COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY
OFFICIAL REPORT
(Hansard)
Clostridium Difficile
14 February 2008
Members present for all or part of the proceedings:
Mrs Iris Robinson (Chairperson)
Mrs Michelle O’Neill (Deputy Chairperson)
Mr Thomas Buchanan
Rev Dr Robert Coulter
Dr Kieran Deeny
Mr Alex Easton
Mr Tommy Gallagher
Mrs Carmel Hanna
Ms Carál Ní Chuilín
Ms Sue Ramsey
Witnesses:
Dr Michael McBride ) Chief Medical Officer
The Chairperson (Mrs I Robinson):
Dr McBride, you are very welcome.
Dr Michael McBride (Chief Medical Officer):
Thank you. To echo the comments of my colleagues, I welcome the opportunity to appear before the Committee to provide insight and some assurance to the public regarding the steps that we are taking to rise to the challenge of healthcare-associated infections. I am happy to take questions on any matter arising from earlier discussions or, indeed, other matters, because this is an important issue.
I apologise for my hoarseness — even doctors are human and sometimes get chest infections, but we do not always need antibiotics for them.
This is an important and serious issue. Our first thoughts are with the patients directly affected by the outbreak, and their relatives. It is a tragedy when patients come into hospital and develop healthcare-associated infections. It is tragic for them and for their relatives, but it is equally distressing for the staff involved in trying their best to provide treatment and care for them.
I echo the earlier comment that we cannot be complacent about healthcare-associated infections. It is a global challenge. To put the situation into context, across the world between 5% and 10% of patients contract healthcare-associated infections. The most recent figures for Northern Ireland showed that in 2006, 5·4% of patients contracted healthcare-associated infections, compared to 8·2% in England. We cannot be complacent, and we must redouble our efforts to drive those figures down. Hence, the Minister’s targets to reduce clostridium difficile by 20%, and MRSA by 10%, by March 2009 are very welcome. It is great to hear the welcome that those targets have received from my colleagues in the Health Service.
Mrs O’Neill:
The Minister said that he had asked the Regulation and Quality Improvement Authority (RQIA) to conduct a detailed, independent review of all the circumstances surrounding the incident and to make recommendations. Yet, we heard earlier that there will be views from all the trusts. Is that correct?
Dr McBride:
The Minister outlined the terms of reference for the RQIA review that he has commissioned. The authority was established in 2003 under the Quality Improvement and Regulation ( Northern Ireland) Order 2003. It is worth pointing out that that puts a duty of quality on chief executives of trusts. That is an onerous responsibility, as it relates to all aspects of care provided in hospitals. However, it also gives the RQIA powers to require information and in relation to entry and inspection.
We need an independent, comprehensive, thorough investigation of all the circumstances surrounding the outbreak in the Northern Trust, and why it occurred there and not elsewhere. Undoubtedly, there will be lessons to learn from that. It is important that we learn those lessons quickly and share that learning across the health and social care system. That is why the Minister has announced that he will examine not only the response of management and the clinical team in the Northern Trust, but also the response of the board and the Department to the outbreak. He will consider all matters that arise during the investigation, and the learning will be shared throughout all the health and social care organisations.
We must establish the facts in a timely manner and establish what we can learn from the outbreak, because this investigation is all about preventing further outbreaks. Obviously, that could equally be achieved by a public inquiry. However, the issue is one of timeliness. Public inquiries — while independent and rigorous — by their nature, take much longer. The review will quickly establish all the circumstances, because this is about preventing a further outbreak and saving lives.
Mrs O’Neill:
Can you confirm that the review will only investigate the outbreak at the Northern Trust?
Dr McBride:
There has only been one outbreak, and that is in the Northern Trust. There is no evidence of an outbreak, or of whether this strain of clostridium difficile is present, in any other trust in Northern Ireland. The review will immediately seek to ascertain the circumstances of the Northern Trust, but it will go much wider, as it has full rein to examine a ny other relevant matters that emerge during the course of the review”.
The Chairperson:
You have said that there was only an outbreak at the Northern Trust, but clostridium difficile has been mentioned on death certificates from the Ulster Hospital, Whiteabbey Hospital, Craigavon Hospital and Belfast City Hospital. Did you say that there had only been an outbreak in the Northern Trust area because it has had more deaths than the other areas?
