I beg to move,
That this House
notes with deep concern the increased levels of hospital-acquired infection and, in particular, that the incidence of methicillin resistant staphylococcus aureus (MRSA) has doubled since 1997;
welcomes the report by the National Audit Office 'Improving Patient Care by Reducing the Risk of Hospital-Acquired Infection: a Progress Report' (HC 876);
regrets the lack of timely action by the Government which this discloses, including higher bed occupancies and the resultant impact of Government waiting list targets on infection control measures, lack of surveillance data other than hospital-wide MRSA and post-discharge surveillance and isolation facilities, and lack of progress on a national infection control manual;
is deeply concerned that recommendations for bed or ward closures by infection control teams have been refused;
and calls on the Government now to act urgently to secure the action needed to reduce hospital-acquired infections.
A week ago, the Health Minister, Lord Warner, announced what he described as the first national campaign to promote hand cleaning by health care staff. Well, 150 years on from Florence Nightingale's work in the Crimea, I think that we can fairly say that it was not the first such campaign—but what did it tell us about the Government's response to the crisis of hospital-acquired infection? Four and a half years ago, in its 42nd report in the 1999–2000 Session, the Public Accounts Committee made the following recommendation:
"Hospital hygiene is crucial in preventing hospital-acquired infection including basic practice such as handwashing. We find it inexcusable that compliance with guidance on handwashing is so poor . . . We . . . look to" the NHS executive
"to audit progress and report back to us by the end of 2001."
Four and a half years later, the Department of Health announces a campaign. Only now is it showing, in this limited respect, the urgency and determination to achieve cleanliness and hygiene in our hospitals that have been urged on it not only by the PAC but by others.
We do not know the extent of hospital-acquired infection and the costs that it imposes. That, too, the PAC asked for four and a half years ago—it was asked for but not achieved. What we do know is the human cost: several thousand lives needlessly lost and patients suffering weeks, even months, with their wounds failing to heal. Every Member of Parliament will know from constituents of the pain and distress that these infections cause. That is why we all want and expect the risk of hospital-acquired infection to be combated with all the energy and urgency that we can command, and why we in the Opposition brought the matter to the attention of the House immediately on its return.
The National Audit Office report, four and a half years on, lays bare the failure to act or to achieve the progress called for by the PAC and, frankly, by so many others. In June 2000, my hon. Friend Dr. Fox made exactly the same points here in the House.
I hope that we do not have a debate in which Opposition Members all say that the glass if half-empty and Government Members all say that the glass is half-full. The issue is too important for that and my contention is not that nothing has been done. NHS staff across the country are becoming more aware of the need for comprehensive infection-control measures. I and other hon. Members know that exemplary work is being done in many parts of the NHS so that patients see clean wards and can be confident of not contracting infections.
Equally, however, some places are not clean and infections are endemic, sometimes even in high-risk areas. What is deeply disturbing and lies at the heart of the debate is the fact that, far from doing everything that they could to deliver safe care to patients, the Government have not done so. Worse, they have pursued their obsession with central targets, which have frustrated the achievement of effective infection-control procedures. The purpose of the Opposition motion and today's debate is to require of the Government the urgency of action demanded more than four years ago, but which has been so sadly lacking.
The evidence is depressingly clear. In 2000, the Public Accounts Committee said that the NHS did not have a grip on the extent and costs of infection. It recommended that the nosocomial infection national surveillance scheme be developed and made mandatory. Ministers chose not to do so, as the National Audit Office report of July describes it. It says:
"Instead of developing mandatory specialty specific surveillance of bloodstream, surgical site and urinary tract infections whose information would be fed back to clinicians to improve practice, the Department focussed on trust-wide surveillance of MRSA bacteraemias and other specific organisms, together with plans for mandatory reporting of orthopaedic surgical site infection."
That is methicillin-resistant Staphylococcus aureus in the bloodstream, rather than MRSA where surgical site infections are concerned. It continues:
"This is a critical issue. Leadership and clinical responsibility is at the heart of infection control measures. Data which is not specialty specific is not leading to clinicians taking their responsibility for reducing infection, nor is it equipping patients with the key information about the incidence of infection in the wards to which they may be admitted for operations, especially if they are high-risk areas."
