 Good morning, and welcome to the ninth meeting of the Health and Sport Committee in 2019. Can I ask everyone in the room please to ensure that their phones are off or on silent, and while it is acceptable to use mobile devices for social media purposes, I would ask you not to record or photograph the proceedings. We have received apologies this morning from Sandra White MSP. The first item on the agenda is subordinate legislation and consideration of a negative instrument. The National Health Service Superannuation and Pension Schemes Scotland Miscellaneous Amendments Regulations 2019. The Delegated Persian Law Reform Committee has considered the instrument. It did so on 5 March 2019 and determined that it did not need to draw attention of the Parliament to this instrument on any grounds within its remit. The instrument relates to pensions in the NHS, among other things, and I invite Dave Stewart to comment. Good morning, convener. Although this might seem quite technical and remote, I am quite concerned about this particular issue for members who have not followed it in detail. The key issue is that employer contributions will rise by 6 per cent in next month. The reason for that is that there is a change in the discount rate, so the lower the rate, the higher the level of funding that is required, so the rate is dropping by 0.4 per cent. Probably the key issue is that will the Scottish Government receive a full Barnett consequential for this? I am sure that members have all seen the correspondence, particularly from GPs and GB practice. I think that we are all concerned about recruitment and retention of GPs. I am particularly concerned about this and rural areas are particularly affected. The effect could be in redundancies in GPs staff. The other issue that could happen, and again this happens across Scotland, is that some GP practices are reverting to health board control. I think that this will have a major problem for the recruitment and retention of GPs. Of course it is wider than this, and I think that my colleague Miles Briggs might want to talk about the child's issue, but there are particular issues among non-NHS employers such as in hospice, charities and universities. Chaz wrote to us just the other day to say that it is going to cost them £350,000 extra per year, which is covalent to nine full-time nurses. I do appreciate, convener, that these are all reserved issues, but it has a huge effect on the Scottish Government and in health. The wider issue, just to set the scene, is the other factor that is affecting GPs and consultants in particular, is the changes to the lifetime allowance, which is a UK pension restriction. Basically what that does is that once individuals are through the ceiling, there is an adverse tax effect on them in the longer term. My own experience going round GP practices in Highlands and Islands is that it is certainly affecting the ability of GPs to work and consultants to work beyond 55 or to work at more reduced hours. Of course, we all know that we desperately need full-time GPs and part-time GPs. I suspect that there is not much that the committee can do about that factor, but it is important that we highlight that. We can all see that coming. We are facing a GP crisis in Scotland. The employer contributions will affect us. The lifetime allowance is going to affect us. There are other tax issues that we are in the committee with, which are also affecting them. I feel really concerned about the effect on GPs. I am very concerned about the effect on non-NHS employers, particularly hospices. We all have hospices in our area. I know my own one. That is a fantastic job in Inverness, but I am very concerned about the extra costs. In England, they treat it slightly differently. I just put those things on the table to highlight my real concerns about recruitment and retention. The point is well made and well understood. We have until 29 March to report on this instrument, so we have the flexibility to continue this and seek further information. Miles Briggs. I will reinforce what our resident pension expert has just said. It is important that we take some time out, because there was a president set in 2004 around the proposed increase. An additional fund has been set aside to support non-NHS direct employers. It is important. My understanding is that, in England and Wales, they will be included in the scope of funding provided to take account of the additional costs, but we have not managed to get clarity from the UK Government or the Scottish Government on that. I would like us to take a bit more time to see whether we can get those assurances ahead of next week. I will call him. Just to add my support to what David Stewart has raised, this has been raised independently with me, with constituents and GP practices. I agree that I have an anxiety nodding this through without understanding from where this money is expected to come. Thank you very much. Are there other comments? I see nodding heads around the table. I therefore propose that we write to the Government and ask for urgent reassurances as early as they can provide them and as far as they can provide them in relation to the costs that have been covered, thereby mitigating the impact of the changes on recruitment and retention, both in general practice and more widely. We will return to that with that information from the Government next week. Thank you very much, colleagues. The next item on the agenda is an evidence session on the committee's inquiry into health hazards in the healthcare environment. As colleagues will know, that arises from issues at the Queen Elizabeth University hospital. Recently, there have been such issues over a period since its opening in 2015, which have raised concerns regarding patient safety. The committee agreed on 29 January to inquire into health hazards in the healthcare environment across Scotland more generally. We issued a call for written views and received 27 responses. Today, we have an oral evidence session on the inquiry, and we will, of course, consider our next steps following that session. I am pleased to welcome to the committee today Ian Brody, the director Scotland of the health and safety executive. Alice Delaney, director of quality assurance at healthcare improvement Scotland. Jim Miller, director of procurement commissioning of facilities at NHS national services Scotland, responsible for health facilities Scotland. Philip Couser, director of public health and intelligence, also NHS national services Scotland, responsible for health protection Scotland. I welcome, gentlemen, to the committee. If I can start off with a question for Philip Couser to get us under way and perhaps other colleagues as well, which is to ask how far it is possible to identify from the current systems of health protection and management, how far we can judge the level of morbidity and mortality associated with the built environment in the NHS in Scotland? The first thing to say is that we are inherently dealing with a very dynamic situation. I am not just talking about in this point in time. It will always be a dynamic situation. The nature of the threat from healthcare-associated infection changes over time. It is inherent in any microbiology that we have a degree of evolution. What we do with patients is changing over time and what we do with the built environment is changing over time. It is important to look at the longer term. Scotland has a very strong track record in the longer term. We have made significant advances over the past 10 years, reducing the burden from healthcare-associated infection. There is no evidence at this point in time to suggest that we are seeing any significant increase. Obviously, there have been some significant high-profile and, indeed, tragic incidents of late that have merited this hearing today. However, in taking in the broader picture, there is nothing to suggest that there is any significant change or increase as a whole. It is worth saying that, in terms of international benchmarking, not just over time but internationally, Scotland does very well. We can say that with a degree of confidence as well. The monitoring systems in Scotland are, in some ways, a lot more comprehensive than they are in other countries. Even within a UK context, they are more comprehensive. We have a point prevalence survey that we undertake every five years that is an extensive survey. We have an annual report and we have quarterly updates. At the moment, when you look at those in the round, there is no suggestion that there is a significant change. That is not to say that there may not be—there is always that possibility—that things could go in the wrong direction, but there is no indication of that at this point in time. I think that the report that you provided to the committee suggested that 48 HAI infections are rising from the healthcare environment over the three-year period. Do you believe that that has captured the scale and range of issues that are rising? It is a difficult one to be precise on, to be honest, because how do you define an incident in respect of whether or not it has originated from the healthcare-built environment? It depends on how you want to define that. If it is about an inherent design fault or is it about the way the built environment has been used or maintained, it is difficult. Indeed, that is a question that I have asked. What is the proportion of the overall incidence? What is 48? The answer to that is that that is about 10 per cent, but others might take a different view and say that there are other incidents that might be attributable, because you can never isolate and just say that that incident has happened solely because of the built environment. There will always be an element of maintenance and process in there. It is a difficult one to be precise on, but certainly the team and health protection of Scotland, in terms of incidents directly attributable to the built environment, believes that 48 is their best estimate of that, which is about 10 per cent of the total. Your published report on Queen Elizabeth hospital highlighted issues around water systems and the safety of water. Some of our witnesses have also suggested that ventilation systems and cleanliness and cleaning are very significant. Looking at that group of 48 identified cases, would you be able to estimate what proportion of those are water-based and what proportion of ventilation based and what proportion are arising from issues of cleaning or cleanliness? Specifically, in terms of that 48, no. We could provide that information if the committee wanted that information, certainly. Is it helpful what would be your general? It is worth saying that, because of the incidents involving both water and ventilation, work has been done in terms of looking at broader research internationally to look at the burden as a consequence of both water and ventilation systems. Thank you, George Adam. Thank you, convener. Good morning. Philip, you said that Scotland has a very strong record, particularly over the past 10 years in this issue, of infection control. You also said that when you do international benchmarking, we do really well as well. My question would be quite simple. Compared to the rest of the developed world, what is it that Scotland does differently in infection control? Are we doing better in certain areas or are we on the par with the rest of the developed world? We certainly do better on the whole. If you look at the figures at the moment, we have a very strong record. I have some figures with me around looking at this European picture and we are certainly right up there amongst the very best on a European scale. In terms of what is it that Scotland does well, it is about how the different agencies have worked together, which is very pertinent to the discussions here today. A lot of that goes back in history to events such as the Vale of Leven and lessons that were learned from that and how different agencies have worked together. Health Protection Scotland worked closely with Healthcare Improvement Scotland through things such as the Scottish patient safety programme, advising on different bundles of care improvement around healthcare-associated infections. The work of the Scottish patient safety programme is well known, so that is one of the key factors in terms of how, across agencies, we have been able to come together to