Health and Sport Committee

Meeting date: Tuesday, November 19, 2019

Official Report 664KB pdf

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Healthcare Environment (Health Hazards)

The fourth item on the agenda is evidence on health hazards in the healthcare environment. I again welcome Jeane Freeman, the Cabinet Secretary for Health and Sport. She is accompanied by Christine McLaughlin, who is the chief finance officer of NHS Scotland and director of health finance; Fiona McQueen, who is the chief nursing officer; and Alan Morrison, who is capital accounting and policy manager in the Government’s health finance and infrastructure division.

I invite the cabinet secretary to update the committee on the inquiry that she announced into the issues at Queen Elizabeth university hospital and the Royal hospital for children and young people.

I am grateful for the opportunity to address the issues that I understand the committee wants to raise in the course of the discussion, including the inquiry, where we are with respect to the Royal hospital for children and young people in Edinburgh, and clinical waste.

As you know, the inquiry is a public inquiry with statutory powers. We are in the process of finalising who will lead the inquiry, with the support of the Lord Advocate and the Lord President. I hope to be able to announce the lead before the Christmas recess. Members are aware that the chair of a public inquiry has a significant role in respect of finalising the inquiry’s remit: we will undertake that finalising work with him or her, and will be able to announce the inquiry’s final remit and its start date shortly after telling the committee and Parliament who will lead the inquiry.

Thank you very much.

An independent review is already under way on the Queen Elizabeth university hospital. Will that be incorporated into the wider inquiry or run alongside it?

A number of additional issues need to be taken account of in finalising the start date for the public inquiry. Those relate primarily to the Health and Safety Executive’s investigation, the report on which will go to the Lord Advocate and to the Crown Office and Procurator Fiscal Service, who will take a view on whether criminal proceedings or a fatal accident inquiry should be begun. I understand that the HSE’s report is expected before the end of the year. Once we have that, we will find out what will happen thereafter and whether and how that work will interrelate with the public inquiry.

The independent review that I commissioned on the Queen Elizabeth university hospital campus is well under way. Our expectation is that the final report will be available and published in the early spring, although it is possible that the co-chairs will find that they are in a position to outline interim findings and recommendations before then. However, that will be entirely a matter for them as independent co-chairs.

That information, the work that they undertake, the evidence that they gather and the conclusions that they reach will feed into the public inquiry. Whoever leads the public inquiry will then take a view, against the inquiry’s remit, on whether to take evidence in addition to what has been provided by the independent review.

I hope that that is clear.

That was very helpful.

I have a brief question for the cabinet secretary, which my colleague Anas Sarwar has asked me to ask her directly. You will be well aware from the points that Anas Sarwar raised at First Minister’s question time last week of the tragic death of Milly Main and its alleged link to water contamination. The key question is this: will the issue of water contamination be fully examined by the independent review group and/or the full public inquiry? I take your earlier point that the chair of the public inquiry will have a role in aspects of the remit, but is it your understanding that water contamination will be discussed fully in either or both?

My understanding is that evidence on that has been taken in the current independent review, so the issue is part of what it is considering, among other matters. The review has been asked to look at the design, construction and maintenance of the campus and their impact on effective infection prevention and control.

I expect the public inquiry to also take the matter into account. It will be for whoever leads the public inquiry to determine whether they are satisfied that what the independent review hands over is sufficient, or they want to take more evidence. However, it is clear that that issue will be part of both pieces of work.

I understand that the new chair’s role is independent, but could the Scottish Government recommend to them that water contamination be looked at in the full public inquiry? Could you take a proactive approach to that?

We will do that when we have confirmation of who will lead the public inquiry. From memory, I think that I indicated in the statement that I made to Parliament, in which I announced the public inquiry, the work that I expect it to consider. That work includes effective infection prevention and control. We will have a draft remit to discuss with the independent lead in the public inquiry, on which they can comment and make additions to. We will include water contamination in the draft remit because it and other matters are central in what needs to be considered, and in deciding what more needs to be done to ensure that mistakes are not repeated.

Good morning. How many current capital projects that are under way or planned will be impacted by the review?

Do you mean the public inquiry?

Yes—I am sorry.