I have taken a close personal interest in the issue that the hon. Gentleman raises, and I would counsel him to be very careful about the way in which he uses statistics in this matter. For example, a small specialty unit might have only a few patients, but they may all have come in from dozens of surrounding general hospitals. Such units are almost certain to be statistically high up in the league tables. It is a distortion of the efforts made to manage controls. I urge the hon. Gentleman to be extremely careful with the data.
I was not planning to elaborate on that, but the hon. Gentleman makes an extremely good point. The Public Accounts Committee report—I did not originate the proposal—in a sense suggests being much more careful with the data. Let me explain to the hon. Gentleman what is happening at the moment. The currently published MRSA rates measure incidence rather than prevalence, so they do not tell us the likelihood of arriving at a hospital without infection and acquiring it while within that hospital or particular clinical department. We are told only about the total incidence of hospital-acquired infection—or, more particularly, MRSA bloodstream infections in the hospital.
I know how important that is, because Addenbrooke's hospital in my constituency had the second-highest incidence of MRSA. A significant part of the problem was the extent to which the hospital was admitting patients from other clinical contexts, in which MRSA had been detected. The House will be aware of many instances in which hospitals have said that their data were influenced by the extent to which there is MRSA in nursing homes, and by the number of patients from those homes being admitted to hospital.
I do not dispute that it is important to get statistics absolutely clear. We are raising this subject now in part because clinicians want the available data to be much more specialty specific and related to clinical departments. In that way, the data will not be obscured by information that is hospital-wide. Clinicians will then be able to act on the information that is under their control and to be judged accordingly by general practitioners and patients. That is an example of how patient choice will play a role.
The hon. Gentleman speaks about the need for both testing and data to be specific and reliable. Does he understand, therefore, why we have chosen to test for MRSA infection in the bloodstream, but not in open wounds or in respiratory or urinary tracts? It is because, for good scientific reasons, the reliability of the data varies in each case. The incidence of MRSA infection in urinary or respiratory tracts is very low. We are not being negligent, but we are exercising judgment. The hon. Gentleman can query our judgment, or qualify it, but I assure him that we are not being lazy in this matter—there is no question but that we want to cover every eventuality. Our approach is based on the reliability of the scientific data that can be derived from the various forms of infection.
I am making the same point that was made by the National Audit Office. If the Government have specific reasons for departing from the recommendations made by the NAO and the Public Accounts Committee—that the mechanism in the nosocomial infection national surveillance service be continued—they have failed to make them clear. I accept the point made by the Secretary of State about MRSA infection of urinary and respiratory tracts, but it is possible, relevant, practical and desirable to undertake NINNS surveillance in respect of surgical site infections, and of some specialties.
Indeed, the Government are proposing to undertake such surveillance in respect of orthopaedics in 2005. If that surveillance is relevant for orthopaedics, why is it not relevant for a range of surgical-site infections that have been part of the NINNS scheme?
I did not say that such surveillance was irrelevant; I said that it was not as reliable. The hon. Gentleman is right to say that we are extending the surveillance beyond the bloodstream tests, but my point was merely that when we started the surveillance, we chose a limited application because the data gathered in that way were more reliable. I do not need to point out to him that no data were collected over the entire 18 years of the previous Conservative Government. We have responded to the problem, but we have done so first in those areas where the data are more reliable so that we could get a picture as soon as possible. We are now about to extend the surveillance.
I am intervening in the hon. Gentleman's speech because no party political points are involved. I am not trying to score points, and I know that he is not trying to do so either. My aim is merely to explain the scientific basis of the advice on which I am operating.
In the same spirit, the Secretary of State will accept that if some of what is considered to be good practice—for example, the screening of patients before admission to hospital for elective surgery, and post-discharge surveillance—were to be carried out in full, it is possible that the problem of the reliability of data could be dealt with. However, the point is to generate data on which people will act. In some circumstances, the best could be the enemy of the good. I put it to the Government that at the moment they are pursuing the best, rather than what is good.
Clinical teams need to take responsibility for the matter. Indeed, the Government's amendment states that
"mandatory MRSA surveillance raised the profile of infection control with senior managers".
It did, but as the NAO said:
"The main concerns of mandatory MRSA surveillance were that the denominator data was inappropriate as it was collected across the whole hospital, and as a result, clinical staff did not relate to it, and trust management considered it to be a problem for the infection control team rather than clinicians."