address that. Another fact that is clearly well is that I mentioned the extensive monitoring that we have in reporting that we insist on from boards, which is mandatory reporting. It is not optional, so the health infection incident assessment tool, HIAT, which I think we referred to in our evidence, boards have to submit that. Indeed, we have tightened that up. We have created a learning system, if you like, in so much as, if you look even just at the most recent events concerning some of the incidents that are connected with water, we already have in place an action plan of things that are going to happen. We do not wait until we have some extensive formal review. We actually have a learning system that we get on and start to put in place things. Again, it is a multi-agency. It is not Health Protection Scotland sitting in isolation. It is Health Protection Scotland working with Health Facilities Scotland and Health Care Improvement Scotland. So that I can get a scale, you mentioned the figures that you have compared in Scotland to some of Europe. Do you have those figures that you said you had done here? I have them, but I would rather not, because they are difficult to put in context, and it is probably better if something is shared. Again, we can provide those figures. That would be excellent, thanks. Emma Harper Thank you, convener. Good morning, everybody. I am interested in the aspects of infection control because it is complex, because we have moulds, bacteria and viruses. It is a complex issue, and the isolation or standard precautions in the way that we look at managing modes of transmission is complicated. I wonder how the agencies all work together to make sure that the expertise is shared and that there is crossover of knowledge but support of each other, because health infection prevention is quite a difficult task right now. I think that it is really important that, for example, if we take the inspections that we do, we use the standards that are created by Health Protection Scotland to guide what we look at. If we then go out and we need specialist expertise because we come across certain issues in a particular place, we would collaborate with that specialist expertise so that we can understand it better, work together on improvement programmes thereafter and, in terms of the recommendations and advice to the board about how to improve. It is really important to understand the interrelationships between us. We do not have to all be in the one place to do that, but it is absolutely essential that we share information, intelligence and expertise so that we can work together when we identify something. Any other witnesses like to add to that? I would like to come in terms of the role of Health Protection Scotland in being that focus for knowledge around that complexity that you talk about, particularly around the microbiology and keeping that critical mass of knowledge around that and how, in the healthcare environment, you are best practised. We have a team with considerable expertise. We have a number of nurse consultants who are well respected across the infection prevention community, who are seen as the go-to place for advice. That is one of our strengths. We have that critical mass of knowledge. Thanks very much. Ian Brody, the Health and Safety Secretary, sits a little to one side of the Scottish Government agencies sitting beside you. Can you explain how and when you get involved in issues around this topic? On that last question, I was going to come in and say something that we do. We have, for example, agreements in place with Health Improvement Scotland because you are right, as a healthcare-acquired infection is a very complex area. I mean to make sure that, on a case-by-case basis, we either collaborate, co-operate or respect each other's boundaries so that we can undertake our work. In terms of our written submission, we summarised most of our position on this. We are a GBY regulator and we do have an interest in the workplace and work related health and safety across the board. If we are talking specifically about healthcare-acquired infection, where our remit stretches and where our policy and application of our law stretches would not normally delve into clinical care and patient care. That is in clinical judgment. Clinical judgment in clinical care is something that we do not stretch our legislation into, but others are involved in that. In terms of regulatory remit, we recognise that other regulators are often best placed to deal with certain matters, including healthcare-acquired infection, hence the agreement in place with Health Improvement Scotland, which will be the most pertinent point here. I do not know if you would like to comment at this stage clearly on issues around the built environment that are central to your role. Can you explain how your remit adav tails with those of your colleagues at the table? I think that building on colleagues' comments, Health Facility Scotland is an advisory body that sits within national services Scotland. Working with health boards providing a range of technical advice and guidance, some of which are very specific to aspects of the states and facilities maintenance, some of which will be done in partnership with, for example, Health Protection Scotland, or others, where there is potentially an overlap between the management and use of the state, as well as the creation of the built environment. I think that it is important to make sure that people understand that it is a complex issue on how to manage a hospital. My background is clinical education as a former nurse and a former job. How do you support building a new hospital? For instance, are we putting the right equipment, supplies and environment in place? How much of an influence do you set when we are working with contractors on building a new hospital, such as DGRI, in the south of Scotland? As I mentioned earlier, the Health Facility Scotland, as an organisation, is an advisory body. The decision to commission a large-scale or indeed any sizeable hospital would be for that territorial board. Those things do not happen very often and, as you have indicated, they provide a very complex built environment once they are there. I think that the boards draw on a wide range of experience and expertise wherever possible. The organisation that I represent provides advice in a collegiate way through other senior estates and facilities colleagues in health boards and in future control colleagues. That primarily is done through what is called the Scottish Health Technical Memorander, which is a range of documents that provides current guidance, which reflects best practice of that time across a range of the environmental conditions. Those memoranda in themselves tend to be derived from UK-level guidance, but they are made pertinent to the particulars of the Scottish environment. Fyllgor, do you want to add anything on that? Other than just to say, Health Protection Scotland works very closely and contributes to the development of the guidance with Health Facility Scotland. Thank you, convener. Good morning, panel. I have a few questions on monitoring and surveillance. The first question is, can the panel confirm or deny that the only routine proactive testing for contamination of the physical environment is for Legionella? I am not able to answer that. Sorry, I do not have that information. It is based on a submission from one of the NHS territorial boards. Effectively, the question arose from evidence that we received from NHS Fife, who have confirmed in their view that the only routine proactive work that is being carried out is for Legionella. Clearly, I was trying to find out whether that is unique to their board, whether there is any Scottish Government view on this, or whether there is more proactive work being done. If not, of course, if the panel members want to write back to us with further information, that would be very usefully received by the committee. I may come in and make a comment there. Legionella is a specific mechanism or organism that prevails not just in healthcare but elsewhere. There is a specific set of standards that we do enforce, linked in a proof code of practice, linked to the management of Legionella and water systems, so we would expect Legionella to be monitored. It is one of the particularly unique microorganisms that this committee is interested in that we do have an interest in. It is monitored and we did some research before coming here today. We do not have a record of any Legionella outbreak that we have had to intervene on in NHS premises in healthcare premises in Scotland. Thanks, convener. I may get more feedback from the panel. In the panel's view, are boards only aware of contamination in building services when patients are infected? From a Health Protection Scotland perspective, yes. On what comes into Health Protection Scotland, I will need to check, because I am very thoughtful about that previous question, that, as far as I am aware, we do not receive any reports or data around any proactive testing of the environment for microorganisms of any particular sort. As far as Health Protection Scotland is concerned, the data that we receive is about instance-involving patients. That is very useful. That is really the point that I am trying to draw. Do any other panel members wish to contribute? To say that we use that data to do proportionate and risk-based scrutiny thereafter. The data that we have access to, both in terms of the national data that has been mentioned, but also the local data that we request when we have targeted an area, would therefore help us to target where we actually go. I am sure that panel members can pick up the theme of my questions. It is about being proactive and not just waiting until we have outbreaks. I have one correction, if I may. You could look at the point prevalence survey that is done every five years. The methodology for that is different. It is focused on surveying the incidents of potential infection in patients. There is more of a proactive, but that is a comprehensive survey that is undertaken every five years. It does have a significant influence on shaping policy going forward. There is a proactive element of that survey, but it is focused on infection on the patient. It is not necessarily that a patient is suffering from—a lot of the microorganisms that cause infection—most of us in this room will have those microorganisms in us today. However, it is people who are susceptible that have issues with such infection. One of the points that has been made to us by our witnesses is that point prevalence studies while clearly valuable do not capture the infection burden of outbreaks because outbreaks, by definition, are episodic. Therefore, they give a kind of underlying status rather than dealing with the high hazard. Do you acknowledge that? The outbreaks are captured through our—I mentioned the high act, the health infection incident assessment tool, which boards have to report. If there is an outbreak—I say recently, we have tightened that up in 2016, because there are different categories. There is green, amber and red as a classification system that goes with that tool, depending on the severity of the outbreak. I think that we tightened it up in 2016, so all green, even green-rated high act assessments are reported. That all goes into—we have our quarterly figures that we report and we have our annual survey. As we said, Healthcare Improvement Scotland used that to guide their inspection regime. Can surveillance systems be used to prevent outbreaks infections from occurring in the first place? I am doing really well with stomping the panel today, I can see that. That would be a question that would have to be posed to somebody who is a deep expert in the topic. It is something that is outwith my technical knowledge of that topic area. It is a complex question that would have a complex answer. I would not say that I could give you—I am certainly not in a position to give you an answer today. It is an answer that I can certainly take away, and we could provide a view on that if that would help the committee. When you say that we would need to ask somebody with a deep knowledge, do you mean a microbiological level of understanding? What is it that you do not have that we need to access in order to get an answer to that question? If I can be clear, what you are asking