Dr McBride:
As we heard earlier, there will always be a background rate of healthcare-associated infections. There can be no acceptable level of healthcare-associated infections, but they are not all preventable. The vast majority of the infections that have been discussed today, such as MRSA and clostridium difficile, are bacteria that live on or in our body. We have heard that 3% of healthy adults, and 30% of older people, carry clostridium difficile. Thirty per cent of us carry staphylococcus aureus on our skin, and 3% of us carry MRSA in our nose. Those infections are brought into hospitals from the community. When people undergo operations, or when they are given strong antibiotics to treat the infection that brought them into hospital in the first place, it can upset the balance in the normal bacteria, such as those in the bowel which keep clostridium difficile from overgrowing and causing symptoms.
Generally, clostridium difficile causes mild diarrhoea, but it can be severe in some cases and, unfortunately and tragically, it can result in complications and the deaths of patients. The vast majority of those people are already unwell and suffering from serious underlying conditions, which is why they are vulnerable. We know some of the underlying causative factors, but we will never, ever eradicate clostridium difficile from hospitals. It is not possible to do that; there will always be a background rate. The figures for January to June 2007 across all trusts in Northern Ireland show that the rates of clostridium difficile across that period were significantly lower than they had been in 2006. Validated figures from the third quarter of 2007 demonstrate that the rates of clostridium difficile in Northern Ireland were lower than they had been in the third quarters of 2006 and 2005.
I do not wish to convey any complacency that we have the situation of the background level of clostridium difficile under control. However, there is evidence that the actions that we are taking under the policy framework that we set in the Department, and the actions that front-line staff are taking, are containing and preventing an increase in healthcare-associated infections. Everyone, from the Department to the boards to the trusts to the people on the ward floor, is involved in that. It is an ongoing challenge, and it will remain so. Again, there is no cause for complacency, but the figures compare favourably when they are benchmarked across the United Kingdom.
That is why I said that the Department will investigate the current outbreak. This is the first time that the 027 strain has been seen in Northern Ireland. It has caused outbreaks in North America, Europe, Japan and, more recently, in England. As you heard earlier, we are increasing the level of vigilance and redoubling the efforts of the Health Service to ensure that it does not spread to other hospitals. We need to understand why the situation arose in the Northern Trust, and we need to assure ourselves and the public as quickly as possible that any learning from that is implemented in all other trusts in Northern Ireland.
It will be a comprehensive and extensive review. Having read the terms of reference and heard the Minister say that it will be conducted by professionals and experts from outside the health and social care system, I am confident that the review will be comprehensive and timely, that the learning will be disseminated and that it will prevent further loss of life.
The Chairperson:
Mr James McCann from the Upper Cavehill Road phoned me about clostridium difficile. He has a 47-year-old daughter who suffered from measles when she was three years old and has been disabled ever since. She was in a nursing home in Randalstown and was then admitted to Antrim Area Hospital. She contracted clostridium difficile and suffered from it for over one year. She was put on a lactose-free diet for four weeks and recovered sufficiently to return to the nursing home. Mr McCann insisted that she stay on the diet when she returned to the nursing home. She made a good recovery and put on weight for the first time in many years.
Mr McCann said that he was told that hospitals are banned from keeping anyone on a lactose-free diet for more than four weeks. He believes that such a diet could be used to treat clostridium difficile. He questioned why it should be banned by the Health Service and asked how many people who died from clostridium difficile would still be alive had they been put on that lactose-free diet.
Dr McBride:
Perhaps I can provide some further written information on that issue in due course. Lactose is a form of sugar that is found particularly in dairy products. Lactose-free diets are generally reserved for people who have what is known as lactose intolerance. For such people, lactose can cause symptoms such as abdominal pain and diarrhoea.
A number of probiotic interventions can be prescribed for people suffering from clostridium difficile diarrhoea. That may involve the use of live yogurts in an attempt to re-establish the normal flora in the gut.
When elderly people, for example, are admitted to hospital with chest infections, they are treated with a broad-spectrum antibiotic. They may recover from that infection, but the antibiotic may kill off the good bacteria in the gut, which can then result in the overgrowth of the clostridium difficile.
Live yogurts and other supplements can be used to encourage the re-growth of normal bacteria in the bowel, as well as, as Dr Flanagan pointed out earlier, specific antibiotics such as metronidazole — which is more commonly know as Flagyl — and vancomycin.
Mrs Hanna:
Good afternoon; you are welcome here today. I welcome the review, which will hopefully be in-depth, and I look forward to the expert analysis. I understand why the focus is on the Northern Health and Social Care Trust area because that is where the outbreak is. However, it would be useful to have a report from the other trusts on the level of clostridium difficile, and, indeed, hospital-acquired infections so that people can be reassured that the level is decreasing, and can be monitored. There is always a worry that the problems in the Northern Health and Social Care Trust area could be solved, but that the other areas have not been properly monitored. That is an important aspect of the review.