The Secretary of State will recall that elsewhere the NAO found too often a tendency for people across the NHS to see the responsibility as one for the infection control team, or somebody else, rather than theirs. Taking responsibility and giving leadership is central to what we are trying to achieve.
The Government amendment also talks of the advantage of imposing another Government target. As we know, targets set are not necessarily targets met. Even targets apparently met often have unfortunate consequences elsewhere. Nowhere is that more true than in the effect of Government waiting list targets on infection control. The NAO reported that 50 per cent. of trust senior management had difficulty in reconciling targets for in-patient waiting lists with the requirements for infection control. Ministers may say that by its nature that is difficult and that the job of management is to do difficult things. However, in response to the 2000 report, Ministers also said that by 2003–04 bed occupancy could be reduced to 82 per cent., yet the NAO found that 71 per cent. of trusts were operating at higher bed occupancy rates than that, averaging 89 per cent. and 91 per cent. for orthopaedic and vascular surgery respectively.
Where those objectives come into conflict, patient safety must come first, so it is nothing less than an outrage that the infection control teams reported to the NAO that 12 per cent. of them had requested bed or ward closures but had been refused. The situation is worse than that. I asked a trust chief executive if he had refused such a request. He said:
"They know our situation so they won't ask."
Only a few days ago, a consultant told me of an exchange in an internal hospital meeting when the infection control consultant said that MRSA and Norwalk had persisted because the trust had overridden advice to shut wards due to the need to achieve waiting list targets. The chief executive had agreed to that.
What is the Secretary of State's response? Last week, he was asked on the BBC "South East Today" programme whether by having fewer targets—as we propose—staff would be free to ensure cleaner wards—[Interruption.] Yes, fewer targets; getting rid of central targets imposed on hospitals, including the in-patient waiting list, which we are talking about, and its deleterious effects on the NHS. In response to that question, the Secretary of State said:
"I take the advice of the chief medical officer on this".
Where is that advice? Does the Secretary of State propose publishing it? Will he undertake to publish it today?
I looked in "Winning Ways", which the chief medical officer published last December. Of course, the Secretary of State published his own document in July. Is not it interesting that the Secretary of State, when pressed on a difficult issue, says that he takes the chief medical officer's advice, yet where there is an opportunity for him to push himself forward and take the initiative, he publishes his own document rather than letting the chief medical officer do it?
I have looked at the two documents. If everything the Secretary of State does is based on the CMO's advice, why was so much that the CMO said only last December left out of the Secretary of State's document in July? He left out any reference to reducing infection—[Interruption.] From a sedentary position, the Secretary of State says it was additional. In fact, the document was described as a summary of action, so almost by definition it was not intended to be additional; it was a summation of what was being done. There was no reference to reducing infection risks from invasive procedures. There was no advice on the prudent use of antibiotics and no reference to including infection control in the curricula for undergraduate and postgraduate health professionals. The Secretary of State's document made no reference to the role of infection control teams.
One wonders what was the value of the Secretary of State's additional document in July, other than simply to offset the fact that the NAO was publishing its report, which was so deeply critical of all that had been done. The Secretary of State hides behind the chief medical officer when the criticism hits home, but he has his own public relations view pushed forward when he wants.I have not spoken to the chief medical officer about this issue.
The hon. Gentleman perhaps suggests that I should have spoken to the chief medical officer. Indeed, one of the first things that I did when I was appointed to the health team was to write to the CMO asking to have a conversation with him about such matters. I was denied that opportunity. I was informed that as the CMO is a civil servant, he would expect me to discuss policy issues with Ministers, so I shall do so. I cannot therefore say what the CMO advised the Secretary of State, which is why I ask the Secretary of State.
My personal view is that the CMO would say that if, after the necessary risk assessment, an infection control team recommended a ward closure, the requirements of in-patient waiting list targets should not override that recommendation. If the position is otherwise, the Secretary of State and other Ministers have required that that should be so. Their overriding intention to pursue their misplaced in-patient waiting list structure over the interests of patient safety has led to the current problem. Such things have not been done on the CMO's advice, yet the Secretary of State told the BBC that all this was happening because of that advice. Perhaps the Secretary of State would like to tell the House what advice there was and whether he will publish it.