is whether there is a proactive testing regime that you could put in place to control or prevent outbreaks? In simplistic terms, some of my colleagues have touched on the radius, the first point of call would be the construction of new hospitals. Are we getting this right? What is world evidence on that? Secondly, what is the surveillance system like? The panel has already touched on the fact that, by definition, many people in hospital have more impaired immune systems, so they are more vulnerable to any potential infections that might not affect some of us here who perhaps have stronger immune systems. Putting all those things together, is there more that we can do to be proactive to prevent outbreaks and to prevent death and injury in hospitals in the future? I suppose that is the key point that I am trying to identify. Certainly, and there always will be more that we can do, because, realistically, delivery, while we should aspire to attain zero incidents, is not deliverable in reality, because, as I say, the nature of the threat is continually changing. Questionably, when we come to look at the design of hospitals, we are involved in providing expert input in health protection Scotland, so it is a collective exercise in providing that sort of guidance. We are always working closely with health facilities Scotland to see how we can improve that. There is already an element of proactivity. Where I am getting slightly confused is that there is that proactivity in terms of influencing and shaping guidance, which is on going all the time. For example, I mentioned that we are already taking the learning from some of the issues in terms of water systems. We have done a literature survey on water systems. There were reports produced looking at water systems, and there is now an action plan that is looking at how we can change the guidance. I also detected that there was a suggestion of a more active routine forward-looking surveillance element. If I can just come in and use an analogy from another sphere, I have been quite interested in fire prevention for many years. Looking back into time from Grenfell and before that, many of the changes to legislation have happened after tragic fires in homes for the elderly when people have died. Government has then brought in systems to sprinklers, which has prevented that happening. Using an analogy for contamination, is there something that we can do now without waiting for tragedies of people dying or being injured? Is it to look proactively at our current situation so that we can design our hospitals better and look at our systems in a more proactive way? To be more specific, we have talked about the design and development of guidance. We have touched on, and Alistair might wish to come in and talk about the inspection regime, which is taking forward on the back of the monitoring and the data that we do. There is sort of within the question that you ask an issue around should we have, because originally we talked about this legionella issue and there is a testing regime for legionella. I do not know enough about it, because I am not a consultant nurse who works in infection control. In terms of what the literature says, in terms of your ability to test the environment for the burden, if you like. I say test the environment, not the burden on the individual patient, which we do through point prevalence. However, to test the built environment through some testing regime, I do not know the answer to that question. Perhaps I can try to have a final question that might put a bit more light on the theme. Is there any system in place that can pick up invasive fungus-like materials, like cryptococcus and the ventilation system, before patients become infected? As the Laney clearly inspection is your job, are you aware of anything that would pre-empt this that might assist with avoiding future such infections? Again, I think that you need specialist advice as to what particularly you can put in place. On a more general sense, I do not know how helpful it is, but if you would bear with me, I think that the inspection evidence that we found over the past 10 years, there was a significant issue obviously after Vale of Leven and then we had the introduction of the inspections. We were finding a lot going on, which have subsequently been improved significantly over that period of time. That also includes things like improved surveillance of microorganisms such as MRSA and Clostridium difficile. That is improved monitoring at a local level. We have seen significant reductions in that over a period of time, so I would want to say that the evidence shows that there has been significant improvements. However, there are always things that you can do. What is important for me is that we have to build the ability to monitor, to have surveillance and to take action at a local level. You cannot inspect that in. You can only use inspection to encourage that and to look at it and give you an overall picture. However, what has really been important over the past while is to encourage boards and others to develop their surveillance and monitoring system so that they are on top of this day in, day out, and therefore able to take action when it is happening. As for the technical bits about what would be required to do that, I am not a specialist and cannot answer that. I suppose that just to build on the point that, although Health Facility Scotland is only an advisory organisation, it provides territorial boards with a range of monitoring tools that they can use in those sorts of circumstances. One that springs to mind is a system called HCI Scribe, which is the system for controlling risk in the built environment. It is effectively a tool that facilitates the collaboration between the facility staff within a territorial board and the infection control staff. It poses a series of questions that are self-assessed. That comes out with a list of recommendations that can then be prioritised and should boards wish to share their findings from the use of that system with other boards. There is an opportunity for that best practice to be provided. Both HPS and HFS contribute to the development of the tool, and the tool is provided across all NHS boards. There are already processes in place that look at, if you are building a new hospital, let's not put, allow birds to nest like seagulls near the dialysis unit that's going to be built. We already have those issues in place, I understand. I know that when there are unannounced and announced inspections, you are looking at the environment and you are looking at hand washing and direct observation and peer reviews already in process. The processes that are already in place are my understanding to look at infection control aspects, so am I understanding that correctly? From an inspection point of view, we believe that the processes are in place. However, if, for example, we visit a hospital, we are not necessarily looking at everything at every time, we are using intelligence never ends to try to target that because hospitals are big complex organisations. However, what we try to do is to take a broad sweep. We are looking to be given assurance by the hospital, by the board, that they are taking these issues seriously and that their systems and governance are in place. Do we sample, obviously, beyond that to directly check ourselves to see whether that is actually what's happening on the ground or whether the policies are very nice and shiny, but actually that's not what's going on? From that, we can then identify recommendations for improvement, as we have in a number of occasions recently. Obviously, we will, therefore, hopefully improve the quality of safety and care for patients. One thing that's been highlighted to us is who is responsible for plant rooms in a hospital. Are they subject regularly to inspection as part of the inspections that you carry out? Not directly, but if we have an issue that was identified that highlighted in a plant room could be an issue, the team would go and have a look. From a generic safe and clean point of view, rather than a specialist input, we would be handing that on to others to have a look at. That's why we need to be able to refer when an issue occurs that we don't have the specialist expertise on the team to look at. You've been a good morning to the panel. I just wanted to ask very briefly from what you've said in terms of the number of safety and cleanliness inspections. What's the rationale behind why these have halved since 2014? That's the reason. It's not so much a rationale as a real politic, if you like. We've had a number of issues. I joined the organisation, for example, 18 months ago, and undertook a review of our staffing and structure at that point. We had a number of vacancies that we have literally just filled. We've had three new inspectors, for example, start in the last six weeks who are in their induction period. Because of the review that I undertook, we had to hold the vacancies over a period of time for HR processes and other things. It took a little bit longer to fill those. We also still currently have vacancies that we're advertising. Secondly, we are still testing a new methodology, because it's really important that when we visit a hospital, we're able to look more broadly. As, for example, we did when we went to the Queen Elizabeth University hospital, we took a little bit of a step back and had to look at the bigger picture, rather than just on the front line. We've been looking at that, and I have had to allocate some staff time to be able to allow us to develop that, and that will continue during the year. However, I would reassure the committee that, for example, in the coming year, our plans for that will see the numbers of inspections start to move back up again. Also briefly, I'll call Hampton. Good morning to the panel. Miles Briggs has talked about the drop-off in inspections, and you cite workforce pressures. I had a workforce-related question, and we all know in this committee about workforce pressures across primary care in the NHS. I just wanted to know what impact those pressures are having on infection control, in terms of the responsibilities to whom infection control falls, at the ward level, and whether you think that there is a direct corollary between the infections that we are here to discuss and those workforce pressures. Who would like to answer that question? That's a very fundamental question, I guess, is to be confident that the people who are required to do those jobs are actually in post. Is there any of the agencies here with any accountability for ensuring that there is an adequate level of staffing to provide safety? I'll start by saying that if staffing was an issue that was directly impacting on patient safety and care, then we would call that out in our reports. Just to be clear that that would be an issue. It was in a couple of recent reports, as we are aware, and that's exactly what we have done. There is changes going through in the safe staffing bill, which will allow us to have access to a greater degree of intelligence and information about staffing levels. It's going forward that it will become an increasing area that we will be looking at when we are visiting a hospital, because we will have data that will help us to do that before we go, and we will be in a better position to be able to understand that. We can look at it when we have actually visited if it is an issue, but that will give us more proactive engagement and will allow us to check that. At the moment, I don't have information that says—because I don't have the evidence to justify it—that it says that staffing levels are one of the main themes across what we are finding, say, over the last couple of years. You just said that a couple of the reports that have recently come out, you have called that out and said that pressure on staffing was an issue in infection control. Was that atypical? Is that the first time that that's something that you've cited? It's not the first time, but it's not totally typical. It's not a theme that I can yet provide evidence on that says that that is a theme occurring across, say, for example, the last two years. I think that we've found with a couple of recent inspections that they are very particular to the circumstances that they are there, and I would hesitate to ask you not to necessarily extrapolate those across