An urgent action plan should be put in place in tandem with the review and it should be rolled-out immediately. Patients and visitors should be able to walk into hospitals and see that there is a new regime, which will give them confidence, because it is actions such as this that they will be aware of.
There needs to be confidence in all areas, whether it is cleaning, the laundry facilities or the provision of extra toilets. People are approaching their elected representatives about such matters, and confidence needs to be rebuilt now.
Money for a public inquiry should be used to roll-out an action plan immediately. A thorough review in the Northern Health and Social Care Trust area; consideration of the other trust areas, and an action plan are required. Hopefully, those actions can lead to the problem being solved. If they do not, I do not believe that it is going to be solved.
Dr McBride:
I acknowledge fully that this outbreak has caused significant and legitimate public concern. Equally, as my colleagues said earlier, the seeming confusion around conflicting numbers of cases has further undermined public confidence. As you said, Chairperson, the media reports have caused anxiety. In an attempt to provide assurance to the public, the Minister asked NISRA and the General Registry Office to release provisional interim figures, because the matter is of deep concern to everyone.
It is right to say that we live in a time when information is accessible. Patients and the public have the right to expect care that is safe and clean no matter where it is provided — either in the community or in hospitals. Next month, we will be publishing the validated figures to the end of December 2007 for clostridium difficile, by trust and by hospital site, and for staph aureus infection, bacteraemia from staph aureus and MRSA bacteraemia. In the past, those figures were published annually, but in the light of recent events that clearly is not frequent enough.
Mrs Hanna:
There should be regular updates to reassure people that the levels of infection are going down.
Dr McBride:
The Minister said that he wants to make those figures available to the public quarterly. People waiting to go to hospital for inpatient procedures will be able to determine what the rates of infection are in hospitals.
Ms S Ramsey:
I will cut to the chase. The Senior Medical Officer was absolutely right when he said that there were lessons to be learned. However, the figures that we have, as recorded on the death certificates, show that since 2001 there have been 217 deaths related to this infection, and another 116 deaths where it has been an underlying cause. A substantial number of people have died. If there are lessons to be learned, why have none been learned since 2001? That is a relevant question. We are now in 2008, and we are looking at figures that date back to 2001. There is an issue of public confidence here.
In fairness, Dr McBride, you probably gave more information on the radio shows on which you appeared than the hospitals did, for which I commend you. That situation must be looked into.
Judging by the presentation that was given by the trust chief executives, they seem to work to guidelines. Perhaps I was being cynical when I said that lessons had not been learned since 2001. Does the Department have plans to instruct chief executives to issue guidelines in order to ensure that hospitals are deep cleaned on a monthly basis, rather than having to wait? One of the chief executives said earlier that a deep clean occurs once three cases are declared. It should happen on a more regular basis. You have heard the evidence yourself, Dr McBride. You took telephone calls on those radio shows. People are saying that hospitals are dirty. I am not being critical, but we have all seen it. If instructions come from you and the Department about regular cleaning, that cleaning should happen.
I have a genuine concern about the number of people who contracted clostridium difficile and later died of unrelated causes. There are people whose death certificates show the infection as an underlying cause, but, one step removed from that, do we know how many people died who had the infection but it was not recorded on their death certificates?
Mrs Hanna said that she was happy with the review that the Minister announced. I am disappointed, because the chief executives said that they believed that the review would cover all the trusts. According to the Minister and you, it will not. I have a copy of the statement that the Minister made in the Assembly. I am not happy with it, because if we are going to learn lessons, we must learn them collectively across the board. The Minister said that a public inquiry would take too long. However, a time-limited independent inquiry would achieve the same as an RQIA review.
Dr McBride:
Basically, there is a duty of quality on trust chief executives and boards in relation to such matters. Mrs Hanna referred earlier to change in the culture. The major framework for how we tackle healthcare associated infection is outlined in a document, which says that it is everyone’s responsibility, from the trust board’s chief executive right down to the front-line staff of doctors and nurses and cleaners on wards. We all have our part to play, including the public, which is why we have launched a major information campaign, issuing one million leaflets to patients and visitors when they come in to hospitals, to ensure that good hand-hygiene practices are practised throughout our hospitals. That is why the Minister has made further announcements, the details of which will be fleshed out over the next few weeks, and will include hospital visiting and other matters.
The death certificate provides several functions. It is a document that records the legal status of a person’s death; it allows a family to make the necessary funeral arrangements around cremation and burial, and it allows them to take action in relation to the deceased’s estate. It also gives them a permanent record of why a person died, and it should be a permanent record of all of the circumstances that may have contributed directly to the person’s death or may have been contributing factors.
