, and we have to make returns on environmental cleanliness. Recently inspections were carried out in all hospitals, and they were only given 24 hours’ notice. Therefore, if there were any problems, they could not be fixed within that time, especially given the size of the hospitals. The results of those inspections were very good — we have been told that verbally. However, the raw data will be published in due course. It will take a little time for the inspection teams to publish their findings, but that is the initial feedback to all the organisations. Obviously, there is no point in waiting for the publication of the findings to discover that there is a problem.

Today, we want to try and give confidence to people, because that is the issue. We want people to know that we are serious about tackling the problem and are not being complacent about it. We are doing everything we can to control difficult situations when they arise. However, we also want to ensure that people understand that it is comparatively safe to attend hospitals. No one can say that going into hospital is a risk-free experience, because, as my colleague indicated, some treatments carry inevitable risks. However, we encourage people who have appointments to attend hospital. They can ask questions and seek reassurance when they arrive at the hospital, rather than not attending at all. We really want to get that message across to the wider public today.

Mr McKee:

You rightly linked clostridium difficile, MRSA, and other bugs that can be acquired in hospital, because there is a long tail of rare but nasty bugs that are not as well known. All the evidence shows that if hospital-associated infections are tackled as vigorously as we are tackling them, there will be an improvement across the spectrum. Although I do not have the figures in front of me, I have been assured that there has also been an improvement in MRSA rates. We have a separate target to meet for MRSA rates.

Ms S Ramsey:

How many incidents, or deaths, take place before the Department or the Chief Medical Officer is informed?

Mr McKee:

There are reporting and surveillance mechanisms whereby we report to agencies that act on behalf of the Chief Medical Officer. The great thing about Northern Ireland is that we can also lift the telephone and talk to each other. I emphasise that we do not wait until we see the information on a death certificate before we take action. We are at the front end, trying to prevent infections. When infections are detected, we take prompt action.

We have gotten into trouble in the past through trying to reassure people by using unapproved death certification data before the relevant agencies have carried out their checks. We have up-to-date figures for January and February 2008 of the small number of incidences and deaths, but the figures have not been audited. We are happy to submit those figures separately. The numbers are so small that people may be able to identify themselves, particularly if we go into detail.

As Ms Evans said, people who acquire such infections are elderly, they have the bug in their gut already — but there are usually no symptoms with that — and they will have taken antibiotics and had their immune system compromised because of some other medication or illness. A small proportion of people get clostridium difficile, and an even smaller proportion of people die as a result. I cannot emphasise enough that our performance is not just OK — it is good compared to elsewhere. We are not complacent, and every avoidable death is to be regretted and requires a redoubling of effort.

The Chairperson:

There is great concern about whether clostridium difficile and MRSA have been recorded as contributory factors in the deaths of many elderly people in hospitals. There is a whole constituency that wonders whether there MRSA and clostridium difficile were contributory factors in the death of their mother, father or elderly frail grandparent. When the news emerged about the outbreak of all those superbugs, many in the community wondered whether those might have been a factor in their relatives’ deaths. I am not suggesting that hospitals were trying to hide outbreaks, but there are questions over how often deaths occurred before all the public interest in the matter. In other words, how often were those superbugs a contributory factor in people’s deaths but not recorded as such?

Mr McKee:

Because I have lost a loved one, I know that the relative is given a hard copy of the death certificate, which lists the primary cause of death and the associated causes of death. Thus, every family who has tragically lost a loved one will receive that certificate.

We provide training to all our doctors, particularly those involved in training, and I am sure that the Chief Medical Officer can detail the training that he advises us to provide. No doubt further guidance will be issued. The different Departments and agencies involved, including the Department of Health, Social Services and Public Safety and the Department of Finance and Personnel, have worked to improve death certification and the reporting of deaths. However, we have been doing our best.

If there are concerns, then those should be raised. If a person says that a doctor told them that their relative had a certain condition, but that condition is not listed on the death certificate, then the person should query that. We are as open as possible in that regard. The criticism has been made that we have been using information that has not been audited properly. Discussions with the relevant agencies have taken place on our behalf to see if more prompt, audited, information can be fed back to us as part of an effort to restore public confidence. However, I emphasise that we do not wait for deaths to occur before taking action. We act on risk factors and actual symptoms, and we are resolute in that.

The Chairperson:

There is a comparison to be drawn between this issue and the row over organ retention. As you know, Mr McKee, I was very involved in that matter at the time, and it caused people to lose a lot of confidence in hospitals. Indeed, the whole donor system was almost knocked out of kilter because there was no openness about organ retention, and so on. There are questions over the handling of that issue, too.

It used to be a fact of life that a doctor was like a god. People did not dare approach doctors or ask them questions — if they did, they would be given short shrift. I want to be encouraged that doctors no longer take that stance and that if families want to ask questions about what is wrong with their loved ones, or about complications, they will get the answers that they seek. Those loved ones are dearly held within the family unit, and if we put ourselves in their position, we would want to know everything that there is to know about how they died, and about any contributory factors. I hope that the clinicians who, for many years, were like little gods in their ivory towers do not feel that that they are still there now. Rather, I hope that they are open and transparent in their approach. We must encourage people to have faith that they will be told all the facts as and when they ask for them.

Mr McKee:

We can never say "never". Best practice shows that the doctor who has had most to do with the care of a particular patient should have a conversation with the family at every stage of treatment, whether it is because they suspect that the patient has a clostridium difficle infection, or is coming close to the end of life, or to talk about the underlying causes of a patient’s death. We try to encourage that. That is what happens. We inform families that they should expect that to happen.

The Chairperson:

So that is the standard? OK.