I am sure that the hon. Gentleman is making a point, but I must admit that I am a bit lost about what it is. Advisers advise Ministers. The chief medical officer advises the Government. We act on that advice. Sometimes, on the basis of the information and advice that we receive, we publish documents or take action publicly, for which we are responsible. Sometimes, we directly publish documents by the chief medial officer. When advice is put into the public domain, people can read it. When advice is given to Ministers on policy issues, it is a long-standing convention of some centuries in the House that it is not published. The hon. Gentleman may not like that, but this is hardly a unique case. I am not quite sure what point he is making.
The point is simple, and I will not detain the House too long. If the Secretary of State does not take responsibility for his own decisions but attributes them to the advice of the chief medical officer, the advice ought therefore to be in the public domain. I have searched the advice that is in the public domain and there is nothing to suggest that any chief executive who overrides an infection control team's recommendation to close a ward would be acting other than against the interests of patient safety and contrary to the clinical situation.
I must remind the Secretary of State that the motion refers to many other ways in which failings in action have been laid bare by the NAO report. I will not be able to detail them all, but I want to ensure that the House is aware of them.
On isolation facilities, the NAO report said:
"In our original report, we found that isolation facilities in some NHS trusts had been significantly reduced and that many infection control teams believed that facilities for isolating patients were unsatisfactory . . . The Committee of Public Accounts specified that increased investment in isolation facilities was required. In 2001, the Department assured the Committee that the need for isolation facilities was being addressed. However in 2003, we found that while 56 per cent. of trusts had undertaken a risk assessment to determine the number and quality of isolation facilities in the last three years, only a quarter had obtained the required facilities."
Will the Secretary of State tell us what steps the Government will now take to meet that recommendation, which has not been met in the past four and a half years?
I shall mention post-discharge surveillance. The NAO report said that, four and a half years ago,
"we identified between 50 and 70 per cent. of surgical wound infections occurred post discharge but that only a quarter of infection control teams were carrying out any post-discharge surveillance and that there had been no systematic evaluation of the reliability of different methods.
The Department told the Committee that they had commissioned some research and expected to have the results in late 2000. The Committee recommended that these infections should be monitored through NINSS . . . We found that only 21 per cent. of infection control teams had carried out any post-discharge surveillance since our last report."
Will the Secretary of State tell us what he will now do to ensure that post-discharge surveillance of surgical wound infections is carried out?
The NAO report also stated:
"In 2001, the Department commissioned a feasibility study to consider producing a National Infection Control Manual. However there has been little progress on this to date. Responses to our survey and in our workshop showed there was strong agreement on the value to NHS staff of a national manual that could be adapted for local and specialty use. Given the strong evidence of wide local variability in the use of existing guidelines, and significant reinvention of the wheel, there is a need for templates to facilitate local adaptation of national guidelines."
The Government keep on publishing new documents and providing endless guidance, but NHS staff are looking for templates and a manual to enable those guidelines to be put into practice. Where is the manual? The Government have had four and a half years to produce one, but where is it?
In the December document "Winning Ways", the chief medical officer said that
"A rapid review process will be established to assess new procedures and products for which claims of effectiveness are made of their ability to prevent or control healthcare-associated infection."
In a debate in July, my right hon. Friend Mr. Lilley made specific reference to several new products and processes that have been offered to the NHS. He is not able to vouch for their effectiveness—nor am I—but that is why a rapid review process should be established. Ebiox is a non-alcohol cleansing product. NewGenn—which is close to Cambridge, so I have met the company staff and used their products—also makes non-alcohol hand cleansing products, which have been used in several NHS pilots. New synthetic antibacterial agents have been developed for the treatment of MRSA. Companies have produced targeted antibiotics and even coatings for walls and doors that—[Interruption.] The Secretary of State appears to want to make two speeches, one of them from a sedentary position. I do not know whether those products will work, but many people want to know when the rapid review process will start, because there are means by which the NHS could more effectively combat infection that are not being adopted.
I have a company in my constituency that makes a hand-washing machine that would facilitate infection control. Does my hon. Friend agree that part of the problem is that the commissioning process and the bureaucracy of the health service militates against decision making? The way in which the NHS operates has a dampening effect on innovation.