John Compton outlined earlier the good practice that we would expect from all doctors in all hospitals, where they would sit down with the relatives and explain exactly what happened, and that that would be recorded factually and accurately in the certificate of the cause of death. Doctors have a statutory duty to complete that form accurately. It is an onerous responsibility, as medical colleagues will know.
There is guidance on the completion of death certificates, and there is further guidance, which I have reissued in the course of recent events. Members will be aware that a process is ongoing across the UK as regards reviewing death certification with a view to improving accuracy. That involves us working with colleagues in the Department of Health, Social Services and Public Safety, the Department of Finance and Personnel, GRO, NISRA and the Court Service. There is significant underpinning legislation that cuts across many other Departments.
As Chief Medical Officer, I want our services to be as safe as I can possibly make them. I have a responsibility to the public, the Minister, the Assembly and the Committee to provide assurances or point out honestly where I have concerns. In light of the outbreak in the Northern Health and Social Care Trust, my concern is that we do not delay in learning the lessons from those experiences and that we ensure that they are rapidly disseminated to the rest of the service.
I give members my commitment that I will ensure that lessons will be learned, and I give my personal commitment as Chief Medical Officer that I will leave no stone unturned in ensuring that that learning will be disseminated throughout health and social care in Northern Ireland. I will also ensure an improvement in patient safety and reduce the risk of a similar outbreak happening anywhere else, and so reduce the risk of deaths elsewhere.
Ms S Ramsey:
I commend the Chief Medical Officer. He has given us more information than we have received from any other source. He is saying that lessons will be learned, but from 2001 more than 300 people have died directly, or indirectly, as a result of the bug. You can understand people’s concerns.
Dr McBride:
I can.
Ms S Ramsey:
Unless I am totally wrong, the information we have states that clostridium difficile is not always recorded as the underlying cause of death. Therefore, if is it not the direct cause or the underlying cause, are we three steps removed from the situation in which people have died and something else has been recorded on the death certificate, when those people had the bug in their body?
Dr McBride:
I do not want to get technical.
Ms S Ramsey:
Please do. Dr Deeny will explain it to me.
Dr McBride:
The classification recording system on death certificates is agreed internationally. The World Health Organization agrees international classification codes to be entered on death certificates. The reason is so that I, as Chief Medical Officer, can give advice in my annual report to the Assembly, to the Minister, to Government and to the public concerning the major causes of death and morbidity in our society, so that I can give assurances, or not, that our public health interventions are working, or what more needs to be done to improve health and well-being to deal with some of the major killers in society.
Therefore, the death certificate has several functions. It also allows us to benchmark with other parts of the UK and internationally. There is a prescribed, internationally agreed classification of death certification, so we do not have latitude to change that, unilaterally.
Doctors have a statutory obligation to state on the relevant part of the form the underlying cause of death and all prior conditions that led up to that underlying cause. We also have an obligation to ensure that any contributory factor, such as clostridium difficile, if it was not the direct cause of death, is recorded. There is no separate international code for clostridium difficile infection. Therefore, when death certificates are completed, that information is reviewed by the General Registry Office in the Department of Finance and Personnel, and it is correlated on an annual basis.
An electronic check is carried out to identify situations in which clostridium difficile complications have occurred, and then a manual check is carried out to ensure that we do not miss any cases. The process is lengthy and laborious because the information must be factually correct. That is why in May to June each year, the General Registry Office publishes information in relation to deaths in Northern Ireland across all conditions. The recent outbreak has demonstrated that there is vulnerability in the system, which is the timeliness of the information’s availability. It may be OK to have the information available once a year if it is to be used to inform public health policy intervention, but that is certainly not good enough if we are to relate the number of people who are dying from an infection to the rate of the infection. As a result of working across Departments, validated information will be published quarterly.
The situation is slightly more complicated, because not all patients who die — in hospital or elsewhere — will have a medical certificate of cause of death completed at the time of their death. For example, an unnatural death will require a post-mortem examination, and a death certificate will not be completed until later.
The process is complicated, and I suspect that I will have confused members further by trying to explain it. I hope that I have explained why there seems to be confusion around figures and the change in figures, and why GRO could release only interim figures for 2007, which indicated that 77 deaths certificates mentioned clostridium difficile as an underlying cause of death or contributory factor. I hope that that has helped clarify the situation.
Ms S Ramsey:
Yes.
The Chairperson:
We have laboured that point, Sue, and, if you do not mind, we will move on quickly.
Ms Ní Chuilín:
From what the Chief Medical Officer has said, the final figure could be higher, because he has been talking about an interim figure. We know that clostridium difficile was a factor in 77 deaths, but those requiring post-mortems and further investigations could push the figure up.
I would like to return to the RQIA and the perception that its review would cover more than just the Northern Health and Social Care Trust area. I wish to state for the record that an RQIA review will not restore public confidence. We have asked that public authorities and public bodies be regulated. However, the RQIA will not cover the regulation, investigation and reporting that will be required. Like most members of the Committee, I was in the Chamber on Monday when a private notice question on the subject was asked. The answer did not go far enough. It is difficult to achieve balance, but public confidence is a huge issue.
Several members of the Committee have medical backgrounds; the rest of us may not understand the technicalities. However, over time, families have approached me about going private for a particular procedure or operation and I have talked them out of it. I advised them to use the Health Service that they have paid for all their working lives.
People are now saying that they are not going to go into hospital in case they come out in a box — it is being put as crudely as that. It is regrettable that people who have waited for months to go into hospital — in pain, discomfort and stress — now feel that hospitals are not safe places to be. I do not know how we can solve that problem.
I am a public representative, and my confidence will not be restored by an RQIA review.
Dr McBride:
Ms Ní Chuilín is correct to highlight the apparent discrepancies in the number of deaths and the public concern that that caused. The interim figures for 2007 were released in an attempt to provide greater clarity, and I outlined the complexities involved.
Our primary focus must be on prevention and early detection. That is why the figures regarding the rates of infection were published. Validated figures are provided to all trusts on a quarterly basis, which enables them to ensure that the measures that they are taking to control healthcare-associated infections are working. As Ms Evans said, such figures enabled the Northern Health and Social Care Trust to detect the problem, which meant that they could then take the opportunity to intervene.
Early detection and prompt and appropriate treatment is how lives are saved. It is too late to wait to count the number of people who die as a result of the infection. Therefore, prevention and early detection is vital.
I am an advocate of a public-funded healthcare system that is free at the point of delivery. I have worked in health and social care my entire professional career. In Northern Ireland, there are more than 500,000 inpatients in the Health Service each year. The risks of acquiring a healthcare-associated infection are low, and are lower in Northern Ireland than in any other part of the United Kingdom.
That does not mean that we should be complacent — a number of those infections are preventable. That is why we are redoubling our efforts and that is why we have been set challenging targets — which I also welcome — to lessen the likelihood of contracting such infections.
Obviously, it is a matter for the Committee to determine its view on the RQIA review. It is not for me to seek to persuade members in that respect, and I would not attempt to do so. As Chief Medical Officer, I am anxious to ensure that the process is independent, rigorous and comprehensive. The learning needs to be provided in a timely way to ensure — as far as is possible — that we prevent those infections or similar outbreaks occurring in any other trust in Northern Ireland, which will, in turn, save lives.
My concern about public inquiries is that, by their nature, they take a considerable period of time — the Chairperson mentioned the human organs inquiry — they are expensive and may deflect us from ensuring that we learn immediate lessons that can be transmitted and disseminated throughout health and social care in Northern Ireland and save lives.
When the RQIA review is completed the Minister may take a different view, but that is a matter for him.
Dr Deeny:
Michael, you are more than welcome here today. I discovered this morning that my wife teaches with your cousin. It is a small world.
This topic concerns me. I have asked departmental officials to provide the Committee with details of the unannounced spot checks and how often they occur. It is important to get that information as soon as possible. For example, will they occur twice a year? Do you have any information about those spot checks?
The Committee met RQIA representatives on 11 October 2007. At that meeting, Mr Phelim Quinn said that the RQIA, as a DHSSPS organisation, has a small budget of £5·2 million. He continued:
“Our powers in the statutory sector are more limited, although we can make recommendations for special measures to the Minister”.
I asked him if the RQIA’s authority could be used to take the Department to task, to which he replied:
“No. Under the legislation, we cannot hold the Department to account.”
That concerned me, because Mr Quinn described the RQIA as a DHSSPS organisation.
I concur with members around the table — in life and in medicine, time and haste are not good reasons for not doing a job correctly. I do not like the term “review”; it is too mellow to describe what is happening — inquiry is a better description.
I am getting mixed messages: I took it from the trust chief executives that the investigation would be across trusts, but now it seems that it will only be in one trust. All five trusts must be investigated. This morning, I was speaking on a programme on Radio Foyle, and a number of people from the west said that they had only begun to hear about the problem. Although the Northern Health and Social Care Trust area was the only scene of an outbreak, the public only heard that the problem exists in other trusts — albeit not to the extent that it could be called an outbreak — because figures were requested. Sending out the message that the review — which is not a strong enough word for this issue — will concentrate on only one trust, will not instil confidence in me. Northern Ireland is not a big place, and there is no reason for not holding an inquiry into all five trusts.