the country. It may well be, as my colleague said about data, that there is a trend, but at the moment we don't have the evidence to say that that is the case. David Torrance Convener, good morning panel. Just to let you know, my background is in engineering, and I've worked in lots of ventilation systems and tandoons in my early days. Can I ask how infection control, such as water and ventilation systems, is managed when you have an outbreak? I suppose that there are two points to that. Ultimately, the responsibility for a specific healthcare geography or a state remains and still is the responsibility of that board, executive and management team, including the professional facilities and the state's teams. Within the board, each will have a regime utilising some of the tools that are available from agencies represented today, to the extent that those are exactly replicated across each territory board, I would be able to say, in terms of that routine monitoring, where there is believed to be an outbreak, that then moves into a separate set of circumstances, including the call of agencies such as HPS, where the national framework is then cited, and then that sets a chain of events in motion, where HPS will be asked to provide support to the board on that. Exactly, as Jim has just said, there is the national framework, still colloquially known as the CNO algorithm, or the chief nursing officer algorithm, although it was changed in 2015 to the national framework. A board can make a call to invite Health Protection Scotland in, and indeed it does. Equally, the Healthcare and Improvement Scotland, the HEI, the Healthcare Environment and Spectrum, can also call HPS in to provide support. As indeed can the Scottish Government as well. It does happen. I think that in the last year it has been invoked five times in total, which I do not think is exceptional in terms of numbers, but it is very much about putting support in place. Some of that support will be about finding the source and figuring out with the local board what measures need to be put in place. There are very strict guidelines around the reporting of that and the production of action plans to deal with that. That is one of the reasons why Scotland has been so effective at controlling outbreaks. Again, this is all based on a lot of lessons that have been learnt from previous incidents. You mentioned guidance earlier on. How do health boards adhere to that? What systems are easy to test, but airborne systems or ventilation systems and airborne infections are very difficult to detect? Is the guidance relevant for these systems or do we need it updated? How do health boards comply with the guidance that you are giving them? The suite of guidance that the Health Facility of Scotland provides, previously referred to as the Scottish Health Technical Memorandum, whilst they are based on UK guidance, they are made reflective of the Scottish environment and they change over time. As committee members are aware, as engineering becomes more complex or as it changes from analogue-based systems to digital systems, the guidance has to be reflected on that. The guidance itself never stands still. Unfortunately, sometimes, the guidance has to reflect on incidents that have taken place and understand whether that guidance needs to be more comprehensively reviewed. For example, we are currently looking at further guidance on technical aspects of water systems that perhaps were not in the guidance that was written in 2009. It is also that constant iteration in learning environment. It is probably important to say that the distinction between the guidance and compliance against the guidance from my organisation is one that is presumed. Other than small areas where Health Facility of Scotland would ask for compliance, we would ask for compliance with national cleaning standards and with the decontamination of medical instruments. Those are two areas that we currently have a compliance aspect against the guidance. Others again refer back to the boards' internal management structures and how they use that guidance to best manage their estate. Can I ask how often specialist engineers are used to test the systems? Because they have the ability to do it rather than on my NHS staff. How common is outbreaks of infection from water and ventilation systems across Scotland? I can certainly answer the first part of that question. I think that you are absolutely right that what we are talking about in some of these cases is highly specialist technical skills that may not be readily available within the NHS Scotland workforce. Indeed, it may not be cost effective to try and have that as an in-house resource. Boards and Health Facility of Scotland will go to the market and try to get expert advice on either current guidance or in particular cases where health boards have required that piece. We are also mindful that there is a balance between taking advice from external organisations and being able to use that in built knowledge, if you like, in sharing. Very recently, health boards have asked that they reduce their dependency on third-party contractors and increase the level of authorising engineers that we would effectively use to be higher within NHS Scotland. That is a process that we are looking at. We are now trying to get that balance between ensuring that we have captured the best experience in the market at that time, as well as building that resilience of having a single team. Indeed, health boards have asked that that team, if it were to be bought in-house—if you can use that phrase—should then form part of a health facility to Scotland organisation that it can be called back to individual boards. I am sorry that I am not able to answer the second part of that question in terms of the consequence of that. In terms of the numbers in the second part of the question, we touched on it earlier that, as part of our submission of evidence, we identified 48 incidents in the last three years that have been attributed directly to the built environment. I do not have—we will provide a breakdown of those to see if we can identify how many were attributable to water ventilation, but, as I mentioned earlier, we have done literature research to look at the issues internationally to see what the incident is and, having read those reports, there are similar incidents internationally as we have experienced recently in Scotland. Those incidents are not unheard of, but we can certainly, if it was of use to the committee, provide those reports. I thank you very much for bringing me back in, convener. Further to David Torrance's line of questioning, it is clear from what you have said that we understand that routine testing for sources of infection is very difficult in terms of ventilation and water supply, and in many cases the first indicator of an outbreak would be in patient symptoms. Can you give us an idea, first and foremost, what the process is then to tracking down the source of that infection when an outbreak occurs on a ward Z? I think that you would have to ask a specialist. I do not think that any of us have that experience. You would have to ask a practitioner for that. That is fine. Second question, then, in terms of risk planning around infection outbreak, we are all aware of recent examples where wards are closed. We had a ward closed in the western general just this month because of a water contamination outbreak, and I imagine risk planning for a single ward being closed is easier than whole hospital contamination. Can you talk to us about what you do in the event of, or what your plans are for, infection outbreak on a whole hospital level? Secondly, in terms of mitigation, we know that a hospital recently had to buy tens of thousands of pounds worth of bottled water, that risk management processes are not compounding the issue and that you know where that water is coming from and that it has come from the sterile environment and the rest of it. I think that it is important to understand the governance here, the first part of your question. We would be down to the boards to determine how they respond to an incident to contain that. From an inspection point of view, we would be looking to see what plans they have in place, are they robust, do they make sense? How would they apply them? Are there other responsibilities clear at the time? From a more generic sense, we would be looking across to make sure that they were actually in a position to be able to control something should it happen. As well, it might be important just to mention that healthcare improvement Scotland has the legal power to close a ward to new admissions should we be concerned for patient safety. It is also important to understand that, in the 10 years that we have had that, we have not used it once because actions have been taken while we were on site, which satisfied us that sufficient action had been taken and then subsequent actions were obviously taken and we followed up. I wonder if you could elaborate on the comments that you made in your report on the Queen Elizabeth hospital that you had encountered challenges in the relationship between the Estates department and the infection control team. We have certainly also had evidence from witnesses that infection control doctors and nurses, likewise, appear not to have close working relationships with those managing domestic services in a number of hospitals. I wonder if you could elaborate on those findings, please. I mean, I would not want to get into too much detail, but obviously we covered it in the published report. However, it was a feature of what we found in the Queen Elizabeth University hospital and its associated sites. It is also something that we would be concerned about across the country as a whole because it is absolutely essential that there is good working relationships between the nursing staff, particularly for health and for infection control and the buildings staff. Obviously, in that particular circumstance, we had quite a large backlog of repairs to be done and the communication was not particularly great about how those were being managed and what happened when they were being reported and potentially having to be reported again. Therefore, it demonstrated that the level of leadership governance was really important. The benefit for us in that inspection was that we were able to stand back and look at that and it became a key feature because the front-line staff were doing as good a job as they could in the circumstances. We gave praise to them in the actual report. Some of the problems are more systemic about governance and relationships. We have also received evidence that, for example, the undertaking of routine maintenance, internal and external repairs is often done without consultation with infection control professionals within the hospital. Is that something that you, ordinarily, as an inspectorate, inspect the actions of estates, departments, buildings and maintenance people in the hospital, or would that be only in exceptional cases, like the one that you have just described? It would not be routine. It would be where an issue has been raised. The case that you mentioned applies across the country, because it is a cross-cutting theme. With the estate that we are looking at, if you have, for example, plaster coming from a wall or you have floor tiles that are not sealed to the floor, you cannot therefore say that that room is perfectly clean. It can be cleaned, but you cannot say that that is clean. Therefore, it is essential that that is taken forward. If we come across that, we would then explore that further and try to understand what was being done, how the relationships were and what actions were being taken to deal with those issues. That was exactly what we did in the case of the Queen Elizabeth University hospital. Can I ask Jim Miller and Philip Couser to reflect on those points as well? Clearly, within NHS National Services Scotland, Health Facility Scotland is responsible for design and commissioning of health service buildings. Health Protection Scotland is responsible for the kind of infection control and prevention issues. Does the relationship between the two divisions of the NHS that you represent is a close and daily working relationship? If it is, why is it not reflected on the ground within health boards or something in the way in which you are dealing with your counterparts in boards? That means that you work closely together, but the people in boards doing your equivalent jobs are not talking to each other at all. Just to the correct point of detail, Health Facility Scotland has no direct responsibility for designing and commissioning of buildings or any healthcare operations. It provides advice to those who would. In terms of the points that have been raised, if we look at where that advice is, it has a strong connection between Health Protection Scotland. I would cite the example of the development of the national cleaning specification. The national cleaning specification is one area where its first iteration was in 2006. That effectively covered what would probably be regarded as the routine areas that were covered by domestic staff in hospitals. That set a specification and introduced a reporting regime. The specification itself was developed between the HFS staff in conjunction with Health Protection Scotland. It was further extended in 2009 to take impact of the fabric of the building, so not closed systems that we have discussed earlier in terms of heating and ventilation, but areas that would still be cleaned but would be made more problematic by the fabric of the building. Another was difficult to clean areas, whether those pillars or other obstructions. That is a good example of where the guidance has been co-produced. Can I take you back to the commissioning question? Of course, you are right that the Queen Elizabeth hospital, for example, would have been commissioned by Greater Glasgow and Clyde Health Board. On the basis of your advice on how to ensure that those facilities were correctly designed to avoid health protection risks, would that be a fair way to describe your input? We would hope that all of our territorial board colleagues would call upon the advice that is made available through those suite of technical memoranda. You would not sit down with them at the commissioning stage to say, have you thought about this? We currently have no formal compliance or assurance role in that. That is purely technical and advisory, other than those two areas that I have described earlier. Just to comment on the organisational closeness that you are referring to. Yes, Health Facility Scotland and Health Protection Scotland sit both as parts of National Services Scotland. That is, I think, academic to the nature of the relationship. The relationship would be similar in terms of the working relationship, regardless of whether they are sat in the same organisation. Indeed, Health Protection Scotland works equally as closely with Healthcare Improvement Scotland, and other partners are as well important in that. NHS National Education Scotland has an important role to play in education of the broader workforce, not just the national, but the workforce in boards. There are other partners as well in that. It is a complex piece, but I just thought, just to be clear, that, because we are in the same organisation, it does not mean to say that there is a level of integration that there would not be otherwise. However, the close work that you have described at national level apparently is not reflected at local level. Would that not be a fair comment? I could not say how to go out there. There may be instances of good practice and instances of less good practice across the board. There will be variation across the board. What I can say is that a lot of the role of Health Protection Scotland is that support. If there is an outbreak, if there is an outbreak, one of the things that Health Protection Scotland does do will come in and provide guidance on who needs to be in that situation. Admittedly, this is more in the reactive situation, where there has been an outbreak in terms of pulling together the incident management team that is going to oversee the control of a significant outbreak. Is there a need for an incident management team who needs to be around that table, that the infection control team needs to be there, that you need somebody from estates there? There would be guidance and advice offered in that situation, certainly. I am sorry to perhaps talk about the AGI scribe tool that I mentioned earlier. That contains within it prompts and suggestions where facilities and infection control teams should work together as they move through that piece of the tool. Effectively used would be a useful internal challenge, if you like, whether both parts of the organisation were on the same page. I think that the tool provides and can clearly provide opportunity for that conversation to take place. If I may say likewise, we have not really talked much about the infection control manual that Health Protection Scotland does, which does the same from a health protection perspective. I referenced that we are working on an action plan following some of the issues in terms of water systems, which will look at how those are better managed and provide advice at a board level. However, as Jim identified, there is guidance, and what we cannot comment on—maybe that is where an inspection regime can comment—is how that guidance is put into place. Taking those points forward in terms of input into the safety features that we are talking about today, front-line staff—we have heard a lot in a variety of investigations that we have done in here—has a lack of ability from front-line clinical staff to input into various roles. What influence do they have, or what kind of license are they taking of their input, for example, in facilities management? It seems to me that they, being at the front line, would have an important input into the safety issue. The approach that is taken in major capital projects follows very extensive guidance that is published by the Scottish Government. Throughout the pathway from the initial assessment of the options through to the outline person's case and the final person's case, it encourages a multidisciplinary and multi-agency approach to that. I believe that the guidance encourages an environment whereby all interested parties and stakeholders would be able to input. I cannot comment on the reality of that in terms of what happens with specific instances, but I suggest that the guidance, as it stands, allows for that opportunity to take place. In your view, the guidance would give clinical staff some sort of authority to have the concerns raised within this environment. Would that be your understanding? Certainly. In those examples where I have been more closely involved, I have seen lots of evidence that the design and operation of a facility, whether that is within part of a building or indeed a building itself, has never been done in isolation. I think that the question that I would ask is where the governance stops. Does the governance stop at board level or do your organisations have input above the governance of the board, or would you expect the board to deliver on the plans that are already in place? I think that you are probably going to get a slightly different answer from each agency. In terms of the organisation that I look after, the governance should stop at board level. We would not expect anything to be brought back to us as an organisation. It is important to say that the health facility in Scotland does work collegially with all boards via a group called the Strategic Facilities Group, which has representatives from the Scottish Government, all-territorial and national or special boards, and representatives of the health facility in Scotland. They do not work in isolation, but there is no formal governance report back into HFSs that stands. I agree with what Jim Smith said about formal governance. I think that one of the important points to stress in shaping that guidance, that guidance from the Health Protection Scotland perspective is shaped very much by our experts, our specialists, who themselves have been front-line staff. They have not just gone to university and become front-line staff overnight, but they have a lot of front-line experience, which is why they now work in Health Protection Scotland. They have that experience that they can bring to bear to shape the guidance. In terms of the governance question, we have no formal governance beyond that guidance other than where we are reacting to an outbreak. Just to say from our perspective, we are not part of the governance chain in relation to that either. The boards are obviously the primary governance mechanism and upwards from that to Scottish Government. We cannot escalate concerns should we need to do that if we feel that insufficient action has been taken at a local level. One other thing that I would mention not necessarily to do with buildings, but it could be, is that Healthcare Improvement Scotland hosts the whistleblowing helpline and other means of gathering intelligence and data from individuals or from groups. We would do an assessment of that no matter what the subject matter is. It does not apply to just what you are looking at here, but it could. We would then get involved in taking that forward as part of a potential investigation or it may spark some other kinds of work, should that be required, but the first stage would be an assessment. If I could just… I mean, we have had evidence in here on the effectiveness of the whistleblowing within NHS and I think that I would be fair to say that there would be concerns about that. I am really… I suppose that HIS is probably the most relevant body here around the ability of witnesses, taking evidence from witness-front-signal line staff as witnesses and escalating their concerns. Is it your understanding that that is taking place as part of the investigation? The investigation, sorry. Sorry. What we are looking at in terms of issues around the Queen Elizabeth is that staff are being… front-line clinical staff are part of that investigation through HIS. I cannot comment on the investigation clearly. Our expectation would be more generally that front-line staff are essential in terms of feeding their views and their information in. We would expect to see that on inspection. We would be asking front-line staff about how their thoughts, ideas and views are taken into account in terms of taking things forward. We would always do that. We have that mechanism by which, if we have a concern that we can escalate it through the boards and then further onwards, if we wish, if it was a complaint, then obviously that should be handled in the normal way, which would be through the board's complaint procedures and then on to the SPSO. However, we have that whistleblowing line as well, should people feel that they are not being satisfied with that. However, I cannot comment directly on the on-going investigation. We have had evidence that microbiologists and indeed infection-controlled doctors in Greater Glasgow and Clyde have become whistleblowers because that seemed to them the only way that they could achieve change in things that they considered to be an issue. Is that something that would concern Health Care and Improvement Scotland and, if so, what would you do about it? Yes, it would concern us. If that was coming through to us, it depends on what it was, but we would be looking to take that up with the organisation's concern. There is an individual complaint that might be looked at individually, but something like that would be more of a trend that we would then be asking for an explanation as to why the staff felt that way from the relevant board. Thank you very much. To pick up on what Alasdair was saying in terms of how, because this does not just sit with Health Care Improvement Scotland on how national agencies would come together to pick up some of that that might be considered softer intelligence rather than hard data in terms of numbers. There is a group called the Sharing Intelligence for Health and Care Group that some members here may be familiar with. It has a broad remit. I have sat through a few meetings of it, and each of it is mostly scrutiny bodies. My organisation, I have both Health Protection Scotland and Information Services Division in the business unit that I am director for. We come and we bring our evidence, other bodies, care and spectrate, audit Scotland and national education Scotland. A range of different bodies come and they share the evidence that they have. There is an opportunity through that group to engage with boards and raise issues. Some of the softer evidence