The NHS has historically been poor at introducing new products and processes. Sometimes that is to its advantage, because in America large amounts of money can be spent on new products and processes that are not necessarily effective or cost-effective. However, when we have a problem that is getting worse and that we have to tackle, the NHS should be able to assess the cost-effectiveness of attempts to do so. After all, we have the National Institute for Clinical Excellence, which leads the world in techniques for measuring clinical effectiveness and cost-effectiveness. The monopolistic nature of the NHS should not be a constraint on the adoption of innovative techniques. Indeed, it should be a means of disseminating such techniques more rapidly, but that is not happening in the area of infection control technology.
I shall not go on because hon. Members on both sides of the House want to speak. Our motion is measured and accurate. It requires the Government to act urgently in the future because that was lacking in the past. In the circumstances, we are right to call for that. The information that clinical teams need and for which they will take responsibility must be provided. The power given to ward-based teams—ward sisters, matrons or whatever they are called—is not the issue; what is important is that they have effective control over hygiene, cleanliness and the environment for their patients. They must be able to act in line with contractual procedures that equip them to do so.
We need patient choice to incentivise hospitals to meet patients clear and increasing demands for clean and safe hospitals. That is more effective than the targets that the Secretary of State talks about. We need to get rid of the targets and the constraints that prevent hospitals and NHS professionals from meeting the requirements of patient safety, which they so much want to do. We need the Health Protection Agency to pull a range of organisations and sources of guidance together to ensure that infection control measures are disseminated within the NHS rapidly. We need a rapid review process for new technologies and processes.
My experience in different parts of the country over the summer showed me that patients are deeply concerned. As chance would have it, only yesterday a lady told me of the three months that she spent in hospital as a consequence of MRSA infection and the distress and pain that it caused her. Many other patients are deeply distressed about the prospect of going into hospitals that they believe—rightly or wrongly—will put them at risk of acquiring an infection.
Doctors and nurses across the country tell me that they know how to deliver infection-free environments and that they have experience of doing that. They know that they can do it if they are given the support and the freedom to deliver the requirements of patient safety without being contradicted by Government targets and bureaucracy. That is what is urgently required now, not after the general election. It is what we have called for and why we have tabled the motion. I urge hon. Members to support our motion and resist the Government's amendment, which contains no sense of the urgency for which we have called. I hope that hon. Members give the Government the same message that constituents and the public have given us over the summer—that this is an urgent requirement which needs to be reflected in Government action now.
I beg to move, To leave out from "House" to the end of the Question, and to add instead thereof:
"welcomes the Government's commitment to ensure that patients can have confidence that National Health Service hospitals are clean, safe environments with infection firmly under control;
congratulates the Government on its action plans for reducing infection rates, 'Winning Ways' and 'Towards cleaner hospitals and lower rates of infection', which include the new target for a year-on-year reduction in MRSA, and the designation of directors of infection prevention and control to bring about local change;
notes that the National Audit Office report concluded that the introduction in 2001 of mandatory MRSA surveillance raised the profile of infection control with senior managers;
expects that the new target will act in a similar way, and deplores therefore the suggestion that the target be abolished;
acknowledges that improving patient safety is a difficult medical issue that calls for the hard work and care that is the hallmark of NHS staff;
welcomes therefore the 77,500 extra nurses and almost 19,400 extra doctors that have become a part of patient care since 1997;
and therefore congratulates the Government on a comprehensive programme of investment and reform that has equipped the NHS to deliver improvements in patient safety, and to reduce hospital-acquired infections."
Although we use these words often, I welcome the opportunity to discuss the subject and the Government's approach to reducing health care-acquired infections. Mr. Lansley gave a reasonably balanced speech, although at its centre was a mistake also made by the Leader of the Opposition, which is to imply, if not to state specifically, that hospital-acquired infections, especially MRSA, are the result of party political decisions of the Labour Government.
It is important to get the matter in perspective. We should acknowledge the problem, but it has existed for many years—indeed decades. The Leader of the Opposition was ill advised to introduce party politics on a matter such as MRSA. The problem has existed under both parties in government. It has not just arisen overnight; it has been there for decades. I use those words advisedly—I notice that there is some opposition to them—because they are not mine; they are the words of the Conservative Health Minister, Mr. Horam, in Hansard on
It is far too serious to treat the problem as a party political one, or to undermine it by exaggerating the novelty of the problem. The situation is serious enough without trying to imply that it is more serious than it is. In a sense, that undermines the credibility of the problem.