If there is an inquiry into one trust then I — as a doctor — and most people will take that as an indication that the Department will not carry out detailed and thorough inquiries on health issues of high importance to the public unless there is a major problem. The Department is effectively saying that it will leave the other four trusts alone, but that if there is a future outbreak it will hold an inquiry into the trusts concerned. That is not a good message to send out: if a review is held for one trust, it should be held for the other four too.
Dr McBride:
I apologise if I was loose with my terminology — the term used was “RQIA investigation”, and the word “review” was used to describe the process that will take place. The RQIA is an executive non-departmental public body, and its board comprises lay members and non-executive directors. As I said in response to Sue Ramsey’s question, the RQIA has wide-ranging powers that are established in legislation. It is important that proportionate action is taken in a timely — as opposed to quick — manner. It is important that there is an independent, rigorous and timely process that comprehensively seeks to establish the circumstances of the outbreak in the Northern Health and Social Care Trust area. Reading the terms of reference, it is also important:
“to examine any other relevant matters that emerge in the course of the review.”
The RQIA will have free range to extend the terms of reference of the investigation into the circumstances around the outbreak in the Northern Health and Social Care Trust area as far as it feels is appropriate on the basis of emerging information. Therefore, the RQIA has been given free scope to take the further steps it feels are necessary, which include examining the actions of the Northern Health and Social Services Board and the Department.
My earnest desire is to ensure that we rapidly ascertain what happened and why and how it happened in order that we can all learn and prevent further unnecessary and avoidable deaths.
Regarding the issue of transparency and figures, in 1999, the Department established the Communicable Disease Surveillance Centre and, in 2001, introduced mandatory MRSA and staphylococcus aureus screening, from which the resultant statistics have been published annually for the past six years. In 2005, we introduced mandatory clostridium-difficile screening, from which results were published annually and are readily available. The Minister recently announced that results will now be published quarterly.
Elaine Way mentioned work that is going on to improve patient safety — we have established a Northern Ireland patient safety forum, of which John Compton is the chairperson.
Apart from setting challenging targets, by entering into arrangements with the Institute for Healthcare Improvement in the United States and the Health Foundation, which is a charitable organisation in the UK, we have adopted international best-practice procedures whereby we seek to introduce evidence-based interventions that are known to save lives.
In our priorities for action strategy, we set major planning targets for trusts — which the chief executives mentioned earlier — requiring them to produce evidence-based infection-reduction plans and introduce measures known to save lives. Much of that work was supported by the patient safety forum, and, we will be rolling out intervention programmes that are known to reduce ventilator-acquired pneumonia, central-line infections etc. Therefore, members should not underestimate our willingness and preparedness to put in place intervention programmes, take actions that will make a difference and be transparent.
Carmel Hanna mentioned the importance we place on cleanliness. In 2005, we launched our strategic approach to environmental cleanliness — that three-year strategy offers a toolkit for trusts and will be reviewed this year.
The trusts’ chief executives mentioned the independent audit of all trusts that was completed last year. The report will be completed by the end of the month and published in March. It is vitally important that we demonstrate to the public not only that our infection rates are under control or decreasing, but that we take issues of environmental cleanliness seriously and are ensuring that hospitals are being kept as clean as possible.
Although it is important that those reports are made available more quickly, many of them are in the public domain — and have been for several years. The public have a right to safe, clean care and must be assured, and have confidence, that we are doing everything possible to ensure that we continue to rise to the challenge of tackling healthcare-associated infections. Such events have highlighted our vulnerability to criticism concerning the timeliness of publishing information that allows the public to rightly ask challenging questions of the trusts. Trusts must make such information readily available to patients.
Dr Deeny:
The public will ask why the inquiry will not cover the whole of Northern Ireland. You are setting an unhealthy precedent. Regardless of where problems arise in Northern Ireland, a single trust should not be selected for investigation. For example, if there was an outbreak of bird flu in the west, would we only monitor western regions? I do not think so. I am concerned that we should not set such a precedent.
Dr McBride:
It is important that I reply to that. It is vitally important to remember that, from January to the end of June 2007 — and the data covering the period up to the end of December 2007 will be published in the next number of weeks — rates of clostridium-difficile infection in the acute trusts in Northern Ireland dropped by 19%.
There is no cause for complacency, but it is against that background that we must come to a decision about how best to utilise our resources. If all aspects of the review were extended to all trusts in Northern Ireland, would that run the risk of deflecting front-line staff and laboratory staff into a review that would take up considerable amounts of time and commitment from staff? Or should a review be implemented that establishes what happened in the Northern Health and Social Care Trust and seeks to ensure that that learning is disseminated elsewhere? I suggest that the latter is preferable.
As we review our strategy document ‘Changing the Culture’, which is our underpinning framework for reducing healthcare-associated infections, we will determine whether further steps are needed for reassurance. The Minister’s targets for reducing healthcare-associated infections will be reached — let there be no uncertainty about that. You heard the commitment from the chief executives of the trusts. Each month, those targets will be monitored and each trust will be held to account for its progress on them. If the targets for reductions in healthcare-associated infections that have been outlined by the Minister are not being achieved, resolute action will be taken to ensure that those targets are reached. I am unequivocal about the commitment, from the top of the Department down to the staff who clean the floors in hospitals, to address the challenge. Dr Deeny, you know the commitment that exists in the Health Service. We have been vulnerable in recent times to the perception that we have been less than open and transparent, and we must address that urgently.
The Chairperson:
We have one more speaker, Thomas Buchanan. It may seem unfair, but, given the hour, I ask you to be brief.
Mr Buchanan:
I will be quick. The numbers of deaths due to clostridium difficile have increased every year from 2001-02 to 2006. Why did it take a public outcry to drive the medical people to say that some robust measure must be taken to stop the infection? Dr McBride talked about prevention and detection, and said that it was too late to count the numbers after people had died. Over the years in which clostridium difficile was increasing, why were medical professionals not alerted to the fact that the infection was on the increase and was causing a number of deaths? Why was something not put in place at that stage to reduce the number of deaths, instead of waiting until now? Is it because the continual benchmarking against the UK figures shows that our numbers are a lot lower? Perhaps the medical profession was distracted by that, rather than focusing on the fact that instances of clostridium difficile were increasing and that something needed to be put in place to try to stop it. Instead, it has reached the stage at which there is a real public outcry, and something urgent must be done.
Dr McBride:
I do not wish the Committee to get the impression that action has only been taken after the tragic circumstances of the outbreak in the Northern Health and Social Care Trust area. I am happy to provide written documentation of the efforts that the Department and the Health Service have put in place over a long number of years to tackle the growing problem of healthcare-associated infection.
As was mentioned earlier, people are living longer. When they are in hospital they are sicker and more vulnerable. Potent antibiotics, which we did not have in the past, are used to treat infections. A complication of that is that people can get clostridium difficile, so there is an increasing challenge in dealing with that issue. To put that in context, the infection rates of clostridium difficile, based on information that was available to the end of September 2007, are not on the increase.
When the validated figures up to the end of December are published and become available, we will clearly see an increase, certainly in the Northern Health and Social Care Trust area. The Committee heard the evidence given by the trusts’ chief executives that they know that, at this point, they do not have difficulties with clostridium difficile infection rates in excess of what they would normally have. That is not to say that we should not be doing more to try to reduce the rates, but we know that we do not have, at this point in time, this particularly virulent strain in other trusts, and that is why we are in this situation, because we never had this strain previously — it is a particularly aggressive strain that is more easily transmitted from one person to another.
I can outline the steps that the Department has taken over the last number of years. We established the Northern Ireland Communicable Diseases Surveillance Centre in 1999 . We put in place mandatory surveillance arrangements, and we are rolling out further such arrangements, as well as publishing the information. Dr Deeny will be aware that we established the antimicrobial resistance action group to ensure best practice in antibiotic prescribing, not only in hospitals, but in the community, too. That plays a vital part in reducing the emergence of resistant bacteria and dealing with the problem of healthcare-associated infection.
As part of the COMPASS system, we provide GPs with data on a quarterly basis. That data includes an analysis of antibiotic prescribing at practice level and shows them how their prescribing compares with that of other GPs in the locality and across Northern Ireland. We indicate the two major antibiotics that can cause clostridium difficile — the broad-spectrum antibiotics, the quinolones and ciproxin. That information is provided so that GPs can examine their prescribing practice to ensure that they are not prescribing excessive amounts of antibiotics.
At the end of the day, an antibiotic should be prescribed only if somebody needs it, and for as short a time as is possible. However, as the Chairperson and Dr Deeny mentioned earlier, that creates a challenge, because often the public perception is that when a person has a cough or a viral infection — like I have at present — an antibiotic is required. Recent media campaigns have highlighted the issue, and members will hear more in due course. The Minister will make an announcement on the detail of the expenditure that we will now be able to commit as a result of the settlement in the comprehensive spending review. He will also outline the detail behind the unannounced inspections, screening and efforts to increase reporting. I assure the Committee that we have not been sitting around waiting for an outbreak. This matter has been in the media more recently, and several media reporters have covered healthcare-associated infections for quite some time, but this outbreak has certainly captured the attention of the public. Again, I am very happy to provide a detailed list on healthcare-associated infections, either as part of the Committee’s ongoing investigation, or separate to that.