that you might get through whistleblowing could be considered in that group. To pick up a wee sup, Brian Whittle's question was about what influence do clinical staff have over facilities management. I am aware that NHS and Fruits and Gallow have an environment team that is the infection control leadership led with facilities management and clinical staff on the same group. They all work together to identify issues that might be potential infection control issues. My question is, if we are pulling back from just the Queen Elizabeth and looking at all the facilities that are NHS facilities and hospitals across Scotland, I am assuming that each board has equivalent groups that will meet and discuss and work together and then escalate issues if needed. We have the facilities people and the infection control leadership and clinical staff all talking to each other. Is that a fair assumption? Do we have any evidence that that is or is not the case in any particular part of the country? I am sorry to have to say that. My instinct would suggest that the way that I see best practice shared across facilities colleagues at boards is that if something was working well, they would let other board colleagues know. I could not give the committee an assurance that such a thing was replicated 14 times across the 14 territory boards, as they stand. That would be a question for each board, unfortunately. I just ask Ian Brody in terms of health and safety executive. Just to be clear, we have heard various questions and answers around what would prompt different actions on the part of the healthcare environment inspectorate and what roles the other bodies here might play. What would prompt you to investigate a systemic failure leading to compromising of health and safety in a healthcare environment? I have been very careful not to stray out with my area of responsibility during the questions and answers here today. We do have an interest in NHS Scotland and the boards. To go back to one point there, we would also see the boards as the body who would be held accountable for any fears and who should be managing the risks that are created as a part of that activity. The large portion of our work is focused on health and safety and traditional health and safety issues. We do inspect health boards and we do investigate, but not so much on the area of healthcare-acquired infection, which is the substance of today. There are occasions when we do get involved in healthcare-acquired infection matters, but there is a very clear set of guidelines about when that would not be ordinarily reported to us, which is a trigger for us to be involved. We would then be looking at an outbreak where there is evidence of clear standards, which is a field to be met, where there is evidence of systemic failures failing to meet those standards and where there is a clear evidence that that outbreak has resulted in a death. Who would bring that evidence to your attention? Ordinarily, it would normally come to attention by the Crown Office's Procuret Fiscal Service, but employees and members of the public are entitled to raise concerns with us through our concerns advice team. For example, we have a formal connection to the healthcare environment perspective. That comes back to what we talked about earlier on, as we have an agreement in place with the healthcare environment inspectorate. If our inspectors are out and identify issues that fall within the HIS's remit, there are mechanisms in place to notify HIS, and, likewise, depending on the subject matter, it will depend on how we will take that forward, either collaboratively or individually. There are mechanisms in place, and, certainly, talking to HSE inspectors, they are very clear on what HIS's role is and what subject matter should be referred on to them. Another question for Alasdair Delaney is about—indeed, possibly for Jim Miller—the evidence that we have received that health facility standards against which inspections are made can be seen as confusing by healthcare professionals. For example, the suggestion that current standards apply to new build but that they do not apply to existing premises has come back in some of the evidence as a perception within health personnel. Can you confirm whether the current existing standards apply to pre-existing buildings, to older buildings and be very clear as to what is and is not expected in terms of standards? Generally, I would say that where a standard is updated, it takes cognisance of whether it should be prospective or retrospective. On the majority of cases, the standard is moving forward for prospective. That is not to say that if the change in standard or change in design regulations was such that it had to be retrospective that it would be considered, but very often there is a cognisance of the impact of such a change and the consequential impacts of that. For example, if there had been a change in relation to fire safety regulations or other regulations that would require extensive retrospective treatment that is supposed to prospective treatment, then a judgement would be made on that basis. If I look at the last two or three changes that have gone through, they have not been retrospective. Does that mean that, to take a complex site with buildings of drift and edge, I think immediately of Forrester Hill in Aberdein, but there are other sites that would likewise have old and new buildings? Does that mean that there is a whole variety of different standards applying to different parts of that campus? Well, sorry, I will try to answer the question precisely. There is a possibility within a larger state that the technical advice that is provided from one decade to the next would differ. In that precise case, if I think of the speed at which the technical memoranda changes, it is not as if it is changing every week or every month. It does last for a period of year, so I think that there is a potential that an older piece of the state would have referred to memoranda that may have since been updated. Can I ask others to delay me then in inspecting against the standards? Does that variety cause any particular challenge for your teams if they are inspecting different promises on the same site against different standards? I think that the benefit is that we will know that before we ever go anywhere near the site, so we are aware of any differences that would be there. I think that, in terms of your initial point about confusion, it is important for everyone to understand that we are using the standards that are developed by HPS and HFS rather than us developing something ourselves, so there is one set for everyone. Obviously, if we were going to a site, we would understand the differences before we ever went there. I want to follow in the line of questioning with regard to new builds in the NHS Scotland estate. Specifically, given the cases that we have seen over recent years and certainly in recent months, is it fair to say that we have seen substandard works in construction in some of those new builds? Is there evidence that new development has not taken into account all the matters that you have described this morning? I think that if I try to understand the hierarchy of guidance versus standards versus regulations, so the function of the SHTEMs, the technical memoranda, is predominantly guidance. The guidance is written with reference to standards or codes of practice and the regulations, but it does not repeat them because they sit in statute or otherwise. That again would be clearly the responsibility of the commissioning organisation, whoever that may be, ordinarily territorial boards, to ensure that they had full compliance with everything from regulation down. The guidance that it stands is perhaps a route to compliance, so that if the guidance is there, you can see that you are to comply to those regulations' standards and approve codes of practice that exist. That has not been followed, then, that we are seeing those cases. I am unable to comment as to whether the guidance that it stands is there for health boards to use and to rely on, but not in isolation. I could not comment as to whether cases of projects that have been completed would fail a compliance test if there was such a thing, because of course there is not a compliance test against that guidance. Clearly, where there is is that those next levels up in that hierarchy against a code of practice or a regulation or a standard, and I am not aware of any failings in those aspects. I mentioned at the start that the changing nature of the built environment, the standards, are changing. I cannot comment on the standard of building, but, for example, we have a shift to single rooms. That is admirable in so many senses. I am sure that a lot of patients really appreciate the greater number of single rooms available. However, it comes with a change in the nature of the risk in that, if you are looking at water systems and each room has its own sink, whereas, in years gone by, you may have had a much less number of sinks and a ward with a number of patients, clearly the level of risk will be different if there is almost an unintended consequence. As I said, we are a learning system. Could we have anticipated some of the issues that are concerned with that? Perhaps with the power of hindsight, but we are responding to that and learning from the changing nature of it. I will give that as one example. Given the responsibility, as far as we are aware, to the 14 health boards to sign off those projects with your support, is there a need for that to be reformed and looking towards specifically dedicated expert infection control teams to be part of that? It does not sound like we have 14 dedicated teams doing that for new builds across the country, so it sounds like it is patchy to say the least. Is that right in terms of my interpretation of what we are doing today, when we look at new builds before NHS Scotland takes ownership of them? I would comment that, picking up on Phil's point that, in terms of that continual learning environment, I know from work that is currently going on at that group that I referenced earlier called the strategic facilities group. They are continually trying to understand how they can better work. The incident of very large complex hospital builds is relatively small, which means that that shared learning opportunity becomes quite difficult. It may be once in a career for a lot of people working in a territorial board that is involved in that project, so I think that the facilities groups and other agencies are looking to see whether they can ensure that shared learning for one project to the next is not lost. I think that that is important. For myself as a Lothian MSP, we have the new Royal Sick Kids same construction company, but different design sets have been in place. We hope that we see no incidents in the new hospital, but the guarantees that we need to see and any retrospective fitting, for example, which needs to take place—how that has then followed through, I think is important. Finally, I just wanted to ask—we have been asked to refer to specialists by the panel—do we have those specialists in Scotland today who can do this work when we are looking at ventilation specialists, for example? Who do you use when you are undertaking this work? I will refer back to my earlier comment. If I look at my own area, we have a number of specialists. Whether that covers absolutely every aspect of the built environment, I would not like to say. However, I think that it is important to recognise that both BORs and Adieves Health Facility Scotland rely and go to external marketplace to make sure that we are providing that advice, that cutting-edge advice from others. The literature review that Phil referenced earlier to a committee question is also making sure that, in terms of all the healthcare systems that are in the UK and Europe, we are trying to get the best practice. There is something about the technical expertise, and there is also something about the scientific expertise that is provided that informs the guidance. I know from some of the correspondence that I have received—I am sure that other members across the Parliament have—that the construction sector knows each other, and often in a competitive world we will talk about each other. However, I know from some of the correspondence that I have had that I have raised with the cabinet secretary on-going concerns. Do you ever instigate discussions around concerns that were raised earlier before NHS Scotland took ownership of those buildings? Whether it is a concern, whether it is a reflection or an observation, I am sorry that it sounds like it depends, but it does depend on the on-going relationship that people like—the on-going conversation between the board, the commissioning organisation and the HFS. On the whole, I believe that there is a strong collegiate working relationship, but sometimes there is the case where we need to understand the respective roles and responsibilities, and where a board has made a decision to take forward a project, then we have no automatic right, if you like, in terms of that sort of scrutiny piece, back to the other comment around that kind of guidance and advice versus the audit compliance piece that we currently do not have. In terms of those projects, do you ever have concerns around projects being awarded based on savings, potentially? I am genuinely not aware of any project or contract that is awarded through a single lens, if I can use that phrase. Thank you, convener. I will just follow up on Miles Briggs's question about specialists. I am acutely aware that, as we are changing the model of care that we are delivering in terms of building new hospitals in a different way than we used to, that there are unknowns—not to get old, Donald Drumsfeld—but a knowledge gap might therefore exist. We may have specialists who know forensically how to keep a sink apparatus clean in a bedroom, or how to keep air duct units functioning in a hygienic way. The same specialists might not know, for example, the impact of a helicopter landing on a helipad that is covered in pigeon droppings. Are you concerned that there is a knowledge gap? Would we know who to ask if we identified through the various inquiries on going into incidents that we have that knowledge gap? I am not concerned that there is a knowledge gap in so far as I am reassured that we have an open learning organisation that is NHS Scotland. It would be crazy to assume that we fully understand that. One of the first things that we talked about earlier this morning was that fast-moving change in the environment. That is not just the way that health is operated within its construction and build, but the way that construction and build moves in other healthcare environments. In health facilities in Scotland, we have a very strong relationship, both at a UK and beyond level, to make sure that we have that open learning opportunity that others can learn from us and that we can learn from those. Are you confident that, in terms of infection control, whether that is a specialist or it is the clinicians on the ground or the workers on the ground who are charged with infection control, are sufficient continuous training so that they are on top of—we understand that there is an arms race that exists between the developing infections and the fact that they become resistant to traditional techniques. Do we have a comprehensive suite of training to upskill that workforce that is in charge of infection control with our understanding about the developing nature of viruses and bacteria? I will pick that up, if I may. We have a programme, and it is an integral part. I mentioned earlier on NHS National Education Scotland, who is a key partner in that. In terms of developing any action plans, we are continually looking at, well, there is no partner just writing a piece of guidance if we then do not think about how do we then take that out to educate frontline staff in its application. It is most certainly a key component. Just if I may, I will go back to the unknown unknowns and the surveillance of how we ensure that we are trying to keep up with that arms race. I mentioned earlier the European figures that position Scotland quite strongly. Working in a UK context and working in a European context and seeing what is going on, we mentioned the literature reviews that we have done that are looking at an international context. That surveillance is going on all the time. It is not always about specialist knowledge or training. Sometimes, as we have found recently, it is also about accountabilities and responsibilities and clarity about that, so that, as the healthcare environment develops, it can sometimes become unclear who is responsible for something. There are more single rooms, more sinks and toilets, but if those are not getting used, for example, who is responsible for the flushing regime in relation to that. It is important that the governance, in a sense, keeps up with the development and healthcare. It is not always just about training, but about having clarity among all the staff, including ancillary staff, not just clinical staff, about who is responsible for what and keeping those operating procedures, if you like, up to date. Can I just go back to the question that I asked a little earlier about Scotland's standards? Can I just confirm with Alice Delaney that it would be your view that all buildings that you inspect reach the relevant standard? That would be your expectation and what you would require to have. It would be an expectation that the standards are met. We cannot check every single standard, every single visit, quite clearly, but we would use intelligence and evidence to see if there is anything to give us thought about looking at something in particular. You would apply that intelligence-led approach, whether it is existing buildings or new builds. Thank you, convener. I am interested in looking at some of the issues around cleaning the environment, for instance. If we are comparing new builds with older estate and there are the issues around what makes somebody susceptible to an infection, it is the immunosuppressed, the bone marrow, the neutropenic, the compromised patients that are the ones that are most at risk. If we are talking about new builds and all the pipes and air, the same issue is in the older estate as well. Cleaning is integral to infection control prevention. I am assuming that we have everything in place to ensure that our cleaners are educated and prepared. I know that it is not just about the clinical teams, it is about everybody having a responsibility to wash their hands. However, the cleaning of the environment is essential. I would be interested in comments about that. I would go back to my earlier point. I think that the Ancilli staff cleaning staff is essential. They understand the roles and responsibilities that they are trained appropriately, so they understand what they have to do and why they are having to do it. That dovetails with the clinical input so that they can understand what is required and how they can accommodate the work that has to be done. That is certainly something that we look at on inspection as evidenced by recent reports. The national report that is collated by HFS on compliance with national cleaning specification that I referenced earlier, the current 2009 report, which was published probably about two months ago, six to eight weeks ago. It identifies using a relatively simple red amber green, but it identifies that allocation adherence to those specifications, as well as those shared learning opportunities that are created by the mix of aged estate. In one of our submissions, I read that, if a room was visibly clean or it looked tidy, then it might be skipped from cleaning, but it would seem to make more sense to me that you cannot see microorganisms on the bedside locker or whatever. A regular cleaning routine would need to be implemented no matter whether a place was visually looked okay. I would imagine that that would be the best practice. I cannot remember the absolute detail of the specification, but I would be surprised if it was based on a visual only inspection, but I am happy to refer back to the committee on that point. We were told that in one hospital, current cleaning conforms to a dynamic risk assessment for the first three days of a patient's day. In other words, if it appeared clean, then cleaning would not be carried out on that day. Is that something that would fail on inspection? I think that it depends on the context and the circumstances. I think that we would be looking for information about how we can be assured and how the hospital can be assured that that area is to a standard that is acceptable. Rather than being prescriptive about saying what it has to be, I think that we would be asking for assurances as to how that is being managed and how that is being looked at. The same witness told us, and I do not doubt that this is corrected, virtually all hospitals in the western hemisphere and further afield clean patient rooms or bed spaces at least once a day, but that is not a requirement currently in Scotland. That is not something that you would require hospitals to be able to demonstrate. Again, I am sorry to confirm that I would be happy to refer back to the committee on the absolute detail of the specification, but I do not have it to mind. Thank you very much. There was another witness who talked to us about ventilation and said that he gave a couple of examples. Inadequate ventilation systems have been installed in new-build hospitals. Those are not fit for purpose for specialist patient groups such as Bone Marrow Transplant and hematology wards and also said that the adoption of positive pressure ventilation rooms room design throughout a number of Scottish hospitals is inadequate to protect isolated, immunosuppressed and or vulnerable patients. That really follows on from Emma Harper's questions, but specifically on ventilation. Are those approaches to new-build hospitals that members of the panel recognise? It is not something that I could comment on other than to suggest that. It is a very technical area and I do not think that there is anyone that has been asked for the committee that would have that expertise. Who would make the final choice on equipment and systems such as ventilation? Where is the responsibility for installation and choice of a ventilation system lie? Depending on the model of contract that is used, it would be the commissioning organisation, so in the case of a large hospital, it would be the territorial border. As HFS, do you lay down standards that ventilation systems must comply with that are designed to reduce healthcare infections? Do you lay down those standards and are there choices made only within those standards by the commissioning organisation? Back to the standards in the sense that the standards are there as guidance, we would expect them to adhere to. We have and are continuing to use what we talked about, the review of the guidance on water and water systems, just given the vast increase in complexity. I think that the same could be said for ventilation systems and changes to that, so it is an ever-changing landscape. Is there any evidence that you are aware of where a new-build hospital in recent years has disregarded or failed to comply with guidance on those systems? We have already seen a massive reduction in central venus access device infections over recent years, because we know that we should only put central lines in an area that is clean with a positive pressure environment, such as an operating theatre or a clinical room that is only for line insertion. We have already seen that. Everybody is aware that there are places where invasive procedures need to take place, and that is set up as a standard. I want to reiterate the fact that we have seen a reduction in line infections or surgical site infections because good clinical practice is in place. That knowledge is shared based on inspections and information that is shared throughout the infection control experts network. I am proposing that because I know that that is a fact. Is that something that witnesses would confirm? That is certainly the case. I think that the improvements have been significant, the sharing of good practice has been strong, because everyone has patient safety and patient care at their heart, so everybody will still learn from everyone else. There have been significant strides. There are always going to be places where something has not quite gone right, we need to identify those, fix them and then move forward. The Government level is the antimicrobial healthcare associated infection policy group, which is obviously the Health Protection Scotland support and inform. However, it takes the policy that comes from that and it takes it forward in an antimicrobial resistance healthcare associated infection group of the group of ddangos chi i amserionionolol i ymcribededur yn brosbysgol iawn. Felly, byddai fuddfa o'u gwaith i gêmedd ddyliau fodiau a fyddai'n cael ei ddisigol i'r byddiau i gynnig iawn i'r cael ei ddangos ei ddangos ei ddangos i'n gweithio i'r bwyd. That brief supplementary in terms of reporting up to the Scottish Government in that context… Is it two cases of an infection in one hospital before ministers are made available? I would have to check the detail of the national framework to confirm that but it is all well specified and if the Committee would like a copy of the national framework that is very readily Ben yourself support that will operate such when necessary. Do you do any work around the fact that people are in hospital with compromised immune systems? Rydym ni'n fawr i'n ddaeth i ddod hiw i weldo cwerthio gwahanol, a ddim yn rhoi eich hunywag y ddaeth i ei gweld. Fy rydw i'n cael ei fod wedi'i amser iddyn nhw'n gweld. Fy rydw i'chcessibleg cael ei ddod, rydw i'i ddod ei ddod o'i grannig ac rwy'n gweld a gweld i ddisigibleg a'r cychwyneth teimlo yn ddod i gyflym. Pê ar gyfer gweld Ie tabletr, Sinterfian, Rhyda, i dweud i gychwynedd yndyn nhw the British Medical Association submission, they questioned the need for Scotland to have its own guidance for healthcare premises and said that one of the consequences of that separate guidance was that it was harder to get external experts and training for what's a relatively small market. Now we already had some discussion around that question of external experts, is that a point that is recognised and if so what would your response be? Jim Miller. Two comments, if I can convene us. First, in answer to that specific question, the guidance, if it's based on UK guidance, has changed as little as possible and in some cases not changed at all. It's only changed to a reference if there's a different regulatory regime in Scotland and there isn't in other parts of the UK or if there's something, a fundamental change in healthcare practice such as the instance of single rooms that Phil mentioned earlier. So the changes are not, it's not a rewrite, it's just to make sure that it's appropriate to the Scottish context. Sorry, convener, I wonder if I could just go back to a point that you asked earlier around adherence to the guidance. In checking my notes, there is a current internal report between HFS and Greater Glasgow and Clyde for their consideration where it talks on at least one occasion that I can see from my note that adherence to the technical memoranda is not possible to be absolutely confirmed that it meets the requirements. It's asking Glasgow for comments. I just want to clarify, I think that my comment was not to my knowledge, so there is something that suggests that we have asked a question of the board when they had invited us in. It appears that they may have fallen below the standards because they say that they can't implement the standards. It's not that they can't implement standards, it's when we have looked at a particular piece of water pipe work that we are not able to confirm that it meets the standards perhaps because, again, I'm not a technical expert, maybe because it's a closed system and we can't confirm. I understand, thanks very much. Thank you, convener. We understand that we are currently at the Queen Elizabeth, sitting around about 300 maintenance jobs as a backlog. Is that what you would expect from a hostel of that age and size? Is that normal? From our side, we saw that that number is quite high. Okay. With that, the question then, does that then potentially pose a threat to patient care in that kind of maintenance backlog? Well, anything like that would potentially pose a risk to patient care. The question is how responsive the board are to the maintenance backlog and how responsive they are to dealing with them. They need to prioritise that list, obviously, and that's what they've done, so that they can focus on the areas of highest risk and make sure that progress is made. In relation to that, as you'll see from the report that we published, the board provided an action plan about how it was going to deal with all the recommendations, including that as one. They are taking forward things to our satisfaction as it stands at the moment, and, obviously, we will check their progress at a later date. I think that one of the questions that you were asking is maintenance given the priority and the funding that it potentially deserves. That would be a decision well above my pay grade as to whether that's sufficient if one did to do so. Okay. Do you want to say that the priorities have been set by Greater Glasgow? Do we know what process they followed to set those priorities? I couldn't be able to give you detail about how they did that, but, yes, we would be asking the board how it has set those priorities, and, obviously, patient safety and care would be at the very top of that list. I think that he's followed to that, convener. Are maintenance jobs that the Queen Elizabeth is still responsible with the health board or does the contractor still retain some of that responsibility? I don't know in detail, but it's not, as I understand it, a better place. It's not a PFI build, so I think that the responsibility lies with the health board to make those improvements. I would note that the 300 is across all the sites, as you mentioned earlier, not just the new build. Obviously, some of the older builds have significant issues by its very nature, which is what was your original question, which makes it difficult. We all understand that, but that's the position that we're in in the country at the moment. Thank you very much. Emma Harper. Just to pick up on Brian Whittle's question, if 300 maintenance jobs are required, some of them might be as simple as a light bulb change, so that wouldn't be an infection control issue. Prioritising them on severity of risk—red amber, green, red bean—you really need to do this right now—would need to be part of the consideration. I'm aware that there are facilities monitoring tools that are used to help monitor the facilities, but some are the contractor's responsibility. If a sluice was required in a particular clinical area, because maybe in the original design build it wasn't in the right place, that is a bigger job than changing taps or sinks or light bulbs. That has to have a more planned process of engagement, so that that would need to have a different priority, I'm assuming. I mean clearly you're absolutely correct, they are not all of the same order. The number itself doesn't tell you a huge amount, because it depends on the nature of what those things were. Some of them are easily fixed, can be done immediately, some of them would take a longer term, but also some of them are more important than others when you look at patient safety, so absolutely the case. You would have to delve into the detail to be able to understand better what those things actually amounted to. I think that I understood your previous answer to say that you would ask Glasgow and Clyde health board how they'd set priorities, and that would include presumably asking who had been involved in the setting of priorities. We would be checking that to make sure that there is a prioritisation and a rationale for that prioritisation. And that it involves clinical staff and not only the state staff? Of course. Okay, understood, that's very helpful. Thank you very much. Brian Whittle, did you have one that you want to come back on? Okay, excellent. Thanks very much. My last question, we've already touched on the issue of whistleblowing and so on, and I wondered, and the fact that members of clinical staff have felt the need to go to become whistleblowers in order to draw attention to concerns that they have. Are any of your organisations, the type of organisations to which people can go who are members of the public or members of hospital staff and direct their complaints or their concerns directly and with a consequence that you will be able to do something about it? Yes, it is possible. However, the issue that people have to understand, and it's always a difficulty for us, is that people raise their individual concerns about their individual treatment, and if that's the case, it's a complaint to the board which they have to follow that process, which then goes to the Scottish Public Sector on Bismen thereafter, if they are unhappy with that complaint. We can't get in the way of that process, so we do have members of the public who contact us, but we have to then take that and extrapolate it out and ask if there are generic or general issues which are applicable across a wider range, rather than investigate an individual circumstance. We do use it in intelligence, however, because we get that kind of information. We can see if there are trends or if there are issues building up over time in a particular area, and we can use that to inform further action that we can take. That would be a piece of advice. Similar answer, yes. People can raise members of the public employees, staff can raise concerns with us and us information on the website, but there would be triaged against our regulatory model and where our area of jurisdiction rests. I'm sure that that's very helpful for members of the public and particularly concerned members of medical staff to understand. You've mentioned on a number of occasions that you felt that the expertise that we were seeking to access wasn't within your particular territory. So this is a very general question to ask if there are other witnesses or other organisations you feel we ought to hear from in order to address some of the questions that we've discussed today but not fully resolved. Would there be any nominations from the witnesses or other witnesses from whom we ought to hear? It would depend on a specific question. Obviously, we've covered a range of questions from high-level strategic organisational issues that I think the panel are equipped to deal with down to some very specialist issues that we're not equipped to deal with. I think that in all of our organisations, we rely on a large number of staff to hub that collective knowledge. If the committee particularly wanted to explore a specialist topic in detail, perhaps we could advise, but given the range of questions that we've had, it's quite difficult to identify a particular witness, certainly from a health protection perspective, unless there was a particular topic that the committee wished to explore. I wonder if, when we're talking about 14 health boards in your experience, is the one that you think is getting this right in terms of inspection and looking towards this and future-proofing the NHS estate? If you look at the figures, some boards are doing better than others. It's not a secret. We've talked quite a lot about Glasgow and some of the concerns about Queen Elizabeth. If you look at Glasgow as a health board, they are doing better than the Scottish average. I say that to put things into context. There will be pools of good practice that can be done, but it depends, because some boards will be good at some particular areas of practice. If it's commissioning new hospitals, again, that's a difficult one to call because they do it so infrequently, but there will be other examples. I'm sure that, depending again on the area that you wish to explore, you could find a board that was an exemplar compared to the rest. Thanks very much. The official report of this session will be published later today. I would ask witnesses to reflect on the questions that were raised during the session and not fully answered and, by all means, to come back to us if other thoughts occurred to you in those terms. I think that a number of you have promised to provide further information. I would be very grateful if that could be available by Tuesday. I know that that is quite soon in terms of working days, but it would be helpful to us if we were able to have access to any further information that you have offered to provide by this time next week. I thank you all for your answers to the many questions that we have raised. It's much appreciated. I will now suspend this session and we will resume in private session in five minutes time. Thanks very much.