That question is quite difficult to answer, because we cannot know at this point how long the public inquiry will take. A number of capital projects are coming on stream—for example, the elective centres that are being planned, the Baird family hospital and ANCHOR—Aberdeen north centre for haematology, oncology and radiotherapy—and others that you will be aware of. We will ensure that the recommendations that have already been made by Health Protection Scotland and Health Facilities Scotland, the recommendations and points in the reports on the sick kids hospital in Lothian that I commissioned, with which the committee is familiar, and any recommendations from the independent review of the Queen Elizabeth university hospital, are all fed into that work so that we do not halt what we are doing while the reviews progress.

We already know about some of the failures. Are you taking action to prevent the same mistakes from being made in the capital projects that you mentioned? Are you implementing measures to eradicate the problems?

Yes, we are. For example, there has already been retrospective reviewing to ensure that the new hospitals in Dumfries and Orkney, both of which opened fairly recently, are fully compliant. We asked Health Protection Scotland to undertake that work, which it has done.

We know about the ventilation issues and other matters; that knowledge will proactively be fed into what comes before us for approval in respect of infrastructure builds that are in planning, including the elective centres.

You will recall from the programme for government our intention to establish a national centre of expertise that will have a clear role in all such issues. It will centralise expertise in contract negotiation, contract compliance, microbiology and other matters. The centre will also, to a degree, have a compliance function, and will take inside it the relevant parts of Health Protection Scotland and Health Facilities Scotland. Work is well under way on scoping for establishment of that national centre. We will, of course, advise Parliament of our progress on that.

In all that work, we are attempting to take account of all the lessons that have been learned so far, and to ensure that they are applied to projects that are in the pipeline while we wait for the final recommendations of the independent review, and for the public inquiry to get under way.

What is the expected timeframe for the inquiry to report, and what is the estimated cost?

At this stage, it is not possible for me to give an expected timeframe for the public inquiry. That is, in part, because it is a public inquiry: it is independent of me, so I do not control it. It needs to be led by whoever is appointed to lead it, based on the view that they take about the evidence that is already available to them and the written and oral evidence that they will want to have in order to fulfil their remit. As you touched on in the earlier evidence session, other avenues of inquiry might emerge as the public inquiry begins. It is therefore not possible for me to say how long the inquiry will take; there is always a discussion to be had about that.

A recommendation from previous inquiries is that the discussion should aim to limit the time for public inquiries, but there is a balance to be struck. We need to ensure that a public inquiry fully meets its remit and is seen to do so, and that it takes evidence from those who want to give it and so on, while not leaving it entirely open ended. Once the decision is made about who will lead the public inquiry, I will have that discussion with that person. However, at the end of the day, that lead person will be independent.

Those points about time also relate to cost: until we have an idea of the former, we cannot have a significant idea of the latter, although the costs of previous public inquiries can guide us in estimating the cost.

The cabinet secretary has touched on a lot of the points that I wanted to raise about ventilation and water. Earlier this year, you specifically asked Healthcare Improvement Scotland to carry out an unannounced inspection of the Queen Elizabeth university hospital. The report on that highlighted a number of specific areas in which the hospital could do better. It said that the hospital should develop a strategy that provides assurance that cleaning of high-activity areas is carried out to an appropriate standard; that there should be improvements in the estates and facilities with regard to cleaning, environmental damage and water management; and that the hospital should strengthen the governance around infection prevention and control. Can you update us on QEUH’s progress on implementing the report’s recommendations?

10:30  

Our chief nursing officer will give a significant part of the answer, then I will come in.

As the committee will know, when HIS publishes a report, the board in question has an opportunity to consider alongside it an action plan for taking all the recommendations forward. NHS Greater Glasgow and Clyde fully accepted HIS’s recommendations; some actions were completed before publication of the report.

There are a couple of aspects to highlight. Boards are looking at the more recent report, “A Blueprint for Good Governance”, to ensure that they have in place effective systems of governance, including clinical governance, which relates to the situation that Emma Harper raised. It was recognised that the recommended actions would need to be implemented in order for the board to move forward. The issues that the report highlighted, including improved access to enable cleaning in some areas, and the on-going relationship between estates and clinicians to enable access in order to maintain ventilation systems and ensure that vents are cleaned, were summarised in the action plan.

Six months on, NHS Greater Glasgow and Clyde will provide an update or summary to Healthcare Improvement Scotland, which can at any time review the progress of a board and take a view on whether it will carry out an inspection to see what further progress has been made. An action plan was submitted, and was accepted by HIS. There is on-going monitoring, and it will be for HIS to go back at a time of its choosing.

Does the cabinet secretary want to add anything?

No—that response was sufficient.

I am familiar with hand hygiene audits. When I worked as a clinical educator, we spent a lot of time focusing on hand hygiene, which included the processes and protocols for washing hands and keeping the critical areas clean. I assume that any plan would involve education and tracking of education to ensure that all healthcare workers—nurses, doctors and allied health professionals—are part of a process to integrate hygiene education. That would ensure that simple actions such as hand washing are supported and promoted, and that people are doing those things properly.

Yes—that is part of the plan. As you will know, hand hygiene audits pick up areas where not every aspect of good hand hygiene has been followed. There is then an intervention to ensure that staff are retrained, or that their training is refreshed, so that they remember every element that they need to undertake. That covers staff across areas such as you described. There is a constant process of auditing what is happening and looking to refresh training and education to ensure that people continue to treat those important areas of work with the same focus that they apply when they first start work.

The Royal hospital for children and young people in Edinburgh currently lies empty and is still costing the taxpayer £1.4 million a month. In the light of the revelation from NHS Lothian that the wrong ventilation equipment was used at the RHCYP, would the cabinet secretary now reconsider her response to the committee’s request for a review of equipment in all high-risk clinical areas? That should apply not only to recently built facilities. Given that we have set a standard that air ventilation in critical care should meet, should we not review all settings in which critical care is provided?

We asked Health Facilities Scotland to review the most recent builds to ensure that they were compliant, as we would expect them to be—I discussed that at the outset of the meeting.

If you think about the entirety of our NHS estate, you can understand that undertaking the complete inspection that you are suggesting would be a significant piece of work that could result in our not having the resources that we need in order to ensure that the hospital in Lothian meets the timetable for completion that I have set out. It is important that that timetable is met and that the hospital is up to standard in all of those areas. There will be a piece of work that considers what are the additional critically important areas that we want to ensure are meeting the standards, and we will work through them in order of priority.

I do not believe that I said that a review would not be done. The point that I am making is that the exercise, in its entirety, is a significant one. We have considered the most recent builds, and, as I said to Mr Whittle, we are looking ahead to the builds that are in the pipeline. Following that, we will consider what more needs to be done at other sites, starting with the most critically important areas in terms of impact on patient safety.

Nobody expects you to undertake a review of the entirety of the critical care estate and to conduct remedial work before Christmas—or any time soon, for that matter. However, are you undertaking to ensure that, following consideration of new builds and those that are in the pipeline, there will be a review of all critical care settings in the Scottish healthcare estate, and that there will be subsequent remedial work, even if that takes several years to complete?

Remedial work will be done if it is required, and we need to be clear about whether that is the case. Yes, we will work proactively with boards in terms of their schedules of maintenance and inspection. That will go alongside work that Health Facilities Scotland and others undertake, so that we can systematically ensure that all those critical care areas are at the standard that is required.

On the sequence of events that led to abandonment of the decamp from the old sick kids hospital to the new site at Little France, we know that that happened roughly 100 hours before the decamp was meant to commence. However, we also know that the flaw was built into the environmental matrix when the tender was first issued—that information comes from the KPMG report that was commissioned by the Government—and that several opportunities to identify the problem were missed. How was the problem finally identified? Who identified it and why did they not do so sooner?

As always, Mr Cole-Hamilton, you and I slightly disagree on language. I would not say that there had been an “abandonment of the decamp”. I halted the move in the interests of patient safety.

We now know that the issue around ventilation and critical care stemmed from a failure in the initial environmental matrix and from a number of what were described in the KPMG report as “missed opportunities” to correct that. That environmental matrix became the thread that runs through the construction, and the flaw was not picked up.

The flaw was identified in the final check by the independent assessor of the ventilation in the critical care areas. That final check, which took place a matter of days before the staff and patients were due to move to the new site, found that in the areas where the air change should take place 10 times per hour, it was not happening as frequently as that. Consequently, we decided that that was not the right situation for us to move patients and staff into. That is why I undertook to halt the move. The fact that the flaw was identified so late is why I commissioned the additional work to check all the other critical areas of the site and ensure that they are compliant. As you know from the two NHS National Services Scotland reports, there is more work to be done, but that work will be done in parallel with the work that is undertaken on critical care.

I have a final question concerning the independent assessment that led to the revelation of the flaw with regard to the air change in the critical care setting. Is there an argument that that independent assessment regime should be undertaken throughout the build, rather than at the very last stage, or does it already happen but was just missed?

Independent assessment happens throughout the build at a number of key points. Of course, one thing that the public inquiry needs to look at is what more we can do. Is the nature of independent assessment sufficient for our purposes? Does it give assurance or should we require more from independent assessment? What more needs to be done, if anything, about the frequency of independent assessment, about where the report then goes and about the requirement on the recipient of that report to act? There are a number of things that the public inquiry needs to get beneath, including, as I have said, the nature of independent assessment and what is actually involved.

What role did Health Facilities Scotland have in ensuring that the Royal hospital for children and young people complied with relevant guidance to do with the ventilation system? I ask that from an engineering point of view, because, as a design engineer, I know that it is a specialised area. Was the skill set there for that design, or did people just find out that it did not work when they turned the system on?

That is what we are attempting to address by the creation of the national centre of expertise—my colleagues might wish to come in on this. The way that major infrastructure build is conducted in the health service means that boards have a significant responsibility in that area. Where they believe that it is needed, they contract to bring in additional expertise, which is not automatically in Health Facilities Scotland, at the design, construction and assessment stages. The general view is that for any board to be responsible for such a major piece of infrastructure as the sick kids hospital in Lothian will be a once-in-a-lifetime exercise, so where there is not the necessary expertise within the board, the board must rely on contracting in additional expertise. In moving to the national centre of expertise, our intention is to remove that obligation and responsibility from boards.

Boards will, of course, still have a significant responsibility to identify the local need for a service and what should be in it—by engaging clinicians in designing what the inside of a building looks like, and considering where the different elements of the service should be and what the flow is—and to future proof that, but a country of this size needs to have, in a central place, the expertise that is required across contract negotiation, design, compliance, build, maintenance, microbiology and other areas. We already have some of that in Health Facilities Scotland and Health Protection Scotland, but we need to add to that. That will then become the central place where that work is undertaken, although it will be undertaken alongside the work of boards. We will shift away from it being entirely the boards’ responsibility to it being a national responsibility, alongside the work of individual boards.

When work goes out to tender, what responsibility does a contractor have to check that its building conforms to the national standards that exist for all ventilation systems?

I do not know—perhaps Alan Morrison or Christine McLaughlin can explain.

10:45  

It will be done in conjunction with the boards and the technical advisors, as they are going through the specification for the hospital. The onus will be on them, in conjunction with the boards, to identify what is required. Healthcare-specific guidance applies, as well as building standards and more general guidance. It is through that combination that boards and advisors will arrive at their conclusions.

I know that decisions to halt the moving of patients are not taken lightly, and that patient safety is a huge concern. There are immunosuppressed patients and bone marrow transplant patients—anybody is potentially at risk. There are superbugs such as vancomycin-resistant Enterococcus, carbapenem-resistant bugs and MRSA. Such decisions are not taken lightly.

We obviously need to ensure that patient safety is the number 1 or top priority. I would be interested to hear about the focus on protecting the patients who would be at risk if they were moved when the hospital was not ready.

You are absolutely right: patient safety has to be the number 1 priority in our health service, recognising that there will always be limitations to how much we can protect against infection. As you say, new strains of bugs emerge all the time. The key is to ensure that the expertise in microbiology and elsewhere is built into how we design and build. It should be constantly reviewed and built into how we undertake infection prevention and control measures, so that we identify infection when it happens, take steps to address it and take steps to prevent its spread and control it. You have touched on some of that, but there are other steps that need to be taken by way of mitigation—ventilation and other measures to prevent the spread of infection and to treat infection where it arises.

I am not sure whether that fully answers your question, but the CNO might wish to say a bit more about what we do in that regard.

The cabinet secretary has spoken about the building—the use of ventilation, single rooms and positive pressure rooms. A number of factors can be put into the built environment. You have already mentioned the standard infection prevention control measures, Ms Harper, which not just clinicians but all staff take, including our estates team, who have a particular approach when carrying out any maintenance or construction within the hospital.

You have also talked about the emergent threats. Yes—people whose immune system is not working as well as it could be, because of their illness, are always more susceptible to infection. Unfortunately, there will be times when, despite the best efforts, people will have an infection.

Our job is to minimise that, and that is why we consider on-going monitoring. Every month, boards monitor Clostridium difficile and E coli. Increasingly, Health Protection Scotland is coming up with advice about what organisms we should monitor and whether that should be done by water testing. When a very unusual organism comes into the laboratory, that triggers particular actions to be taken.

There is constant new knowledge, new practice and changes to practice. At the Queen Elizabeth, we are learning about what the alert organisms should be and how many of them are in the background. They have always been there, whether in soil or in water, and those of us with healthy and robust immune systems have nothing to fear and can deal with them quite comfortably. Unfortunately, for some of our patients, that is not the case, which is why the increased monitoring and the triggering of observation are increasingly important.

My point was that it is a complex issue, and multiple approaches—in the built environment, and to do with air quality, water management, hand washing and so on—need to be put in place to protect patients and staff from cross-contamination. The challenge of resistant organisms, and antibiotics that no longer work on those organisms, is almost a moving feast.

I want to continue David Torrance’s line of questioning. The cabinet secretary rightly highlighted that use of the Edinburgh sick kids hospital was halted because of a failure to comply with safety standards, and that the delivery of public services is paramount, especially when public funding is involved. I am interested in the failure to comply with safety standards, because there is liability there in some way. I apologise if I have picked you up wrongly, cabinet secretary, but I think that you said that there were gaps in expertise in the specification element of procurement. It would be worrying if the project went ahead with such gaps. Will procurement, right back to the very start of the project, form part of the public inquiry?

I do not think that I said that there were “gaps in expertise”, and if I did, that was not my intention. What I was saying was that for an individual board to be entirely responsible for a project is something that will happen once in its lifetime, if at all, which means that it does not build up expertise over a number of projects. That is part of the rationale for the national centre. What boards have been doing is commissioning in expertise in areas that are not, as a matter of course, part of their day-to-day business. I hope that that clarifies the matter.

Liabilities and so on are undoubtedly questions that need to be looked at, and the public inquiry is the right place to do that. That partly picks up on Mr Torrance’s point about the various obligations of all the parties who would be involved. In this instance—the hospital in Lothian—that would be the board through to the contractors, the single-purpose vehicle and others. The public inquiry will be the place to unpick various contractual and other accountabilities and liabilities, and it will be down to the expertise of the individual who leads the inquiry to reach a view on all of those.

I will touch again on the NSS report and a couple of points that I do not think have been raised so far. The NSS said that there were major deviations from the guidance in relation to electrical systems and, particularly worryingly, in relation to fire systems. It said:

“Action is recommended to include remotely resettable fire and smoke dampers within the ventilation system”.

We have touched on the fact that, by definition, hospitals contain a lot of vulnerable patients, but the fact that there were faults in the fire system is extremely worrying. To add to Brian Whittle’s point, was that non-adherence down to Multiplex or was it, again, due to mistakes in the tender document?

The proper way for the answer to that last question to be found is through the public inquiry, so I will leave it at that.

On what the NSS report said in respect of fire dampers, we need to remember that the board received a fire certificate for the site, and that NSS said that there was the opportunity for improvement steps to be taken by adding additional fire dampers. That work is being undertaken in parallel with the work on ventilation and so on.

I take that point, but I would throw back at you the fact that two wrongs do not make a right. NSS said that there were “major deviations from guidance”. It could not be much clearer than that.

Why were those issues not identified before the building was handed over to NHS Lothian?

I must make it clear that I am not defending the situation that arose. I am not saying that it was all fine. If I had thought that it was all fine, I would not have commissioned NSS to undertake two major pieces of work. I wanted to be assured that everything was fine. It is self-evident from NSS’s reports that more work requires to be done. If that work was not needed, we would not be spending the money doing it. In addition to ensuring that the ventilation system in critical care is fit for purpose, all those other areas of work will be undertaken, because it is my view that it is important that they are undertaken.

It is not clear to me whether, as with the ventilation system, the issues that were identified by NSS sprung from earlier documents that were comparable with the environmental matrix. The public inquiry will carry out investigative work to come to a conclusion on such matters. There are specific issues that the public inquiry needs to get behind. In a previous discussion, I said that although the KPMG report helpfully set out everything that had happened, it did not answer—it was not asked to—the “How come?” questions: “How come opportunities were missed?” and “How come we got to where we got to?” The public inquiry’s job is to get underneath and behind that while we focus on undertaking the work that the two NSS reports clearly identified need to be done to meet the timetable that I set out in Parliament.

My final question might be one for your lawyer to answer, rather than you. Who will fund the remedial works in question? Will it be the contractor or will it be NHS Lothian, on the basis that it accepted the handover of the building? Is there is a general legal principle in this area? I know that you will probably say that that will be up to the inquiry, but it is important that we get some understanding of who will be responsible for paying for the remedial work, the costs of which will probably be quite substantial.

In addressing that question—which, clearly, I did some time ago—I took the view that the Scottish Government would fund the remedial works to ensure that they would be undertaken, that the timeline would be met and that we would be able to move, as quickly as possible, children, families and staff into the new site, which, overall, represents a significant improvement on the existing site from the point of view of patient care, quality and so on. I want to get people in there as quickly but as safely as possible. Therefore, my focus was to say that we would pay for the remedial works.

Whether there will be any redress against any party is for the public inquiry to determine. It would be wrong of me to express an opinion in advance of that, given that I have no contractual or legal background to base an opinion on. I do not want to compromise the public inquiry, which needs to do its job. While it gets on and does its job, my focus will be on making sure that the work gets done.

I want to ask about hospital waste and the problems that there have been with that. How many tonnes of medical waste are currently being stored in Scotland?

I think that the figure is 500 tonnes.

What work is being done to monitor and inspect where that waste is being stored to ensure that our environment and communities are protected?

The Scottish Environment Protection Agency undertakes that work, and it does so with some rigour, to ensure that those who, under the contingency arrangements, are currently responsible for the collection, storage and disposal of both streams of waste are meeting the required standards and regulations. SEPA is, if you like, the regulator of that.

11:00  

On the future of the system and where we are going to get a fit-for-purpose waste disposal system for NHS Scotland, how much have the arrangements cost NHS Scotland and health boards to date in addition to what they budgeted for?

Will you outline what is being done to address the issue of hazardous waste going to Wales?

We do not have the final cost of contingency arrangements, because we are still in the contingency period. On more than one occasion in Parliament, I have said that when we move from the contingency arrangements to the final arrangements with the new contractor, I will be able to advise Parliament of the additional cost of contingency above the planned cost for the original contract. I will do so at that point.

On the transportation of waste to England and Wales, my understanding is that no bidder for the new national contract offered an option that would take that waste in Scotland, so it had to go outside. However, the new contractor, Tradebe UK, is looking to build—and, I believe, now has planning permission for—a site at Bellshill, which will be its transfer station and area for processing waste, and where it will be able to dispose of a significant proportion of the waste collected.

Can you guarantee that no hazardous waste has been burned in a non-hazardous waste incinerator in Scotland?

If that had been the case, SEPA would have alerted me to it, and I have had no such alerts.

Has SEPA relaxed any licensing around that?

No, not that I am aware of.

Thank you very much for your time this morning, cabinet secretary. It would be helpful for the committee if, at an appropriate time, you were to bring us up to date on some of the matters that Miles Briggs raised on the new contract, recognising that you do not yet have all that information to hand. I thank you and your colleagues for your attendance.

We will have a short suspension. I remind members that you will be moving seats during the suspension, so please gather up your goods.

11:02 Meeting suspended.  

11:12 On resuming—