The Government's approach to the matter sits in the context of our efforts to update and improve the NHS. It cannot be seen in isolation of them. Some of those efforts are criticised by the hon. Gentleman, but I remind the House of them. There is more capacity and more money being put into the NHS in a sustained way than ever before: an average of 7.6 per cent. growth in real terms during the past four years. That has helped to expand capacity and, compared with 1997, the figures speak for themselves. There are more staff than ever: 77,500 more nurses and 19,000 more doctors working in the NHS. Sixty-eight major new hospitals have been built, are under way or are planned. That point is relevant, and I shall return to it later.
As a result—without in any way diminishing the deaths and misery caused by hospital-acquired infections—there are now 280,000 fewer people on the in-patient waiting list, compared with March 1997, and hardly anyone at all is waiting more than nine months for a hospital admission. More importantly, health outcomes for patients in general have improved. Premature deaths from cancer are down by more than 10 per cent., and coronary heart-related premature deaths are down by 23.4 per cent. Those are staggering changes. Out of fairness to NHS staff, let us remember that there are thousands of people alive today who would not have been had the NHS not introduced its reforms, and had we not introduced our improvements to the NHS. Staff have worked hard to achieve all that, so let us give them credit.
That is the context within which we are facing the challenge of hospital-acquired infections, a major one by any standards, and specifically, MRSA. What is the objective position as regards hospital-acquired infections? Almost by definition, hospitals are places where infections are concentrated. That has always been the case; it is not a phenomenon restricted to the current time or Government. What is the volume of hospital-acquired infections? I notice that the hon. Gentleman made no reference to the volume of such infections in comparison either historically or internationally.
Our estimates show that up to 9 per cent. of in-patients acquire an infection of some kind. They also show, as far back as we have reliable data, that that has not changed materially since 1980, not 1990. In 1980, the number of those infected stood at 9.2 per cent.; today, it is estimated to be 9 per cent. I shall go further. The advice I have is that, as far as we can make out, the total volume of hospital-acquired infections as a percentage has not substantially changed for the past 50 years.
What has changed within that overall total is the main type of bacteria or organisms that we have to deal with. Today, it is MRSA, but if one goes back to the 1950s, one finds it was staph aureus—the methicillin-sensitive organism. In the 1970s it was E. coli, in 1980 it was pseudomonas and in 1975 it was klebsiella. A mutation has occurred. As we have been successful in controlling some types of infections through antibiotics—and perhaps the overuse of them—others have grown to present the problems we have today.
I do not wish in any way to diminish the seriousness of the problem, but I caution against historical exaggeration of such infections as a novel problem with which we have had never had to deal before and which is exclusive or enhanced under a Labour Government.
Health care-acquired infections are not just a problem in this country. The estimated rate of infection here is 9 per cent., compared with 7 per cent.—admittedly, a lower figure—in the Netherlands, 8 per cent. in Spain and Denmark, and rates of 6 to 10 per cent. in France, and 5 to 10 per cent. in the United States. In giving those figures I do not wish to diminish in any way the scale of the problem. I want to make sure that we take it seriously by avoiding exaggeration. However—
I understand what the Secretary of State is saying, but he will accept that the incidence of MRSA in particular has risen dramatically since the mid-1990s. I entirely accept, however, a number of bacteria constitute MRSA and that they have developed over time. Indeed, I have corresponded with him about the need to prepare for the possibility, hopefully remote, of an outbreak of vancomycin-resistant Staphylococcus aureus. In the international context, we are lucky not to have experienced an outbreak of severe acute respiratory syndrome, but some countries have combated MRSA, as they did SARS, with a dramatic change of culture within their health care systems. For example, a Dutch strategy was based on the policy of search and destroy set out in "Winning Ways". Clearly, other countries with an increasing incidence of MRSA responded in completely different ways, and the Secretary of State must explain why that was not the case in Britain.
I shall come on to that. We have set the record straight and got rid of the tabloidy misrepresentations of a novel problem in certain quarters. I am not saying that the hon. Gentleman was guilty of such behaviour today, although the Leader of the Opposition, in search of another bandwagon, jumped on that one without much success. We do not diminish the seriousness of the problem by putting it in the correct context, which helps us to identify the challenge facing us. However, as I was about to say before the hon. Gentleman intervened, it is true that MRSA infection has become more of a problem in the United Kingdom. It has replaced problems previously caused by E. coli and other organisms that I mentioned. There are complex reasons for that, including some unknown ones, but it is possible to identify a number of the interrelated causes.
The hon. Member for South Cambridgeshire asked me to grapple with the reason why MRSA is more prevalent in the UK, even though the overall infection rate is lower here than in some countries. Part of the answer is that the strains responsible for most infections in the UK are different from those in many other countries. [Interruption.] I do not know whether Dr. Murrison is asking about strains of infection. He is much more qualified than I am, but I am advised that about 12 to 15 years ago, we witnessed the development of Thames strains—two particularly virulent forms of MRSA that are not common in other countries, but which are particularly well adapted to spread between patients compared with other strains.
If I understood the Secretary of State correctly, he said that when one looks at the totality of health care-acquired infections and compares the UK's performance with that of other European countries the UK is doing better. If so, where is the evidence? As I understand it, the surveillance systems in place do not collect that information.
Our figures are based on the data that is collected and the estimates. No country is compiling data in forensic detail on all aspects. I have given the hon. Gentleman our best estimate. The rate of hospital-acquired infections—the aggregate sum that he mentions—in England is 9 per cent. Twenty-four years ago it was 9.2 per cent., based on the same estimates but perhaps less data. Historically, therefore, as a global aggregate sum, the current rate is not out of kilter with what has been the case for 24 years. Indeed, I am told by my advisers, including some very well qualified advisers, that the rate has probably been of the order of 9 per cent. for the past 50 years. The comparable rate in the Netherlands is 7 per cent., 8 per cent. in Spain and Denmark, between 6 and 10 per cent. in France and between 5 and 10 per cent. in the United States. Those are the best estimates available to me.
However, within those aggregate totals, it is true that we have a particular problem with MRSA, which we are attempting to face. In order to do so, we must understand why we have that problem. The first reason that I identified is that there are a number of strains under the generic name MRSA. At least two of those strains, which we used to call the Thames strains because they originated in this region, are particularly virulent in crossing from patient to patient. They are a different strain from those that occur in some other countries.
A second objective fact is that we have a higher proportion of patients who are susceptible to infection than we had 20 or 30 years ago, because of the increasing number of elderly in our country, largely as a result of the success of the national health service in maintaining people for a longer period.
Thirdly, infections are caused by a wide variety of micro-organisms, often bacteria from our own body. As the NHS undertakes increasingly complex and invasive medical procedures in vast numbers—remember, we are dealing with some 7.5 million treatments a year in our hospitals—and our patient population is increasingly susceptible because of age or immuno-suppression, it is perhaps not surprising that the rates of hospital-acquired infections are not decreasing.
From the complex battery of reasons, I have given three that are objective circumstances. That does not lessen the seriousness of the problem, but it begins to get us towards a mature debate on the causes so that we can address them. That is surely what the entire House wants.
Before my right hon. Friend moves on, can he tell me whether he has made any assessment of the extent to which the accuracy and transparency of our collection of data in this country is comparable with data collection in other countries, and whether that might be another factor in the differing rates?
Yes, in general terms. In terms of international comparisons to date, we have done more than any other country to collect such data. In historical terms, I was about to say that we had done 100 per cent. more than the previous Government, but in fact we have done an infinitesimal percentage more than they did, since they did nothing at all about collecting such data. Does that mean that we have satisfactory and reliable data on detail and volume? No. I am not content with that.
That is why, as the hon. Member for South Cambridgeshire was kind enough to say, we started off with the most reliable indicator for the compilation of empirical data—the search and study of bacteria in the blood. For a host of technical reasons it is much easier to identify infections there than in a wound, because there might be a wound without bacteria, bacteria without a wound, or bacteria all round a wound, making it much harder to test. It is not as reliable for culturing as blood. For all those reasons, we did not start off with open wounds. We did not start off with respiratory or urinary infections either, because in both those cases the incidence of MRSA is much less.
We started off by testing for bacteria in the blood, and, as the hon. