JOINT COMMITTEE ON HEALTH AND CHILDREN díospóireacht -
Thursday, 2 Mar 2006

MRSA Issues: Presentations.

Chairman

I welcome the officials from the Department of Health and Children and the Health Service Executive. The delegation will update the committee in respect of issues surrounding MRSA. I welcome Dr. Colette Bonner, deputy chief medical officer at the Department of Health and Children, Mr. Peter Hanrahan, assistant principal officer at the Department of Health and Children, Ms Dympna Butler, principal officer at the Department of Health and Children, Dr. Kevin Kelleher, assistant national director at the population health directorate at the HSE, and Dr. Mary Hynes, assistant national director at the National Hospitals Office at the HSE.

Before I ask the delegations to commence their presentations, I draw their attention to the fact that members of the committee have absolute privilege but that this same privilege does not apply to witnesses appearing before the committee. Members are also reminded of the long-standing parliamentary practice to the effect that members should not comment on, criticise or make charges against an person outside the House or an official by name or in such a way as to make him or her identifiable.

This meeting is a follow up to that held on 17 November 2005, when the committee agreed to invite officials to appear before it on a quarterly basis to update it on progress in respect of MRSA. I call Dr. Bonner to make her presentation, after which members may pose questions.

Dr. Colette Bonner

On behalf of the Department of Health and Children, I thank the committee for inviting my colleagues and I, and colleagues from the HSE, to update it on this important area of health care associated infections. The Department of Health and Children, in partnership with the HSE, is totally committed to reducing preventable health care associated infections, which have significant implications for the system, both in terms of human suffering and financial costs.

As most members are aware, we initially met the committee on 17 November 2005. On that occasion, we had a wide-ranging and informative discussion. The meeting's key message was that the cause of health care associated infections is multifactorial and that any solution to reducing the incidence of these infections involves several key elements, which must be tackled in tandem. These elements are: hospital hygiene and compliance with hand hygiene; improving the physical and personnel resources within hospitals to control infection; collection of meaningful data in order that comparisons can be made at international, national, regional and local levels; and a reduction in the overall use of antibiotics in both hospital and community settings. I will now hand over to Dr. Kevin Kelleher who will update the committee on progress made since our previous meeting.

Dr. Kevin Kelleher

I thank the committee for the invitation to come before it. I understand that members have received a document from us, which I will briefly go through because it contains a considerable amount of detail, which I am sure members have already read.

The first three or four pages of our document deal with the general issues surrounding health care associated infection. As we noted at our previous meeting, although most of the discussion has focused on MRSA, we are concerned about the much wider area of health care associated infection and antimicrobial resistance. This document sets out some of those issues.

On page 2, members can see how people are significantly affected by being infected while they are in hospital. Infection significantly increases their chances of further illness, of enduring extended stays in hospital and of dying as a result of such stays. The health services have always known that this is one of the most significant problems we face and one of the major clinical risks faced by hospitals and the health care system. We face the challenge of trying to prevent and reduce the impact of health care associated infection.

Ireland is not unique in experiencing problems with health care associated infections. Every hospital throughout the world has a problem with these infections. Some of the earliest cases about which people are aware in this regard date back 200 or 300 years and involved women dying after childbirth as a result of nurses or doctors not washing their hands in between dealing with patients. This problem was identified and changes took place. Matters of this nature have become more complex.

The level of MRSA in Ireland is shown on page 3. There has been an increase in the number of cases of MRSA but there has also been a much larger instance of infection with staphylococcus aureus among members of the population. This demonstrates that we are getting better at identifying this problem and seeking to do something about it.

This problem is not unique to Ireland. However, the distribution of it throughout the country is unique. The map shows that Ireland resembles the UK and some countries in southern Europe but differs from countries in northern Europe. The problem does not solely concern MRSA and staphylococcus aureus. The graph on page 4 demonstrates the extent of infection with e.coli, another bacteria with which people are familiar. There is an increasing possibility of resistance to e.coli, which must be addressed. This is where the issue of antimicrobial resistance is very important.

I will now deal with what works, based on international experience. The points heard by the committee at our previous meeting are very clear. Active surveillance and screening, availability of isolation facilities, appropriate levels of infection control staffing, staff use of various precautions and hand hygiene and lowering levels of antibiotic use all help to prevent and reduce hospital acquired infection. The HSE undertook a survey in 2003 to identify where we needed to take action, which we are now acting upon. Some of the results are pinpointed in our document. Our previous meeting with the committee came just after we published the results of the first national audit of hygiene. Members can see some of these results in our document. We are now in the throes of the second hygiene audit, which began in February 2006. The results should be due sometime in the summer, with the first report to the national hospitals office, I hope, appearing in June 2006.

We are also in the process of finalising our national standards for infection control and cleaning. These standards have gone through an extensive process with the help of the Irish Health Service Accreditation Board and are being piloted in a number of hospitals. The results of these pilot projects will give us the final standards in infection control and hospital hygiene and cleaning.

We have also examined the very important issue of training for staff and how it should be carried out. We have identified a clear need for us to provide training for professional clinical staff and other staff within the system. Section 7 on page 8 details some of the measures we have examined to provide this training to staff in hospitals.

Another issue of great importance to us is ensuring that products, be they cleaning agents, chemicals or laboratory tests, are appropriate to prevent and reduce the impact of hospital acquired infections. We are, therefore, establishing a group to examine how this can be done in order to ensure that we obtain good products that are clearly evidence-based, work and are cost-effective within our system.

Public communication and publicity are very important. We have had the "Clean Hands Save Lives" campaign and the publication of a number of documents indicating what needs to be done. We will address the need for us to undertake a much larger publicity campaign this year. We also recognise that we must carry out similar measures within our system for our staff. Aside from training, we must increase people's awareness and understanding of what needs to be done. Those are some of the issues we intend to address.

In parallel, we have accepted that the issue of visiting may have an impact on what is happening. The National Hospitals Office has undertaken a cross-system review of visiting procedures and made proposals on a new standard national visiting policy. This document is still in consultation but it will hopefully be published shortly. It is hoped that the policy will allow visiting in a compassionate way but will also meet the needs of a modern health care system by ensuring that hospitals are not so overrun that it will be difficult to provide safe care for patients.

We are involved with our colleagues in the United Kingdom in a major study on the prevalence of health care associated infection. This study, undertaken under the auspices of the professional organisation of consultant microbiologists and infection control staff, is being carried out in all four parts of the United Kingdom and we have agreed to participate. The study will be important because it will one day give us exact information on how much hospital acquired infection is in our system. It is not a routine study but the information will allow us to see the full scale of the problem in order that we can determine what to do. Due to the way in which the study is being carried out, we will be able to compare Ireland to the four parts of the United Kingdom. Consequently and because of other studies in the United Kingdom, we will be able to see some of the economic and social impacts, as we will be able to extrapolate them from our database and what we know of the United Kingdom's data.

We met the MRSA and Families group in February and arranged to meet with it twice a year, in the months of May and November. Dr. Hynes and I have just received a communication from Professor Drumm in which he indicated that he will join us at one of those meetings in the near future because he would like to meet the families.

Much of the discussion beyond this room has been on the level of resources required to deal with the issue. In the Estimates voted to the HSE this year, nothing was specifically given to deal with this problem. However, the HSE believes it is an important issue that must be attacked and in respect of which something must be done. In the processes we undertook, which have culminated in recent days, it was agreed that €5 million, taken from elsewhere in the system, be set aside this year to deal explicitly with the problems of MRSA and hospital acquired infections. In addition, a directive has been sent to the rest of the system to the effect that when people are engaged in other developments in the clinical area, they must put in place infection control measures that will improve the system, particularly where it is expanding. This is the up-to-date position.

Deputy Twomey

I thank the witnesses for their very informative presentations. There is often a feeling that the committee is working in a cocoon — that we discuss this matter and obtain all the information in respect of it. How much of what happens here gets out to and impacts on the hospitals and the people working therein? What would be the response if the media ran a major campaign asking whether people feel their hospitals are always clean or whether the procedures and protocols discussed by our guests are being followed?

We are discussing a visiting policy and protocols. We know, more or less, that hospitals are open shops when it comes to visiting hours. Any number of people can visit, day or night, sit on other patients' beds, pull chairs across wards and use the facilities willy-nilly. It does not take a report to know this. Someone must take control of each hospital.

A question we keep avoiding — our guests avoided it in their presentations, which focused on antimicrobial problems, infection control nurses and so on — is that if people went into hospitals in the morning and saw something they were not happy with, such as dirty toilets, wards or linen or overflowing dustbins, is there a clear chain of command in place in order that they might identify who is responsible for these issues or will patients continue to get the run-around by being told to send their complaints to one person or another, only to receive a meaningless standard reply from a hospital manager? From day one, we have been telling everyone who has come before the committee in respect of this issue that there should be a chain of command, not nice brochures or stickers about washing one's hands, in place.

On the clean hospital summit, at which the Department of Health and Children sponsored the Irish Patients Association, it is strange that the HSE also sponsored the association. Invitations were not extended to members of the committee. If the summit was exclusively for HSE staff, why was it not run by the Department and the HSE? Why did the HSE sponsor the Irish Patients Association in hiring a room in the Four Seasons Hotel, when no invitations were extended to people outside the HSE? One criticism that cannot be made about the HSE or the Department is that they are bad at organising conferences. I am surprised they received outside help in that respect.

Deputy McManus

I wish to question the policing of standards. Does every hospital have a hygiene nurse or person responsible for dealing with this matter? Do members of the cleaning staff of every hospital work after 5 p.m.? I know of one hospital in which the cleaning staff goes home at 4.30 p.m. or 5 p.m., leaving no one to provide cleaning services. In another case, I received a distressing report from the family of an elderly patient who has been moved from ward to ward, one dirtier than the next. One ward's floor had human faeces on it.

I agree with Deputy Twomey in that there is a concentration on compiling information and reports in a way that looks as though something is being done but it is not clear — I stand open to correction on this — whether there are people in place who can be held responsible or who are charged with carrying out the work. From where will the €5 million to which Dr. Kelleher referred come? Will it be used to employ more staff, how will it be spent and what areas will lose out as a consequence of this amount being transferred to address these types of infections?

Deputy F. O’Malley

It is practical that, as Deputy Twomey stated, people who go to hospitals should be aware of the processes that obtain. It is important to have information on the hygiene habits of staff and changing those habits. St. Columcille's Hospital in my area of Loughlinstown has an appalling record, which does not surprise me because constituents have informed me that it is filthy. They need to know that the hospital is cleaning up its act. As Deputy Twomey asked, how do people know toilets are being cleaned and waste paper baskets emptied on a 24-hour basis? Will our guests outline the practical steps being taken in this regard?

I welcome the reduction in visiting hours. Hospitals are places of infection and must be contained to a certain extent. The habits of staff have been mentioned but the wearing of uniforms was not. I know the Minister is concerned about the wearing of uniforms outside hospitals. Due to the nature of hospitals, have recommendations been made that staff should not wear uniforms outside and change into them when they arrive at work?

What is the outcome of the meetings regularly held with families? Are they hand-holding exercises or is there a practical outcome?

I was disappointed and surprised that there was not one mention in the presentation of the over-prescribing of antibiotics, which is another cause of MRSA. Why was this element ignored? What percentage of infections arises from it? I know it is a tricky issue because one cannot interfere with clinical decisions made by doctors. However, it is an enormous cause of the prevalence of the bug and the problem will not be solved until that issue is dealt with. I want it to be addressed.

Chairman

We will take those questioners first.

Dr. Mary Hynes

One of the results of the first national hygiene audit was putting this issue much more centre-stage on the agenda of hospitals. I am aware from contact, not only with hospital managers but also with staff who have had concerns about this issue for some time, that there is now a focus, attention and will to address hospital hygiene in the practical ways referred to. I hope the second hygiene audit under way will provide evidence as to whether that effort has been translated into an improvement in hospital cleanliness but if we do not measure it, we will not know. There will always be a hospital that will come out best and one which will come at No. 53 or 54. We hope the hospitals at the lower end of the scale have improved and are not at the same level as they were last summer. There has been a focus on training and providing information within hospitals, not in brochures or leaflets but through face to face meetings with staff and holding information and training sessions. People are taking on board what they learned from the findings of the first audit and working on those issues which can be dealt with quickly. Dealing with issues on facilities and infrastructure will take longer.

On visiting policy, it would be easy for three or four people to go into a room, draft a policy and send it out. However, we want the policy to strike a reasonable balance between what we believe should happen and what is workable. Hospitals differ from each other. What is necessary in a children's ward or in a children's hospital and what is appropriate in a maternity ward or intensive care unit must be taken into consideration. Patients in intensive care units are critically ill and families have a high level of anxiety. The purpose of the consultation document is to take on board all of these needs to ensure the final policy will be capable of implementation. Some maternity units have stated to us they already have measures in place such as only allowing fathers to visit between certain hours and not allowing visitors in at all hours of the day or night.

Regarding the chain of command, ultimately the chief executive officer or the general manager is responsible for cleanliness and hygiene in hospitals. Within a particular department or ward, the head of that department or ward is responsible. As with a complaint about any other aspect of care, the best place to handle a complaint about hospital cleanliness is as near as possible to where the incident happened and we encourage this. The higher chain of command is invoked when people do not get satisfaction at local level and the complaint cannot be handled there.

I spoke a great deal about cleaning standards. We must be clear and separate cleaning from infection control, which is a much broader agenda. Some elements such as waste management, linen, hand washing and the handling of sharp objects and dirty needles are an important part of the broader infection control agenda. However, we must remember that, even if all of our hospitals were spotlessly clean, we would still have to address other infection control issues. It is important that we make that distinction.

Hospitals are identifying where they need cleaning staff beyond 5 p.m. An accident and emergency department is an obvious example, where services are run 24 hours a day. It is not as important in an outpatient department which closes in the evening. Progress has been made in some hospitals but I acknowledge that more must be done. One issue we identified on which more must be done is that of a policy on uniforms. We hope to have one finalised by the summer. Staff know they should not go down town in their uniforms. It is a matter of enforcing this as a policy issue.

The overprescribing of antibiotics is an important question in infection control and a pilot project has been run in the southern part of the country. It is a community as well as a hospital issue and involves the education of general practitioners. Prescribing antibiotics involves a number of decisions such as whether to prescribe in the first instance, whether to prescribe a narrow or broad range antibiotic and its duration and dosage. The pilot project resulted in significant changes in the choice of antibiotic and its duration and dosage. It did not have quite as much impact on the decision to prescribe. The education programme is being modified to take this into consideration. The funding we have at our disposal this year will allow us to roll out the project nationally.

Other countries further advanced than us have found that there is no point in having a prescribing initiative without a public education campaign on not demanding a prescription from a general practitioner and on finishing the course of antibiotics prescribed. We hope to run such a campaign this year. They are two important planks of the infection control and antimicrobial resistance problem that we will be able to advance this year.

Dr. Kelleher

I am sorry if we did not mention antibiotic prescribing. The last time I was here I thought I had probably belaboured the point to a degree. Fundamentally, the key issue in the medium and longer term, as Dr. Hynes said, is that of antibiotic prescribing. We have evidence of very effective control of antibiotic prescribing in hospitals which we now intend to pursue across the country.

On the issue of a hygiene nurse — the term we use is a control of infection nurse — our survey of what is happening across the country has identified the areas where there are gaps, sometimes total, others relative, in the number of control of infection nurses. Our intention, with the resources made available this year, is to close those gaps. Having said that, as well as the difficulty of obtaining resources, we must also live under the manpower ceiling within the health care services. That is a very important issue for us and we must determine how the matter can be best addressed.

As Dr. Hynes said, we have clearly identified a number of areas where we can see effective action resulting in positive outcomes. We intend to pursue these issues more generally throughout the whole system, particularly antimicrobial resistance and overprescribing.

Members asked about the clean hospital summit. It was important that the staff concerned should come together to debate, listen and discuss the issues involved. We took a very important step by involving an outside agency such as the Irish Patients' Association in the process. It provided for a degree of separation from the Department of Health and Children, allowed people to come together to have discussions and hear experts in the area. It was a very successful day in allowing people to see what the possibilities were. Patients were also invited to the summit. It was an important day for us. I am not sure that in the overall scheme of things the sum of money involved presented a problem, as it was very important to get people together and for us to learn from the proceedings.

The policing of standards forms part of what we are examining. The audit shows the direction in which standards are moving. Once the measures are fully in place, they will form part of the performance management systems being put in place within the Health Service Executive which will ensure standards are being adhered to throughout the system.

On the issue of resources, one would expect somebody in charge of a very large budget to make sure that he — that is, Professor Drumm — will do what is expected of him within the system. He has made arrangements to ensure everything asked of him by the Tánaiste and the Department of Health and Children will be provided. Equally, he has sought to try to address other issues he considers to be important, of which the distribution of resources is one. Some developments will not be fully completed this year, although funding has been provided for them. Therefore, only some of the money will be used this year and we will seek the remainder in subsequent years. The papers have been made public and a press release was issued last week outlining how this is to be done. I am sorry but I do not have the exact details with me this morning.

We met the MRSA and Families group recently and a number of issues were raised, particularly how people were cared for in the community and how MRSA was being dealt with in that setting. They were immediately brought to the attention of management and professionals in the community care sector who were asked to address them. We will report back to the group on how we are progressing at our meeting in May.

Deputy Neville

I must apologise in advance because I will have to leave to attend the Order of Business in the Dáil but I will pick up on the response given to my question in the Official Report. My question relates to communication with patients and other relevant persons. It seems there is still a lack of communication in informing those who have contracted MRSA and their families. In particular, it seems there is a lack of communication with nursing homes when patients are transferred from the hospital setting. We have received complaints that hospitals are not communicating to nursing homes the fact that MRSA has been contracted by patients. I fail to understand why this would happen, given the acceptance of the seriousness of the issue.

Has any progress been made on the development of facilities for those who have cystic fibrosis? The Cystic Fibrosis Association of Ireland met this committee approximately two months ago and every committee member was extremely concerned about the absence of specific services required by cystic fibrosis sufferers. We were struck, in particular, by the comparison made between the services available here and those on offer in Northern Ireland and Great Britain.

Again, I apologise for having to leave to attend the Order of Business. I am Acting Whip for my party today.

Deputy Connolly

The message that must be sent when a patient is in hospital is that he or she is very sick and more often than not unfit to receive visitors. I have spoken to people who told me that they were not fit to receive visitors having come through major surgery. When people travel from the country to Dublin, they believe they must spend a certain amount of time with the patient they are visiting, often leaving him or her exhausted. I have heard patients say they were glad when visitors left, though this was not meant to be offensive. This message should be sent and would be better than adopting strict rules that visitors are only allowed in, for example, between 2 p.m. to 4 p.m. because they would then feel they would have to visit between those times. The point should be emphasised that very sick patients are not fit to receive visitors.

There was an inference in the presentation that general practitioners were prescribing antibiotics recklessly. In that context, communication with general practitioners is very important, given that they are the only ones who can write prescriptions.

The issue of cleaners being available at particular times is an important one. They should be available when there is hospital traffic. Many hospitals have contract cleaners at times when there are no patients in the hospital. At such times the hospital is spick and span. Management can state it has dedicated a certain amount of its budget to cleaning, which gets it off the hook.

No reference has been made to disinfecting beds once patients are discharged, a major source of concern for me. I regret that I must also leave now.

Deputy J. Breen

I thank the delegates for their presentation. In 1993 the then Minister for Health and Children, Deputy Howlin, issued guidelines on the MRSA superbug but they were never adhered to. We can have all the papers we like in front of us, but they will not change reality. What disciplinary measures are in place in hospitals for doctors and nurses who do not comply with hygiene standards? How many have received verbal or written warnings or been suspended?

I know of a case in the west where a 66 year old man was admitted to the intensive care unit in the regional hospital in Galway one Friday morning. When his neighbours went to see him on the Saturday afternoon, they found him wearing the same trousers he had been admitted in and that they were saturated with urine. I rang the hospital authorities to ask them why this had happened. They rang me back the following day to say they could not tell me but that they would tell his family. I told them the man had no family in Ireland and they said they would tell his neighbour. I argued that there was no point in telling a neighbour, that they should tell me, as his public representative, but they would not do so.

I ask the delegation to investigate this matter and discipline the individuals who left the man concerned in his wet trousers in bed for almost 30 hours. Will they investigate it? No, they will not. They will simply come here and pay lip service to tackling MRSA. Cleaners are every bit as important as the most senior surgeon because if they do not do their jobs properly, paint will flake on ceilings. Why is emulsion paint used on walls when a hard gloss paint can be washed down?

I am a victim of MRSA which I contracted in a doctor's surgery rather than a hospital. No doctor or nurse has been disciplined for the lack of hygiene in our hospitals and there is no intention of doing so. The paperwork with which we have been presented today is no good to any man if his legs have been removed. A lady in the Visitor's Gallery was not even told that her husband had contracted MRSA but learned by accident. People's lives are being destroyed, including my own, because of MRSA. We want implementation, rather than more fancy paperwork or reports.

I agree with Deputy Twomey's comments on visiting hours, given that ten or 12 people can be found sitting on a patient's bed. Why can we not revert to the old regime, under which two visits per patient per day were allowed? Years ago, when I was in hospital, anybody found in a ward after the bell rang would have been thrown out by the matron. That is not happening today.

Chairman

I do not mean to plámás Deputy Breen when I say we are aware he is a MRSA sufferer. However, we must also acknowledge the importance of the papers presented by the experts who come before us.

I attended the meeting in the Gresham Hotel which revealed the ongoing concerns of MRSA sufferers and their families. While it is acknowledged that we need to avail of expertise in dealing with this matter, nobody seems to be assigned specific responsibility for controlling it. At our meeting in November the committee made the point that somebody should be given responsibility for controlling MRSA and made answerable to the HSE if standards were not met. We also noted the pyramid approach to grading hospitals. Who is answerable if grades are not achieved? The public has to be persuaded that someone is in charge and held to account but mere appearances before this committee will not achieve that level of confidence. I support Deputy Breen's comments. While expert advice must be presented, we must be clear in our minds that people have to be held responsible. If they are not removed for their failures, we will not be able to restore confidence.

I thank the Department and the HSE for briefing us but to make a real success of these three-monthly appearances, they will have to inform us at our next meeting of the safeguards in place, whether people are being held responsible in each regional hospital or health service area and to whom they report. Otherwise, the briefing sessions will not restore confidence.

Senator Henry

I thank the delegation for attending. I am aware of the hierarchical system within hospitals and recently read a report which described a survey conducted of hand hygiene standards in a certain hospital. Various staff had been surveyed, including nurses, junior doctors and registrars, but consultants had not.

Does the HSE intend to survey private hospitals? Given that 50% of the population have private health insurance, the increasing numbers of private hospitals should not be left out of the loop. The aforementioned consultants work in both public and private hospitals.

Senator Feeney

The Chairman summed up the matter succinctly. Given the level of frustration experienced by this committee, the mind boggles at what sufferers and their families must feel. Last November we discussed the same issues, cleanliness and hygiene in hospitals and contract cleaners, yet we continue to see contract cleaners come and go and hear Dr. Kelleher say the head of a ward is responsible. Bathrooms are still dirty and reports continue of blood splattered on walls and floors and overflowing bins not being emptied for three to five days. Sufferers do not see any change and, as Deputy Breen noted, paperwork is not worth a damn to them. When will the next hygiene audit be conducted?

I read in The Irish Times yesterday that the Tánaiste had written to the head of the HSE, Professor Drumm, on imposing visiting hours of 2 p.m. to 4 p.m and 6.30 p.m. to 8.30 p.m. I welcome this proposal and hope it will be policed. As a child, I remember the ringing of a bell at the end of visiting hours, in response to which visitors ran out of the hospital. That is not the case today.

I am also delighted to learn that there will be an ethical and legal onus on doctors to inform patients that they have contracted MRSA. Why was this not done earlier? I formerly chaired the ethics committee of the Medical Council and was involved in rewriting the guidelines on medical ethics. There is an onus on the medical profession to be open with patients if, for example, they have cancer. MRSA can be just as fatal, yet it is covered up. This is unacceptable. I am cross and can feel the frustration of sufferers.

Deputy Cooper-Flynn

I welcome the delegation, in particular Dr. Hynes, a former colleague of mine in the Western Health Board. In her presentation she mentioned that hygiene was only one aspect of infection control. However, it is the aspect that creates the greatest impression on hospital visitors. We all realise that MRSA is a more serious issue, but it is important that hygiene in hospitals is addressed. I was astounded by Senator Henry's remark that hospital consultants had not been audited also.

A number of hospitals did well in the last audit. Have they shared their experiences with hospitals which did not perform as well? Unfortunately, my local hospital is among the poor performers, although two hospitals in Galway fared better. After the audit, did the training programmes apply to the consultants, temporary staff and everybody who has a part in cleaning in hospitals?

On the contract cleaners, I do not think anybody cleans anymore. Nobody gets down on their hands and knees and cleans. It has gone out of fashion. When I was growing up my mother was a nurse and to clean one had to get down on one's hands and knees and scrub. Having visited hospitals and been a patient I feel people are not prepared to clean. This is difficult to resolve because contract cleaners see their work as just a job, many of them are temporary workers and it is difficult to instil in them the importance of their work. The training programme must address that. Cleaners in hospitals must know that their job is as important as that of the consultants and surgeons.

The presentation stated "the evidence provided on the level of effectiveness of in-house training varied across the country". Why is that? Who monitors the effectiveness of the training programme? How was that observation made?

Deputy Fitzpatrick

I have been examining the report on the national hygiene audit which gave the results good, fair and poor. Only 9% of hospitals were rated good, 43% were rated fair and 48% were considered poor. I realise this is the first audit and there are other audits to come. I presume that since the first audit steps have been taken to improve training, cleanliness, attitudes and supervision in hospitals. The committee seems to feel that cleaning should be taken in house again. When I worked in hospitals the cleaners were hospital employees and came directly under the ward sister or whoever was in charge. In our hospitals nobody takes ownership of anything. Nobody is responsible for cleaning and hygiene. One can take this analogy too far, but hospitals are similar to hotels in that they deal with people, although they provide extra services. Any large hotel has a duty manager in charge and with whom one can deal. That is not the case in Irish hospitals after 5 p.m. or 6 p.m.

With the publication of the Lourdes Hospital report we must get away from the idea that consultants are a breed apart in hospitals. While they are important, they are employees like anybody else. Until we communicate the idea that they are as responsible for their actions as anybody else, this trouble will continue.

Deputy Twomey

Hospitals often have no changing facilities for nurses. An extra 5,000 have been employed recently in the HSE and there seems to be no ceiling on the employment of staff in the HSE. I am surprised that the €5 million mentioned is not to be spent this year but over several years. I disagree with the idea of cleanliness and infection control being separate because we use the word "hygiene" to cover both. If a hospital is clean, infection might also be under control. The problem with consultants is that they are independent contractors and are not subject to the same standards as hospital employees. Do the witnesses consider accident and emergency consultants responsible for the hygiene of their departments? The report referred to "performance management systems", "groups of key stakeholders" and stated "national policies and procedures need to be developed". It also included the following paragraph:

The workshops were facilitated by national partnership facilitators whose role was to ensure that information was captured under each of the questions above on templates as supplied and to document burning issues from each of the plenary feedback sessions.

That is the kind of gobbledygook we hear. The HSE monitors approximately 57 hospitals under the hygiene audit. Could we get the reports from those workshops on each hospital group? They cover a number of questions on policies and procedures, waste management and technical support. Then we could see whether the hospital workers think they fall down on equipment, training and staffing. Could the Department tell us the name of the person responsible for hygiene in each of those 57 institutions? If somebody telephones me and tells me a certain hospital is dirty I could then provide the name of the person he or she should contact. That might make more difference than talking around facts and figures. The HSE could send this information to the committee.

Chairman

We are not trying to rubbish the fact that the witnesses have come here with expert advice. We must refer to the meeting we had last November. It would be wrong of me not to pinpoint the issue. We had presumed and believed that a tier of responsibility would be put in place and although I am loath to suggest this, there is little point in having three-monthly meetings unless we attain that objective. Somebody must be put in charge of each hospital or institution, whether regional hospitals or hospitals for the elderly — I do not know how we can tackle doctors' surgeries. That person would report to somebody like a health or cleanliness czar in the overall structure. Until that happens we are not convinced we are making progress. It is important the witnesses give us the expert advice and we welcome that.

I return to Dr. Fitzpatrick's basic point which this committee has often discussed. A basic process should be in place. As we grade guest houses and hotels, surely we can grade hospitals. If we do so, and if there is somebody responsible, the ultimate sanction must be to remove that person from his or her job. I recently attended a meeting of MRSA sufferers in the Gresham Hotel. A doctor visiting from the UK, whose name I have forgotten, made three points. He showed how he had reduced the level of MRSA in his hospital and in the district for which he is responsible. He showed us how he achieved that through cleanliness methods, roster controls and the basic issue of equipment and the methodology of cleanliness. Until we see specifics like that we cannot be convinced. I was admitted to Portlaoise General Hospital over Christmas. Although it did not fare well in the hygiene audit, it seemed clean. I begin to wonder how the hospitals are graded.

We see no point in meeting on a three-monthly basis unless we hear from the witnesses over the next month on how we will deal specifically with areas of responsibility and people being responsible. I recently attended a meeting at which a senior member of the Government involved on the committee asked hospital staff who was in charge of cleanliness in the hospital and they were not able to say. I found that embarrassing. If senior staff in a small hospital are not aware who is in charge of cleanliness it defeats our purpose. We are putting down a marker, although not in a negative sense. If we are to bring this to a successful conclusion we must be able to identify the people responsible for such matters.

Members referred to cancer care. We cannot prevent cancer, though we can control it. However, we can prevent MRSA and the fact that we have not done so is why people are annoyed. It is not the fault of Dr. Kelleher but we have heard that manpower constraints hamper the process. I ask him to prepare figures for the next meeting outlining the required manpower levels. The committee can then bring pressure to bear to bring them about. Dr. Kelleher has many questions to respond to and I do not want to distract him.

Dr. Kelleher

Many questions have been asked and I will try to deal with some of them together. Following the last meeting and those of the Tánaiste and Minister for Health and Children and ourselves with the group MRSA and Families, we have emphasised to our management and professional divisions the clear need for our policies to be communicated to people. There is an ethical obligation on all professionals, not just doctors, to pass on all relevant information and we will continue to emphasise that. We need assistance so we are trying to produce information leaflets that not only inform people but empower them to ask necessary questions.

We will address visiting arrangements. Now that we are a single organisation we intend to issue a statement setting out national visiting hours and addressing all the issues raised today. We must, however, have some compassion and where people arrive outside the set hours from, say, distant parts of the country or abroad, they should be accommodated.

We had discussions with Mr. John O'Brien, the new head of the National Hospitals Office, and he is considering in detail the issue of reporting. He agrees with what Dr. Hynes said to the effect that the hospital manager or chief executive is in overall charge and each ward or department has its own head. We will have a further meeting with him to relay the joint committee's comments. It is important that if a person is concerned about a problem on a ward or in a department there is, at all times, a person in charge such as a ward sister, a senior nurse or a head of department.

Deputy Twomey

In accident and emergency departments, if there is a hygiene problem who is in charge? Is it the consultant or the ward sister? If somebody identifies a problem in an accident and emergency department on a Saturday night who has overall responsibility?

Dr. Kelleher

I can speak only generally because there may be variations. It would initially be the senior nurse, though a number of consultants in accident and emergency departments take the responsibility themselves. We are trying to encourage doctors to become more intimately involved in the management of their services so that they understand the issues.

As a consequence of the hospitals audit, information has been exchanged on what the better hospitals are doing. A person we work with has heard of instances where hospitals whose last audit report assessment was at the lower end have taken direct action to address the problems. He has since been sought to give advice in that regard and we expect to see the fruits of that in due course. The audit was carried out shortly after the first one and it will be repeated so that the necessary changes are made. The changes in the short term may not be as dramatic as people would wish but we felt a further audit was necessary to demonstrate that we take the matter very seriously.

We were not briefed on cystic fibrosis in advance of this meeting. In the Estimates, just under €4 million was allocated to cystic fibrosis, which will address a number of matters about which Deputy Neville spoke. We will need to be assured that the new and enhanced services arising from the proposed resources make an important impact on the control of infection. If necessary we can communicate further details to Deputy Neville on that matter.

We will try to get further information on how cleaning is carried out, both in and out of normal hours.

With a little relief I will ask my colleagues from the Department to comment on private hospitals because they are not an issue for the HSE.

Dr. Bonner

We are concerned about private hospitals because we do not have any information systems or a means of monitoring and evaluating their procedures. We are trying to address this under the HIQA legislation and we will let the committee know how that progresses. We are trying to bring private hospitals within the legislation to mean they will be accountable to the system.

Deputy J. Breen

When a patient receives a subvention from the State the HSE has some responsibility to ensure proper procedures are in place, such as alcohol gel in private nursing homes. I am led to believe from a trainee doctor that there is no alcohol gel outside any ward in a certain psychiatric home in the east . Why is that the case?

Senator Henry

Are consultants completely outside the loop?

Dr. Kelleher

No.

Senator Henry

I read a report that their handwashing habits were not monitored.

Dr. Kelleher

I am not au fait with the detail. Was it in the Irish Medical Journal?

Senator Henry

Yes.

Dr. Kelleher

As I understand it that is definitely not the case.

Senator Henry

I am a member of the Irish Hospital Consultants Association and it is important that consultants lead by example.

Dr. Hynes

Hand hygiene is an issue for everybody but the Senator has touched on something very important. Even consultant microbiologists say they sometimes find it difficult to engage with their own colleagues on the matter. They are not, however, let off the hook. As touched on by Deputy Cooper-Flynn, cleaning is a basic issue but the Geneva hospitals have been working on hand hygiene for ten years. After ten years, hand hygiene compliance has reached 61%. Hence, this is an ongoing battle rather than something that can be undertaken on a once-off basis. The Health Service Executive has displayed posters as it is necessary to show people how to wash their hands. Subsequently one must check, using ultraviolet light or whatever means, to identify any missed areas.

This will not be a once-off effort as every year, two new batches of non-consultant hospital doctors arrive and new nurses come on stream. The problem will not be fixed this year. At best, much more attention is now given to it than was the case heretofore. More training, auditing and checking are now undertaken and people are aware that they are scrutinised to a much greater degree than was the case previously. These changes are real.

Senator Henry

That is depressing. My understanding is that at present, without doing anything about the problem, the compliance rate for hand washing here is approximately 60%.

Dr. Hynes

I wonder.

Dr. Kelleher

On the point regarding resources, the HSE intends to spend €5 million this year. Through a detailed process which it undertook last year, the major gaps in terms of both resources and required actions within the system have been identified. The HSE intends to make an effort to address those gaps during this year and, subsequently, to build on it over time. We have clearly identified and have previously highlighted significant problems in the necessary infrastructure. They have been referred to in this forum in terms of the hygiene nurse or the control of infection nurse. This resource is crucial and must be built up, which is what we will try to do with the resources we obtained this year and will try to obtain in future years. We intend to try to address these issues to make progress. The use of these resources will act as a catalyst to get the entire health system to address this issue and to accept its importance.

In respect of a point made by the Chairman, this area is not unlike cancer. Some but not all can be prevented. Similarly, in cancer systems, while some cancer can be prevented, it is not possible in all cases. Consequently, one must deal with cancer by both trying to prevent it and by dealing with the consequences. This must also be done in respect of this issue. The proportions are not markedly different.

Dr. Hynes

I wish to return to two points. A number of people have commented on the issue of contract cleaners and to be fair, I must point out that in the last hygiene audit, three of the top five hospitals used contract cleaners. The issue is not whether someone is an in-house or contract employee, but whether he or she understands the job and has been trained to do it. The issue concerns the monitoring and auditing of cleaning within a hospital, whether it is conducted by a contract cleaner or an in-house employee.

As for Deputy Twomey's comments regarding workshops, they were not held in individual hospitals. They were held in the old health board regions. Hence, any feedback would have been compiled on a regional basis. However, as far as individual hospitals are concerned, members can find the hygiene audit's report and results on the HSE's website. It shows the areas in which——

Deputy Twomey

I know that, as I have read the report. Has there been feedback from the individual hospitals in respect of those headings? Some would say——

Dr. Hynes

I do not believe so. It was grouped into——

Deputy Twomey

Should each of the 57 audited hospitals not be asked to send back in a non-confrontational manner its own critique on the statements made about it? Progress would be made if hospitals responded to the HSE by stating the areas on which they disagree with the assessment and by outlining their procedures. This would help to move the process forward as we have become bogged down and are merely talking about the issue. It does not seem that progress is being made if the people responsible cannot be named. This has been a burning issue for a year and a half.

Dr. Hynes

There was a certain amount of that kind of feedback. My attitude was that I would not listen to excuses in this respect and that the hospitals in question should get on with it.

Deputy Twomey

I would hope that they would not make excuses. I hope the responses would be more in the way of a critique.

Deputy Fitzpatrick

The Chairman asked the question whether there should be a standards authority for all hospitals, both public and private, as well as for nursing homes. I am aware that the HSE is concerned with implementing rather than making policy. However, in reply to Deputy Twomey's question as to who was in charge of matters such as infection control or hygiene in a ward, Dr. Kelleher stated that it was the senior nurse or senior nursing officer. While I believe that Dr. Kelleher mentioned accident and emergency units, consultants in such units tend to work full time there, whereas in other specialties, they may have a commitment to their speciality rather than a full-time presence. In the public sector, the Minister for Health and Children is trying to introduce full-time consultants in both the medical and surgical fields. Is this not the way forward? The witnesses may not want to answer the question as this is a policy decision. However, Dr. Kelleher has indirectly answered the question in his reply to Deputy Twomey's question.

I received the impression from Dr. Hynes that the training in hand washing starts at a rather high level, namely, for new housemen and nurses. Should such training not have begun when they were in medical or nursing school? Surely this is the first thing they should have been taught?

Senator Henry

In Dr. Hynes's opinion, are the cleaning staff made aware of their importance in the hospital? Are they sufficiently well paid to retain them in the job?

Dr. Hynes

In recent years, hand washing has been introduced at undergraduate level. However, we find that this training must be reinforced. One cannot conduct the training on a once-off basis and assume that a person has been trained in hand washing thereafter. Given human nature, people become sloppier and one must verify that they still do it properly.

The hospital hierarchy was mentioned earlier. There was often a perception that, somehow, doctors were more important than nurses. We try to emphasise the importance of team work. For many patients, the person who brings them their dinner or who brings them to the X-ray department in a wheelchair may sometimes spend more time with them than do the consultants. Hence, we emphasise the notion that everyone in the hospital is important and stress the importance of the team. This has been helped by recent events, and cleaning staff with concerns are now listened to in a much more constructive manner than would have been the case two or three years ago. I cannot comment on cleaning staff's pay, although I imagine that many receive the minimum wage.

I wish to comment on the grading of hospitals, because other countries have done more work in this respect. While a hospital might receive a grade A for its cardiac service, its dermatology services might only receive a grade C. Hence, it can be difficult to give an overall grade to a hospital.

Chairman

Public confidence will not be created until some scale measuring the cleanliness factor has been established. While this might be difficult, if we seriously wish to create the belief that hospitals have resolved their cleaning issues, grading is the only way to so do. Moreover, I do not believe it would be overly difficult.

Years ago, I served on the board of CERT. While the tourism industry is a far cry from the Department of Health and Children, nevertheless I recall that at the outset, it was difficult to grade bed and breakfasts and hotels. However, it was done and this brought success to the industry. If people had no option but to work out how to grade hospitals——

Dr. Hynes

The hygiene audit graded them.

Chairman

Yes. However, this point goes back to the committee's difficulties with this session. Dr. Hynes can discern the frustration levels among its members. It is all very well pointing to the hygiene audit but the committee is not convinced that further progress has been made. This is no reflection on the Health Service Executive which has a particular brief and is not responsible for dictating policy. That responsibility lies with this committee which promised those affected by MRSA that it would mark progress on a three monthly basis. However, we will never mark progress until we know the persons responsible for hygiene standards in each hospital to whom people can make complaints. It is a very basic requirement. We need to know which person is responsible in each regional hospital or hospital for elderly persons. If someone has a complaint, he or she should be able to contact the individual concerned rather than the matron, the director of nursing or a consultant. As Deputy Breen noted, if it emerges that an individual has not been given information because he or she is not a relative but a public representative who contacts the individual responsible for hygiene standards in a hospital, this request must be considered a legitimate complaint or inquiry. We will never solve the MRSA problem until those responsible for hygiene standards within hospitals realise that they must carry out their duties in this regard. This is the way we see and hear it as ordinary practising politicians. We will never achieve closure on this issue until we know somebody is in charge. It is not a matter of passing the buck in the manner of a typical politician or attempting to condemn. I am sure that if we decided to advertise a particular position in each hospital, people would apply. Those applying would know the exact requirements of the post and associated pitfalls and what the postholder would have to deliver. We will not make progress until people assume these posts.

I thank the delegation for appearing before the committee and giving their best. At our next meeting we will discuss how MRSA can be dealt with. While we appreciate that the Health Service Executive is not responsible for dictating or agreeing policy, we ask the delegation to ponder how we can grade hospitals and designate individuals who will be responsible for hygiene standards within hospitals. If there are difficulties, we should hear about them in order that we, as politicians, can seek to solve them.

The joint committee adjourned at 11.15 a.m. until 9.30 a.m. on Thursday, 9 March 2006.