The Chairperson:
Thank you very much, Michael.
Members are very concerned that RQIA’s powers are very limited. Given that outbreaks have occurred since 2001, one would have imagined that we would have learned a lot since then. I would not like to think that efforts to hold a wider public inquiry were being stymied because of cost ramifications, because I know that the RQIA has a small budget.
As a Committee we have a duty of care to the wider community. We must show that we are doing our business well enough to allay fears, and it must also be clear that we are adopting a more involved approach to the wider problem rather than simply conducting an inquiry into the outbreak at the Northern Health and Social Care Trust.
With members’ permission, I will propose the wording of a motion. I briefly noted down a form of words, which could be changed or added to:
“This Assembly, following the number of deaths associated with hospital-acquired infections from 2001 to date, calls on the Minister of Health, Social Services and Public Safety to initiate as a matter of urgency a full independent time-bound public inquiry.”
My proposal will need to be seconded. However, in view of what we have learned to date about hospital-acquired infections, the roll-out programme that Dr McBride has described can proceed in the interim. It will deal with cleanliness, in-depth cleaning, hand-washing, reduction of the patient-to-bed ratios, reduction in visiting times and the expenditure of £9 million which the Minister has made available to help.
I mean no disrespect, but I do not want the inquiry to be restricted to a quick fix. I want a full-blown public inquiry, as that is the only way — because of the serious lack of confidence in the Health Service at present — to address those serious issues.
I call the Deputy Chairperson of the Committee to second the proposal.
Mrs O’Neill:
I second the proposal and fully agree with the Chairperson. I quote my colleague Mitchell McLaughlin:
“Circumstances have demonstrated that a much wider investigation is necessary.” — [Official Report, Vol 27, No 5, p283, col 1].
I fully support the Chairperson’s proposal.
The Chairperson:
Can I see a show of hands in support of the recommendation?
Mrs Hanna:
If the Committee wants that, I will support it. However, I was not aware that we had discussed it, other than during the discussion on the Private Notice Question which was asked a couple of days ago in the Chamber. Before the inquiry is held, we need to know what may be expected from it, a timescale for it and how much it will cost. Those are important points.
The Chairperson:
I agree absolutely. Those aspects will have to be worked out. We will also have to consider the screening of the inquiry’s staff so that they do not carry infection into hospitals. They will be on the front line. The inquiry will have to be far-reaching and in-depth. We will have to examine the modality of how such an inquiry can be achieved.
I thank members for supporting the proposal. Our proposal will go to the Minister, but he will have the right to say no. That is up to him. However, because of the seriousness of the issue, and bearing in mind that older folk are afraid to go into hospital, I feel it incumbent on us to make this proposal.
Thank you for your time, Michael. However, we will appreciate delivery of the various documents which you said that you would let us have. I have omitted to ask the chief executives, who were to send us a number of documents, including the paper on the practices in place in each trust to address clostridium difficile and the most up-to-date figures for January and February on the number of cases and deaths.
Dr McBride:
It is not for me to speak on behalf of the Minister. He will want to consider carefully the Committee’s proposal. All I wish to add is that it is not an “either or” scenario. It is important that we quickly establish lessons learnt from the outbreak in the Northern Health and Social Services Trust area. As Chief Medical Officer, having studied in detail the terms of reference, I am aware of the legislation underpinning the powers of RQI. I am confident that an independent review by RQIA will be comprehensive, and will ensure that learning will be disseminated in a timely manner throughout the health and social care system. It will then be for the Minister to consider whether he is satisfied, or whether he feels that there is a need for a much wider inquiry, as the Committee proposes.
Ms S Ramsey:
I will respond briefly: I am conscious of the time. No one is criticising the RQIA: Sinn Féin is certainly not.
There is an old saying that he who pays the piper calls the tune. I am not saying that that is true, but the issue is one of public confidence. The Committee must be cautious, because it is scrutinising the Department.
The Chairperson:
It is a narrow-based inquiry into the Northern Health and Social Care Trust, but we would like an inquiry to cover all the trusts and boards. On a matter of clarification, are we sending our recommendation to the Minister, or are we putting it down as a motion to be debated in the House?
Ms S Ramsey:
We should propose that the motion be debated in the House.
The Chairperson:
That clarifies the matter. Thank you for your time. I apologise for the delay.
Dr McBride:
It is an important matter. Thank you for the opportunity to address the Committee and thank you for listening attentively.