Chamber
Plenary, 26 Mar 2008
26 Mar 2008 · S3 · Plenary
Item of business
Health Care Associated Infection
We have heard a lot—and I am confident that we will hear a lot more as the debate progresses—about the virtues of cleanliness in preventing health care associated infections. That is right, because methicillin-resistant Staphylococcus aureus and, to an even greater extent, Clostridium difficile are easily spread as a result of poor hygiene—I yield to my Latin-usage adviser, Ross Finnie, as to the correct pronunciation of difficile.
Initiatives ranging from the deep cleaning of hospital wards to a simple insistence on regular hand washing to a wear-nothing-below-the-elbow policy all have their place in prevention, although I assure the chamber that the wear-nothing-below-the-elbow policy refers to the arms and not the rest of the body.
Moves that the cabinet secretary has announced, such as implementing a screening programme for MRSA in three pathfinder boards, are welcome. However, there is more to HAI than that. I want to break away from the cosy consensus that has pervaded the chamber and consider another factor in the genesis of HAI: the pressure on clinical staff to treat more and more patients under circumstances that are less than ideal. Part of the problem is that there are two measures of a hospital's efficiency. First, there is the financial or accountancy yardstick, in which bed occupancy is a measure of success. By that measure, the ideal outcome is 100 per cent bed occupancy 365 days a year. That is recognised in hospital private finance initiative contracts, where the number of beds is reduced to achieve that so-called efficiency. Here in Edinburgh, to achieve affordable unitary charge payments under the PFI contract for the new royal infirmary, there had to be a 24 per cent reduction in acute hospital bed numbers throughout Lothian.
Apologists for that sort of draconian reduction, which is not confined to Lothian, claim that a reduction in the number of acute beds is justified because more people are treated in the community, and even in their own homes. Although it is true that many people with medical problems such as asthma can now receive satisfactory treatment without involving a hospital, the same is not the case for surgical conditions. Several years ago, I happily excised cysts or removed toenails in my health centre treatment room, and one of my colleagues had a regular vasectomy list. However, all of that has now stopped. My old health centre, like the majority of general practitioner premises around the country, cannot be modified to suit the requirements of the Glennie report, which was aimed at preventing the transmission of new variant CJD, and such operations now have to take place in hospitals.
It can be argued, rightly, that minor operations rarely end up with admissions to a hospital bed, but they add to HAI risk, because they occupy hospital staff's time and expertise. Further, they introduce patients into an environment that is more likely to be populated by antibiotic-resistant pathogens.
What is the result of the policy of shrinking the number of available beds so that 100 per cent occupancy rates can be achieved? I mention in passing that, for many weeks over the past few months, GPs in Lothian have received a message informing them of the red status of Edinburgh royal infirmary, which states:
"Capacity on site is at present challenged. Any deferrals or alternatives to admission would be appreciated."
GPs are being asked not to send to hospital patients whom they feel unhappy about treating at home. That certainly involves a health risk, but not a cause of infection.
The real threat of infection comes from the so-called hot bedding that needs to take place so that treatment can continue. Patients lying on trolleys in accident and emergency wards have to be found a bed somewhere. In some hospitals, patients having operations such as hip joint replacements, in relation to which wound infection is a disaster, end up in inappropriate wards because they must go where a bed is available. Further, the shorter the time between one patient leaving a bed and another filling it, the greater the chance that the cleaning process will be inadequate.
I mentioned that there are two measures of a hospital's efficiency. The second is a clinical measure. It does not mind a proportion of empty beds; it requires a bed in an appropriate ward at an appropriate time. It requires staff who are not rushed off their feet. Perhaps we should examine the effect of some of our waiting list targets on that measure. It also requires an environment that is conducive to care, not speed. Unless and until we can return to those basic clinical principles—well known to Florence Nightingale—fighting HAI will be an uphill struggle.
Initiatives ranging from the deep cleaning of hospital wards to a simple insistence on regular hand washing to a wear-nothing-below-the-elbow policy all have their place in prevention, although I assure the chamber that the wear-nothing-below-the-elbow policy refers to the arms and not the rest of the body.
Moves that the cabinet secretary has announced, such as implementing a screening programme for MRSA in three pathfinder boards, are welcome. However, there is more to HAI than that. I want to break away from the cosy consensus that has pervaded the chamber and consider another factor in the genesis of HAI: the pressure on clinical staff to treat more and more patients under circumstances that are less than ideal. Part of the problem is that there are two measures of a hospital's efficiency. First, there is the financial or accountancy yardstick, in which bed occupancy is a measure of success. By that measure, the ideal outcome is 100 per cent bed occupancy 365 days a year. That is recognised in hospital private finance initiative contracts, where the number of beds is reduced to achieve that so-called efficiency. Here in Edinburgh, to achieve affordable unitary charge payments under the PFI contract for the new royal infirmary, there had to be a 24 per cent reduction in acute hospital bed numbers throughout Lothian.
Apologists for that sort of draconian reduction, which is not confined to Lothian, claim that a reduction in the number of acute beds is justified because more people are treated in the community, and even in their own homes. Although it is true that many people with medical problems such as asthma can now receive satisfactory treatment without involving a hospital, the same is not the case for surgical conditions. Several years ago, I happily excised cysts or removed toenails in my health centre treatment room, and one of my colleagues had a regular vasectomy list. However, all of that has now stopped. My old health centre, like the majority of general practitioner premises around the country, cannot be modified to suit the requirements of the Glennie report, which was aimed at preventing the transmission of new variant CJD, and such operations now have to take place in hospitals.
It can be argued, rightly, that minor operations rarely end up with admissions to a hospital bed, but they add to HAI risk, because they occupy hospital staff's time and expertise. Further, they introduce patients into an environment that is more likely to be populated by antibiotic-resistant pathogens.
What is the result of the policy of shrinking the number of available beds so that 100 per cent occupancy rates can be achieved? I mention in passing that, for many weeks over the past few months, GPs in Lothian have received a message informing them of the red status of Edinburgh royal infirmary, which states:
"Capacity on site is at present challenged. Any deferrals or alternatives to admission would be appreciated."
GPs are being asked not to send to hospital patients whom they feel unhappy about treating at home. That certainly involves a health risk, but not a cause of infection.
The real threat of infection comes from the so-called hot bedding that needs to take place so that treatment can continue. Patients lying on trolleys in accident and emergency wards have to be found a bed somewhere. In some hospitals, patients having operations such as hip joint replacements, in relation to which wound infection is a disaster, end up in inappropriate wards because they must go where a bed is available. Further, the shorter the time between one patient leaving a bed and another filling it, the greater the chance that the cleaning process will be inadequate.
I mentioned that there are two measures of a hospital's efficiency. The second is a clinical measure. It does not mind a proportion of empty beds; it requires a bed in an appropriate ward at an appropriate time. It requires staff who are not rushed off their feet. Perhaps we should examine the effect of some of our waiting list targets on that measure. It also requires an environment that is conducive to care, not speed. Unless and until we can return to those basic clinical principles—well known to Florence Nightingale—fighting HAI will be an uphill struggle.
In the same item of business
The Presiding Officer (Alex Fergusson):
NPA
The next item of business is a debate on motion S3M-1621, in the name of Nicola Sturgeon, on the health care associated infection task force.
The Deputy First Minister and Cabinet Secretary for Health and Wellbeing (Nicola Sturgeon):
SNP
I am pleased to open the debate and to present our ambitious new plans for tackling health care associated infection in Scotland during the next three years ...
Margaret Curran (Glasgow Baillieston) (Lab):
Lab
I emphasise how much we in the Labour Party welcome the debate. We acknowledge that our amendment will be accepted. I associate myself with many of the point...
Nicola Sturgeon:
SNP
I hope that I can reassure Margaret Curran that the investment that we have set aside for the next three years is 260 per cent higher than the investment ove...
Margaret Curran:
Lab
I will take that—graciously, I hope—as an indication of the cabinet secretary's commitment. However, as I understand it, England has prioritised the issue, a...
Mary Scanlon (Highlands and Islands) (Con):
Con
It is always good to follow the gracious Margaret Curran. The Conservatives welcome the debate on health care associated infection. We also welcome the inves...
Ross Finnie (West of Scotland) (LD):
LD
I do not discern—and I suspect that, by the end of the debate, I will not discern—any disagreement with the proposition that, because health care associated ...
Nicola Sturgeon:
SNP
I am pleased to intervene on that very serious point. I hope that the member will take some reassurance from my pronunciation of "coherence" during my speech...
Ross Finnie:
LD
I am greatly comforted. We must maintain standards in the chamber.Health care associated infection is a serious issue, and I welcome the debate. Margaret Cur...
Ian McKee (Lothians) (SNP):
SNP
We have heard a lot—and I am confident that we will hear a lot more as the debate progresses—about the virtues of cleanliness in preventing health care assoc...
Helen Eadie (Dunfermline East) (Lab):
Lab
I agree with Ross Finnie's suggestion that there is likely to be near unanimity on this vital issue. I welcome the cabinet secretary's announcements about th...
Nicola Sturgeon:
SNP
I am always happy to consider lessons from elsewhere, and I appreciate Helen Eadie's point, but I remind her that I mentioned our policy, which I launched ea...
Helen Eadie:
Lab
I am sorry that the cabinet secretary feels aggrieved, but if she had been listening she would know that I congratulated the Government on its screening init...
Michael Matheson (Falkirk West) (SNP):
SNP
I welcome the Cabinet Secretary for Health and Wellbeing's statement. In the spirit of consensus, I acknowledge the work that the previous Labour and Liberal...
Irene Oldfather (Cunninghame South) (Lab):
Lab
I welcome the commitment that the cabinet secretary has made and the opportunity that the debate gives us to consider how we can reduce the risk of contracti...
Nanette Milne (North East Scotland) (Con):
Con
This debate on dealing with health care associated infections is extremely important. However, I cannot help feeling sad that the reputation of a health serv...
James Kelly (Glasgow Rutherglen) (Lab):
Lab
I welcome the opportunity to take part in this afternoon's debate on health care associated infections. I endorse the cabinet secretary's announcement and, o...
Sandra White (Glasgow) (SNP):
SNP
The cabinet secretary is to be congratulated on this initiative. As the Labour amendment states, the previous Government is to be commended for the establish...
Rhoda Grant (Highlands and Islands) (Lab):
Lab
Many members have talked about consensus, but consensus does not make the debate any less important—we should debate such issues.The cabinet secretary mentio...
Nicola Sturgeon:
SNP
Rhoda Grant makes an important point. It may be of interest to her and other members to know that we are working with the trade unions on a national uniform ...
Rhoda Grant:
Lab
Yes. I am grateful to the cabinet secretary for that information. The BMA position shows that doctors have the will and wish to see the proposal progressed.W...
Jamie Stone (Caithness, Sutherland and Easter Ross) (LD):
LD
I agree with nearly everything that has been said in this worthwhile debate. The unanimity of the message will be encouraging to patients and health professi...
Jackson Carlaw (West of Scotland) (Con):
Con
We welcome all that Nicola Sturgeon has said today in her speech and her interventions, including the MRSA pilot that she announced, in what has been a usefu...
Dr Richard Simpson (Mid Scotland and Fife) (Lab):
Lab
As all other members who have spoken have said, the debate has been consensual, informed and of a high standard. As Jamie Stone said, that should give comfor...
Nanette Milne:
Con
My point was that it does not matter who actually does the cleaning. What is important is the supervision of a high standard of cleaning.
Dr Simpson:
Lab
I hate to say this, but I could tell Nanette Milne numerous stories of when contract cleaners have come in, done their bit and gone away, leaving the questio...
The Minister for Public Health (Shona Robison):
SNP
I have listened with interest to this constructive, stimulating and wide-ranging debate, which has served as a stark reminder that the Scottish Government an...