Ms Evans:

I would like to comment because, probably, the Northern Health and Social Care Trust was the trust about which the most questions were raised. Two sources of information are available. One source is the information that we take from the infection control teams, which we have already talked about. That is real-time information that we receive on a daily basis. We published our figures yesterday. Therefore, I know that yesterday we had 15 active cases of clostridium difficile and 13 patients who were recovering from that infection. We know that we had four deaths that were associated with clostridium difficile in the preceding week. We gather real-time information because we are in an outbreak situation.

A difficulty arose because we used infection-control information, in good faith, and reported 13 deaths that — we believed — we had had in the final two quarters of 2007. We analysed the preliminary figures that came from the Registrar-General’s Office that showed that there were 31 deaths in the Northern Health and Social Care Trust for the whole of the year, 20 of which occurred in the final two quarters. Therefore, there was a difference of seven deaths between those figures and the ones that we had declared, which again I emphasise, were taken in good faith from our infection-control team who were monitoring patients on a daily basis.

We have now got the names of all of the patients that the Registrar General’s Office identified as having died in hospitals in the Northern Health and Social Care Trust area. We are reviewing all of the files and cross-referencing them with those of the patients we declared through infection-control. It is a complex process. For example, after a person has recovered from clostridium difficile, for how long does one consider them to have recovered before one records on their death certificate that they had clostridium difficile? Should it be two weeks, a month, or a year? Those are the kinds of difficult decisions that clinicians have to consider when completing death certificates. We will know the answer when we complete the review of files.

Infection-control staff in my trust suggested that they had stopped tracking some patients because they no longer had the infection. If those patients died subsequently, the clinician may have said that although they had already recovered from the infection prior to their death, the infection had had a significant effect on their deterioration at some point during their illness. Therefore, clostridium difficile would be recorded on the death certificate even though we have stopped tracking them through our infection-control figures.

I do not know if that explanation helps the Committee to understand the discrepancy in the figures. I can assure you that, as far as the Northern Health and Social Care Trust is concerned, staff have been completely open and honest. We have provided accurate figures to the best of our ability. Unfortunately, that stance has rebounded on us because those figures were not validated, but we have tried to be open. We told people that we had an outbreak and we have provided the press with information on a weekly basis, as they have requested. I do not know whether my explanation is useful to Ms Ramsey.

Ms S Ramsey:

It is quite useful. It has been said that 30% of older people have that type of bug. Earlier, it was said that when people presented at accident and emergency with vomiting and diarrhoea, they were not put into a general ward. Surely it is common sense that if 30% of older people have the bug they should be screened for it?

Ms Evans:

One cannot screen for clostridium difficile. If someone presents with diarrhoea then a specimen can be tested and one can identify the infection. In the middle of the Northern Health and Social Care Trust’s clostridium difficile outbreak in December, we also had a norovirus outbreak. Therefore, a number of people had diarrhoea although it had nothing to do with clostridium difficile. It is important that one undertakes a microbiological examination of a specimen to be sure which bug one is dealing with, what ribotype it is, and whether it is clostridium difficile. Not all of the patients in the Northern Trust area have had ribotype 027. However, the largest proportion of them have.

Ms S Ramsey:

How do you explain the clusters? There have been no major outbreaks in other trust areas.

Mr McKee:

Frankly, the Northern Trust was simply unlucky. There is an element of chance.

Ms S Ramsey:

Part of the Committee’s job is to uncover that information.

Mr McKee:

Central to the issue is the fact that 30% of older people have clostridium difficile in their gut. All other matters being equal, they will not be aware of it and will not have symptoms. Three out of any 100 people who come through this room will have the bacterium and not be aware of it. It is difficult to obtain a specimen and to grow it in a lab. With the best will in the world, it takes several days to identify.

Trusts can, however, identify whether patients are at risk. For example, patients are transferred from regional hospitals to hospitals in central Belfast because of their acute condition. On balance, it is best to admit the patients, because they need particular clinical treatment. However, a risk analysis is carried out to determine whether the patient has come from a hospital where there have been cases or a cluster of clostridium difficile; has had diarrhoea recently; is on antibiotics; or has a compromised immune system. Then we take action based on that, just as infection control teams who work with front-line ward staff monitor diarrhoea and other symptoms and take action in advance of the result of the analysis. Because it is so difficult to grow the bug, the result simply states whether a particular toxin has been found that suggests that the bug is present. The point is that people who carry the bug do not know who they are.

Mr Easton:

I shall try to be as brief as possible. I have six questions, but yes or no answers may suffice. Do any of the trusts deal with clostridium difficile in the community, rather than just in hospital settings? Does any antibiotic work against the bug? Can trusts reassure the Committee that all patients who are infected with clostridium difficile are isolated?

It is positive that staff in Northern Trust hospitals, where there has been an outbreak of clostridium difficile, seek to ensure that infected patients are isolated and that their visitors are asked to wash their hands. However, should it not be the case that all trusts provide wash-hand basins outside every ward, with visiting restricted to once a day, and somebody standing at the door to ensure that visitors wash their hands? That may seem draconian, but I think that it would help a lot.

The Minister has suggested new staff uniforms. Have his proposals been implemented?

Mr McKee:

We all know of specific instances when a patient has had to be admitted to hospital from a community setting with symptoms of clostridium difficile infection. Because such a high proportion of older people have the infection, it is present in the community. The preconditions for catching the infection — having a compromised immune system, being on antibiotics — happen outside hospitals. If I were to sum up on the issue, I would say that this issue goes beyond hospital trusts.

I am not a qualified pharmacist or clinician. Therefore, I would need to take advice on how the infection is treated. As far as I know, one treats the symptoms. Ms Evans probably has more knowledge, because of her recent experience in the Northern Trust.

Ms Evans:

My understanding of the advice that is given is that certain antibiotics must be avoided. There is always a risk from the use of broad-spectrum antibiotics. Dr McBride, who is a clinician, will be speaking after us. My understanding is that there is always concern about the use of antibiotics to treat people who are immunocompromised.

Dr Peter Flanagan (Northern Health and Social Care Trust):

Two antibiotics — metronidazole and vancomycin — are specifically used to treat active clostridium difficile infections, and part of the approach is to ensure that such patients receive treatment as promptly as possible. It is slightly confusing because, on the one hand, we are saying that certain antibiotics can cause clostridium difficile and, on the other, specific antibiotics can be used to treat it.

Mr McKee:

Each trust is rolling out new, tougher visiting arrangements. Although we always seek to strike a balance between making our hospitals open and welcoming to relatives and loved ones and protecting the safety of those loved ones and others, nevertheless, we are all rolling out those new, stricter hospital-visiting arrangements.

The provision of wash-hand basins depends on how modern the particular hospitals that we have inherited are; some are well equipped and others are not. However, we make the best of what we have. Hand-sanitising solutions are universally available, either at the bottom of every bed or at the entrance to every bay or ward.

Mr Easton:

Do you believe that visitors should be made to wash their hands?

Ms Evans:

In the case of clostridium difficile, it is important that one washes one’s hands, because alcohol gel does not work. However, for other infections, we recommend that people use the alcohol gel that is provided and which is effective.

Mr McKee:

In addition, depending on the availability of single rooms and other methods to barrier-nurse, cohort or isolate patients, we take further actions to deal with clostridium difficile.

Uniforms are problematic. Huge investment would be required to provide facilities for all front-line staff to change from their uniforms into going-home clothes or from standard nurse’s uniforms into theatre scrubs. Much work has been undertaken by the Department to devise proposals; however, the cost would be great.

Once again, we must strike a balance. The Minister has made £9 million available in order to tackle hospital infections, and each trust wishes, for example, to beef up its cleaning-intervention teams in order to intensively clean particular at-risk areas. In addition, each trust would like to employ antibiotic-prescribing pharmacists to work alongside medical and nursing staff in order to improve their knowledge of, as Dr Flanagan said, whether or not to prescribe medicines depending on whether one is trying to avoid or control an infection. It is complicated, and therefore we will probably use the £9 million in various areas. The cost of dealing with the wider issue of nurses’ uniforms would be much bigger.

The Chairperson:

Obviously, there would be costs, and many hospitals would not have the space to isolate, or be suitable to provide, changing rooms. However, we must investigate that. Recently, I was in hospital, and I was amazed to find that one did not know who the doctors were unless they had stethoscopes around their necks. They dressed in their daywear and did not have coats. Considering that doctors are supposedly identified by their dress — in a white coat or whatever — I was amazed that they came in wearing their ordinary gear.

Mr McKee:

I agree with you. However, if I may say so, we are showing how old-fashioned we are. Regardless of what people wear, we expect each member of the clinical staff to clearly introduce and identify themselves when they meet a patient, and not rely on having a stethoscope around their neck. Often, white coats are considered to be more trouble than they are worth and can be a device for carrying infections. We encourage doctors to wear short-sleeved shirts and not to have long ties, such as the one that I am wearing. Now, it is difficult to persuade younger doctors to wear bow ties.

The Chairperson:

Those were the good old days.

Mr McKee:

In society, dress has generally become more informal. However, the current best-practice guidelines are to have short-sleeved shirts and not to have long ties.

Mrs Way:

I would like to pick up on the issue of isolation of patients by the trusts. We audited 48 patients who had acquired clostridium difficile since last August, and found that in four of those cases we had been unable to provide a single room. In those cases, we apply extra preventative measures and ways of looking after those patients as we try to get each of them into a single room.

My colleagues envy me because of the capital announcements. The west is doing very well in that we have two new-build hospitals, one in Enniskillen and one in Omagh. The Minister has said that those hospitals will comprise 100% single rooms. We would all agree that that is the way to go in preventing and controlling infection.

Mr Buchanan:

Many issues have been covered today. We have heard about the measurements that have been carried out against UK and international standards. There is no getting away from the fact that it is good to benchmark against something. However, we must be realistic today. The recent outbreak of clostridium difficile has caused a huge loss of public confidence and a mistrust of the Health Service, to the extent that elderly people are cancelling appointments. To stop that from happening, we must deal with that lack of confidence.

The infection prevention and control measures that have been taken have been described as "robust". Have those measures been applied in all trusts? That is important. We talk about hand-washing, in and out of the hospital, but the cleanliness of the hospitals and the wards is also a big issue. How often are wards cleaned? Constituents have told me that they have been in hospital for two or three days and not seen anyone cleaning the ward. That raises concerns for me, and I wonder how often wards are cleaned.

We have also talked about the importance of clean beds. I have been told by some folk that beds are now cleaned just with soap and water. I am not sure whether that is correct, but that is the message that I am getting from folk who have been in hospital or who work in hospitals.

Mrs Way talked about the high-occupancy beds in Altnagelvin Hospital. I am concerned about that, and about why it is happening. I could go into why that is happening in the west, but I am going to spare the Committee this afternoon. We know why that has happened in the west, but I want to know what the Western Health and Social Care Trust is doing to address that problem.

The private clinics are not affected by this infection at all. Why is that? Is there a message there? Is there something that we should be looking at? How can the infection be acquired in one area, while other areas are unaffected?

The issue of front-line nurses talking to their line managers was raised, and whether they could discuss concerns, difficulties, or things that could be changed. I welcome that, but many front-line nurses are afraid to speak out when they discover a problem or a difficulty because they are afraid of being reprimanded. I would like to see a situation brought about in which nurses have the confidence to speak out if they see something wrong or something that could be improved.

There were 77 deaths as a result of clostridium difficile infection in 2007. Did all those people go into hospital with the infection, or did some of them pick it up while in hospital? That breakdown may or may not be available, but I would like to know whether some people went into hospital without this infection and picked it up while they were there.

Mrs Way:

I suspect that some of those issues are specific to the Western Health and Social Care Trust. I would like to have the information relating to the patients who have said that they have been in our hospitals for days and that the wards have not been cleaned. It is my belief that every ward is cleaned daily. If people have different information, I will need to examine that.

Mr Buchanan:

I will pass that information to you.

Mrs Way:

Thank you. With regard to the high occupancy levels in Altnagelvin Hospital, we are working with Tribal, which is a consultancy that has done some work in England, to examine reducing the length of stay for medical admissions. That will require us to redesign things, to care for people differently and to move towards some out-of-hospital care. I am happy to meet you again and talk through that project.

My own belief about private clinics is that they deal with client work. They do not deal with the emergency admissions, such as cases of pneumonia, which come through the NHS doors. Therefore, we often deal with the most vulnerable patients. I cannot comment on the 77 deaths, because I do not have that information.

Mr McKee:

It is unfair to compare the work of health and social care trusts with smaller private hospitals, for a variety of reasons. We are subject to more public scrutiny than the private sector; therefore, the fairer comparison is with other public-sector health systems, or even privately-funded health systems, as opposed to small private hospitals. It would be better to compare us with England, Wales, Scotland, Ireland, or with the international comparisons that we have available.

With regard to those people whose underlying or associated cause of death was clostridium difficile, the difficulty is that 30% of older people have the bug in their gut without displaying any symptoms, so we do not know whether they have brought the bug into the hospital and well-intentioned actions around prescribing antibiotics allowed it to overgrow in the gut and contributed to their deaths, or whether the infection was transferred from one patient to another, or from one patient to another through a member of staff. We would not know whether they brought the bug into the hospital unless we went through a detailed analysis, because it is a hidden feature that three out of 10 older people have the bug without displaying any symptoms. We can identify some cases where we are pretty sure that the bug was caught in hospitals, but it is a small number, because 30% of people already have the bug.

Mr Compton:

The issue of confidence is central to this matter. The fact that we are here at the Committee is contributing to that confidence, because the purpose for us is to reassure people that no one is taking the matter lightly. We understand the issues around confidence. I hope that the willingness and openness that we are demonstrating today to provide whatever information we can is a sign that we believe that the issue of confidence is important, and we want to contribute to the restoration of that confidence.

We all follow standard cleanliness schedules across the Province. All of those schedules are audited. We relate in detail to our colleagues in the Department what we are doing on the cleanliness schedules, and a similar pattern of cleaning takes place in all our hospitals. It will vary slightly because of the age of buildings — newer buildings will have different patterns to older ones.

The Chairperson:

In the same way that you go to job interviews, we must go to the electorate. We get it in the neck if things do not run smoothly. With a newly devolved Administration, people want to see accountability and openness more than ever. It is very important to send out a message that there is openness and co-operation between elected representatives, who have been ignored in the past when trying to represent the rights of our constituents, and the public sector. Today can be a learning curve for all of us — we do not complain for the sake of it; we are trying to represent human beings who have a difficulty or a concern.

Mr Compton:

I was making the point that we are keen to hear those concerns.

The Chairperson:

With the new dispensation, it is good to have a rapport that helps politicians and the trusts know what the public think on various health issues.

Rev Dr Robert Coulter:

William, you have scared the life out of me.

Mr McKee:

I am nearly in the age bracket as well.

Rev Dr Coulter:

I am one of those older people you described, and I have just taken a double course of antibiotics. I will have to ask Dr Deeny here for a prescription.

I pay tribute to the Northern Trust for the way that it has responded to an extremely difficult situation. We congratulate Ms Evans and her team on the way that they handled the situation.

A number of my concerns have been addressed. Alex talked about staff hygiene, and we have heard nurses and medical personnel say that sometimes they have to change their uniforms in toilet cubicles. That is not good enough in this modern age. It will cost a lot of money to provide sanitised areas for staff to change their clothes because two, at the very least, would be needed in each hospital. One of the main concerns should be that staff areas are as sanitised as the ward areas. Is that too much to ask? The problem of staff wearing their uniforms to and from work is being addressed.

Another issue that has emerged from some of the media programmes is the amount of unchecked goods going into hospitals. I heard a delivery man say that he often walks into hospitals, delivers parcels to various wards and walks out without being checked. Would it not be better to have one centre that checks all incoming goods?

Alex also mentioned community health; I know the emphasis that the Northern Trust places on keeping older people in the community and the great work that it does in that regard. However, what happens when an older person is suddenly taken with diarrhoea? Are they expected to sit for 12 hours in an accident and emergency department? Having had diarrhoea, I would not like to sit for 12 hours in accident and emergency before receiving any treatment, or even attention.

What is happening in the outpatient areas? How clean are the vehicles that transfer people, including older people who have a 30% chance of having clostridium difficile, from their homes to hospital? There are many other issues, but that is enough for now.

Ms Evans:

I appreciate your comments in recognising the efforts that the staff and the trust have put in to trying to manage the outbreak. I did not refer earlier to staff, as my colleagues did. However, I must say that the staff in the Northern Trust — everyone from the trust board down to those at the front door of the hospitals — have been absolutely superb in their determination to address the situation. They are committed to ensuring that we get on top of the outbreak and that we manage and overcome it.

Mr McKee has said already that the issue of staff changing facilities is quite difficult, particularly in some of the older hospitals. We have good changing facilities — or better changing facilities — in the newer hospitals such as Antrim Area Hospital and the Causeway Hospital, whereas the facilities in some of the older hospitals, such as the Mid Ulster Hospital and Whiteabbey Hospital, are not as good. We have a very strict rule that staff should not wear their uniforms in public. If they do not have access to changing facilities before they go home, or when they are coming in to work, they should wear a coat over their uniform to cover it.

The majority of the patients in the current outbreak are in the Antrim Area Hospital and in an isolation ward, where all of the nursing staff change their uniforms every day. They have changing facilities and they have a clean uniform every day, and when they are going home they change into their day clothes.

With reference to the issue of people coming in from the community, as colleagues have already said, it is clear that clostridium difficile is in the community. In some cases, we are admitting patients with a confirmed diagnosis of clostridium difficile before they come to the hospital. It would be impossible for someone with diarrhoea to remain in an outpatients’ department for 12 hours without having facilities. I appreciate that it is an undignified situation. To the best of my knowledge, all of our accident and emergency departments have toilet facilities. Given that a lot of those people are older, many will use a commode or portable facility, which will be cleaned after each use.

In Antrim Area Hospital we have identified a separate area for the treatment of people who present with diarrhoea, because of the current problem. We try very hard to respect the dignity of people in that situation and respond to them appropriately. We will fast-track someone in that situation and try to get him or her into a bed and a more appropriate situation. I hope that no one with diarrhoea has had to sit for 12 hours in accident and emergency, and I hope that no one will say that their mother did. Nevertheless, that is our intention and aim.

Outpatient areas are cleaned in exactly the same way as all of the other areas of the hospital. In some ways, outpatient areas are easier to clean because that tends to be a nine-to-five or eight-to-six service. Those areas are empty of patients and staff for fairly lengthy periods, which facilitates cleaning — particularly of toilet areas. We clean all the toilets in the hospital every hour. We have put notices up in all the toilets asking people to advise a member of staff if they find a toilet that is unsatisfactory.

Vehicles are a major challenge for our colleagues in the Ambulance Service. I cannot speak for the Ambulance Service, because I do not know what its decontamination procedures are, although I know that it has procedures. Currently, the Ambulance Service is working closely with the Northern Trust. When we have to transfer patients with a clear diagnosis of clostridium difficile, the Ambulance Service provides a vehicle that is used for those patients only and is thoroughly cleaned before it goes back into the general fleet. I cannot speak about any other situation.

Mrs Way:

It was I who mentioned the target of 12 hours. Every patient who is delayed is treated with complete dignity. They are placed in discrete areas with access to a toilet. We would not want to admit a patient, who is known to have diarrhoea, into a six-bedded unit when a single room is not available. That patient is still counted as being there for more than 12 hours if he or she is not admitted to a bed. I assure you that patients are treated with dignity.

Dr Deeny:

Ladies and gentlemen, you are more than welcome. I know all five of you now. I speak as a member of the Committee and also as a GP who has worked in the Health Service for years. I am glad that I have been called to speak near the end otherwise I could have had around 20 questions.

Hospital visitors have a responsibility for hygiene, as do health professionals. Mention has been made of staff moving backwards and forwards. Hygiene and cleanliness were mentioned, and that is where your role, as chief executives, comes into play. How often do you monitor the people who clean your hospitals?

I am the first to admit that doctors, including me, are often guilty of giving in to the public when they demand antibiotics for the second or third time. There is no doubt that we must be more firm.

The Chairperson, and others, referred to openness and transparency. I see the need for that through my role in public representation and through the job that I am involved in. For far too long, the public have felt that things are being done on an in-house basis, and the perception is that things are going wrong in hospitals and in the Health Service but are not getting into the public domain. I have heard those concerns since entering politics.

I commend Norma Evans and the Northern Health and Social Care Trust; you have led by example. Since coming into public representation, I have learned that the public want to hear the truth, warts and all, rather than having serious issues dealt with on an in-house basis. When issues leak, as they usually do, situations become far worse. It is nice to be open and upfront, and to identify a problem and deal with it.

I have been a GP for more than 20 years, and I recall working as a junior doctor in Newry when William McKee was there. Perhaps the problem is global, but the bottom line is that there are more people coming out of hospital with infections. They are frightened and they are getting sick. I will not blame or point the finger, but I will give two examples.

As you know, I work two days a week as a GP. In the last couple of months, a young lady, who was very ill after a Caesarean section because of a hospital-acquired infection, came into my office. I cannot remember that type of situation happening years ago. A mature lady, whom I have no reason to disbelieve, came to me about a similar issue in a hospital in the southern area — the area that Colm Donaghy is responsible for. Nurses and midwives at the hospital are run off their feet because of the large number of babies. Only a few weeks ago, that lady wiped a cot in the hospital’s post-natal ward and she could believe the amount of dirt that she found. The person who raised that issue was being honest, and I hear about similar sorts of issues.

As Mrs Way is aware, this is not a blame game. Elected representatives, health professionals and senior managers need to work together to address these issues.

The Chairperson made a point about whistle-blowing. Perhaps that is a term that people do not like to use as it is deemed to be like informing; perhaps a different term needs to be used. I have received two letters in the past year or 18 months about hygiene in the Erne Hospital. However, I could not do anything about it because the letters were anonymous.

People are frightened to raise issues in case they get punished. Staff members have approached me with problems, and I have asked them why they have not informed their line managers. They said that they were afraid of giving the hospital a bad name. They also believed that nothing would be done about the problem and that it would be hushed up. The public also perceive that there is no point in complaining as nothing will be done. What I am trying to say is that openness and transparency are required.

The five trusts are relatively new, and this is the time for a new beginning. A lot of the things I have been talking about may have happened in the past — and I am not pointing the finger at Mrs Way. I have worked in the Health Service for long enough to know that patients are the priority; that is paramount. As a health professional, I feel that if one of my colleagues is underperforming or putting a patient at risk, or if there are hygiene issues, then I am obligated to report it.

Political representatives, trusts, and, indeed, the Department and the Minister need to make a public statement soon to encourage health staff to come forward with issues without fear of punishment or recrimination. That is vitally important. For far too long, people have been frightened to raise issues in case they are blacklisted.

Several people have told me about awful situations in which relatives have to wash their loved ones in hospital beds or have to feed them because nurses are too busy. The understaffing of nurses has to be investigated.

The Minister has announced that spot checks are going to take place. I want to know what the witnesses think of that.

The Regulation and Quality Improvement Authority (RQIA) has been asked to conduct a review into the deaths that have been linked to clostridium difficile. I am delighted that Colm Donaghy and John Compton have said that that review is going to involve all of the trusts — that should be the case.

The RQIA gave evidence to the Committee on 11 October 2007. It has strong powers regarding nursing homes and so on. However, one of their representatives stated:

I want to know how much power the RQIA is going to have when conducting the review. The authority is a Government agency, which comes under the DHSSPS, and it concerns me that people may see its review as an in-house investigation.

Mr Donaghy:

Perhaps I have been prompted to speak; Dr Deeny said that I was staying quiet. I was staying quiet because I did not feel the need to intervene at any stage.

A specific issue was raised about births at Craigavon Area Hospital. It is a public fact that Craigavon Area Hospital currently provides a service to more mothers than it was doing over the past five years — births have increased exponentially. That does not mean that we are any less vigilant when it comes to detecting infection. In fact, our maternity and obstetrics services are as much a part of our detection process as any other part of the hospital. Therefore, owing to the detection, surveillance and audits that are in place, we would be aware if there were adverse impacts due to hospital-acquired infections. There are no adverse impacts.

Dr Denny spoke about cleaning, and a cot was mentioned. Perhaps he will make me aware of the specific incident. I assure the Committee that all wards are cleaned regularly — more than once a day. The work is monitored closely by trained hospital staff.

I also wanted to mention stewardship as regards the prescribing of antibiotics in relation to clostridium difficile. As Ms Evans said earlier, stewardship of narrow-spectrum antibiotics is part of our 10-point plan in Craigavon Area Hospital. There is a greater risk with broad-spectrum antibiotics as regards clostridium difficile. Therefore, antibiotic stewardship is applied where clostridium difficile has been caused by an antibiotic, and we take action very quickly. It is usually very effective.

Openness and transparency were mentioned, and Dr Deeny talked about what is truthful and what is hidden. We endeavour to be as truthful, open and transparent as we possibly can. If there is anything else that we can do to be more open, truthful and transparent, please tell us, and we will do it. We will be as open as we possibly can. My colleagues have already rehearsed the issues around information that is sometimes not validated. It is important not to mislead the public. We must be confident that the information that we give out builds public confidence.

I am not sure whether my colleagues have anything more to say about that.

Mr McKee:

I will go in to bat for a while. Dr Deeny was kind enough to remind me that nearly 30 years ago we were together in Daisy Hill Hospital. However, medicine has changed a great deal in the past 30 years, Kieran. You asked why, with all the good work that is going on, there is a new threat in the form of hospital-acquired infection. It is worth restating that infection rates here are lower than elsewhere, and but for the current outbreak of clostridium difficile in the northern trust area, we would be able to show very impressive figures.

We are not complacent; there is no acceptable level of hospital infections, but some of them are unavoidable. The trend is well researched, and it is well understood across the world that antimicrobial prescription and its use in agriculture and other areas has led to widespread resistance to these interventions. I had a difficult debate with a close family member who, quite rightly, demanded to know from me why a GP would not prescribe antibiotics for a cold. However, you will understand that there is a wider issue beyond hospitals, medicine and healthcare in general about the use of antibiotics.

Hospitals have changed. We do things that we would not have dreamed of doing 30 years ago. We treat very ill people with very risky interventions, and we are working at the cutting edge. For example, I have seen a doubling in the rate of Caesarean sections during my career. There are more Caesarean sections now, partly because of safe practice, and partly because of personal preference on the part of the mother.

The point is that the comparatively low level of hospital infections here is coming down. We will meet the tough ministerial target of a 20% reduction in clostridium difficile by April 2009 and a 10% reduction in the incidence of MRSA. In response to another question, I said that if we are doing the right thing, it will have an impact on the whole range of bugs that people are susceptible to in hospitals.

Dr Deeny:

I did not complete my question to Mrs Way about whistle-blowing. I have received two anonymous letters about the Erne Hospital being dirty. I could not use them because people would have accused me of undermining the hospital. One letters was sent to me before she took up office. However, if those people had identified themselves, I could have contacted her. Why can people not go to someone they can trust, so that the situation can be dealt with? If not, they will come to people like me, although they are more than welcome to do so.

Mrs Way:

Your comments about whistle-blowing were very significant to me, Kieran.

When I was chief executive of Altnagelvin Hospitals Health and Social Services Trust, I spent five months out and about in preparation for the merger of the three trusts in the west. I received a number of anonymous letters from what I now describe as the southern sector of the trust. Since becoming chief executive of the Western Health and Social Care Trust, I have received a number of anonymous letters from the same sector of the trust. That says a lot about staff feeling unable to express their concerns openly to managers.

It is very early days in the new organisation — it is only the start of month 11 — but I am encouraged by the track record in two previous trusts, whereby staff have always felt enabled to say it as it is. For example, as some Members from the west will know, when we considered how to safely provide out-of-hours cover in the laboratories in Omagh and Enniskillen, a doctor went to the area to talk about the issue. He asked whether he could speak about this matter, and we told him to be open. I completely agree with others who have said that the new structure of five organisations presents a new opportunity to be absolutely open, particularly with public representatives. The point is well made that this is a completely different world in which there is the power to change things. We want to be open and work with you to create a better service for our patients.

Dr Deeny:

Who should the public go to? It took the Western Health and Social Services Council to carry out an inspection of the Erne Hospital — having given the hospital an hour’s warning — to find out that the wards were dirty. However, I had been told in two letters that the wards were very dirty.

Mrs Way:

That inspection by the Western Health and Social Services Council was part of the Bugwatch survey, and the findings were presented to me by the council’s chief officer the day after it was completed. She has commended us on our approach — both on how we received the report and how we have developed an action plan. The point has been made today about the relationship between environmental cleanliness and the spread of infection, and I rest on what Mr McKee has said several times. If we look at the evidence, it is clear that infection rates and deaths in the Erne Hospital are among the lowest in the Province. Staff are working very hard to control infection. Since that survey was carried out, I have tried to address some of the environmental issues as well.

Mrs Hanna:

Good afternoon. You are all very welcome today. Obviously, everyone here wants the same outcome: we want to reduce the number of clostridium difficile cases and control the outbreak in the Northern Health and Social Care Trust area. Although we must keep this outbreak in perspective, it is undeniable that clostridium difficile can lead to a very nasty and undignified death, particularly for elderly patients. The experience is very traumatic for relatives, too. The spotlight is on this Committee meeting, and it is particularly on you as the senior personnel involved, because accountability stops with you.

We all agree that we must inspire public confidence, because that is a big problem at the moment. No one wants to hype up this issue and get it out of perspective, but there are concerns about it. Indeed, there have been concerns for quite a while about hospital-acquired infections such as MRSA and others. They have always been fairly high on the agenda, and the feeling has always been that we never quite got to the bottom of the problem. I welcome the fact that you said that the rates of MRSA have gone down.

We need a whole new regime and culture in our hospitals regarding cleanliness. We must demonstrate to the public that the culture has changed. It may be old-fashioned to say this, but I believe that people want to see us go back to basics. They want to see us go back to having respect for hospitals and for the fact that they are full of sick people who are vulnerable to infection. For some time, we have wanted to be all things to all people. Hospitals have become more like social centres: they are very open, and lots of pictures have been hung on the walls, and so on. That takes away from respect for the service being provided, and even respect for hospital personnel.

Visitors want to walk into a hospital and see clear signage on hand-washing and to know that nobody goes through the door of a treatment room without washing their hands first. I know that this matter is not all about hand-washing and cleanliness, and I have had discussions with consultants who have said that it is not. However, you have admitted today that hand-washing and the washing of hard surfaces are important.

Cleanliness is terribly important. Public confidence will not be restored unless cleanliness is improved. I want to be able to walk around hospitals and feel differently about them as soon as I open the door. Every day, we hear stories about the lack of cleanliness in hospitals. I do not blame hospital staff — everyone works hard. However, hospitals are so hi-tech nowadays that minor details, as they might have been considered, are being forgotten.

We do not want to return to the time of two patients to a bed and the ringing of bells. However, there certainly needs to be a return to those standards. When thorough cleaning and spot checks are carried out, they must be recorded. If there are door scores in restaurants, there must be door scores in hospitals. We must ensure that that level is maintained and that checks are carried out regularly. Public confidence cannot be restored until that happens.

As regards the culture of supplying information, to which Ms Ramsey and others referred, we live in a time when people are far better informed and when MRSA and clostridium difficile are household names. People turn on their computers and ‘Google’ terms in order to find out about them. Indeed, they often know more about them than the so-called experts. Therefore, there is an expectation that when information is released, it must be kept up to date.

There are concerns about the information’s accuracy. In order to pinpoint the focus and learn from what has happened, information must be accurate. However, it must also be fast, particularly with regard to the current outbreak. Although the information must be correct, people assume that with all of the information technology that is available — despite there being an issue in hospitals that it does not work as well as it should; a matter that has been discussed for years — there is no reason why it should not be easy to record and collate information quickly. People have that expectation.

Although you may not be able to provide details now, I am interested to obtain and examine the figures for all hospital-acquired infections — not to hype the situation in any way, but because it is important that we do not lose focus of the fact that clostridium difficile is still a problem. The public must be satisfied that cleanliness is being addressed. I understand that that is a simplistic view: lots of other factors must also be considered, such as antibiotic therapy, and so on.

It was asked why the outbreak was confined to the northern trust area. It is hard to believe that that was simply a matter of luck. I do not know whether it has anything to do bed closures in any of the other trusts’ hospitals. I do not expect an answer to this today. However, there must be more to it than simply luck. I do not understand that. You may have time to respond on that issue.

Is there any less control exercised over cleaning staff who are privately contracted? Is that an issue in hospitals in which cleaning is no longer carried out on an in-house basis?

I will run through the rest of my questions. If you do not have time to answer all of them, you can respond to them later.

Has a blanket approach been taken regarding the figures, or are hospitals being considered individually in order to determine whether different circumstances have contributed to the variation in the rates of clostridium difficile infection? For instance, some hospitals are in old buildings and some have few toilet facilities. Such matters must be taken into account. Is it possible to provide more toilet facilities in hospitals? Toilets are provided in the streets and when concerts take place. Toilet provision is important when people present with diarrhoea. I am not sure whether that is the first symptom or the only symptom of clostridium difficile infection.

While I am on the subject, I understand that examination of faeces is the only way to confirm that the infection is present, and that it cannot be done by blood test.

Antibiotics stewardship has been mentioned. That is a public-health issue and presents an opportunity to raise the matter of people’s saying, "doctor, doctor, give me a prescription" and to reiterate the sound reasons why that should not be done. Do hospital pharmacists have a role to play? I am not sure about their role. Dr Deeny mentioned the regulating body, the RQIA. Certainly, when the Committee talked to that organisation, it did not appear to have much control over hospitals. It is vitally important to know its role as regards acute hospitals.

Hospitals should provide much more education and information on how everyone must take responsibility for personal hygiene. It is important that people know that the hospitals do not have sole responsibility for preventing infection.

It is also important to provide information to the relatives of patients who are being discharged. Today, a patient spoke to me about MRSA, but it could equally have been about clostridium difficile. The patient, who had major surgery less than two weeks ago, was told that their father had MRSA. When the father returned home, the family was not told whether he still had MRSA. They did not know whether the infection was located in his wound or where the drip had been inserted. There is simply no co-ordination in the provision of information to relatives.

Mr McKee talked about an infection control co-ordinator. Every hospital must have someone who can provide information to relatives before a patient goes home, so that they are much better informed. People do not have enough knowledge about such conditions. My brother was already seriously ill when he contracted MRSA. It was regarded as a major problem that he had contracted MRSA on top of other conditions. I never got to the bottom of why, or how, my brother was infected. As he died very quickly, none of my family’s question was ever answered, and my brother was confused about his condition. Relatives, and particularly patients, are vulnerable and are not in a fit state to ask questions. It is important that relatives and visitors are much better informed.

Mr McKee:

Carmel has raised a raft of issues. Her comments are extremely wise, and I am sure that we all fully endorse what she said. I will try to rattle through the points that she raised.

I said that all trusts are in the process of rolling out a new, more stringent visitor policy. I am not sure that we will be ringing bells, Carmel, but we will certainly impose a strict limit on the number of people who can be at each bedside. You made a wise suggestion that the trusts need to devise a new compact with patients and the public about how we manage hospitals. We must acknowledge that involving patients and the wider public will lead to improvements. The trusts regard openness as the first step, and I hope that we are displaying that today.

Carmel is also correct in saying that there must be a return to old-fashioned values such as diligence and vigilance. The trusts rightly consider that their performance as regards cleaning is being extensively monitored internally and externally. The RQIA is only one example: trusts are required to monitor and audit their cleaning performance, in addition to the external monitoring that is carried out. It is reasonable to say that we, our managers and staff feel under the cosh in that regard.

I think that I am the only chief executive of a trust that has an outsourced cleaning team. I inherited the team from the Musgrave Park Hospital site, but I have given a clear undertaking that, as soon as that contract expires, there will be an in-house cleaning regime. The rates of infection are collated by trust, but are also broken down by hospital and by site.

Variations in infection rates relate primarily to the nature of the hospital. A hospital that, for various reasons, treats younger people tends to have a lower rate of infection than one that treats older people. Hospitals that treat people who are seriously ill — particularly those whose immune systems are compromised or who are receiving medication that, as a by-product, compromises their immune systems, as in the treatment of cancers — will have different rates of infection, because those are all risk factors. The figures are published on a hospital-by-hospital basis. The rate of infection is likely to have more to do with than the nature of the hospital and the type of patient that it treats than the number of toilets provided.

Pharmacists have a crucial role to play in the development of antimicrobial policy. As additional money has been made available, the trust is bidding for funding for specialist antimicrobial pharmacists to advise doctors on best practice and to monitor and audit its performance as part of the prescribing stewardship that others have mentioned.

I cannot comment on the RQIA. I can simply point to the fact that there was a much larger and more damaging outbreak in Stoke Mandeville Hospital in 2006. The equivalent body in England carried out the review that caused such a shake-up in England. We have learned from that, and I assure the Committee that we will also learn from the review of the outbreak in the northern trust area.

Ms Ní Chuilín:

My comments are not meant to be personal, but to describe the clustering and the outbreak in the Northern Trust as unfortunate is offensive. The Chairperson has pointed out that we are elected representatives. People have serious concerns about the situation. I appreciate the length of time that you have been here, but that comment does not reflect what is happening in that area. It is not good enough.

Mr McKee:

I am sorry if I have given that impression. I have tried to emphasise on the one hand that we are performing quite well but, on the other hand, that every avoidable death is tragic and we very much regret it, as do all the staff. I probably used the word "luck", and I meant it to mean that the Northern Trust was unlucky to get clostridium difficile. The fact that it has not spread elsewhere is down to the vigilance and diligence of staff. I am sorry if, in what has been a very long session, I used the word "unfortunate" when I could have used a stronger word. It is very much regretted by everyone. The openness and style of answering here reflects that, rather than one isolated word.

Ms Evans:

The Northern Trust has been open in expressing regret to the patients and the families about the situation. We have been treating the outbreak with the utmost seriousness since we were made aware of it.

The Chairperson:

I realise that we have been here since 1.30 pm and it is now 4.10 pm. Nevertheless, I welcome the fact that we have had a long discussion because of the nature and importance of the debate, and the expectations of the general public as to how the matter will roll out, and the answers we, as elected representatives, receive. We must also be realistic and recognise that the public have major concerns about the situation. The spectacle of older people not wishing to take up appointments to attend hospital when they are sick, because they are afraid of contracting one of the superbugs and having their life expectancy reduced, is understandable. We have an awful lot of work on our hands to try to bring back public confidence by rolling out the various programmes that are being enacted.

Thank you all for coming. The Chief Medical Officer will be speaking to the Committee next. Based on what we hear, we will decide whether to call for an independent, time-bound inquiry. Thank you for your time.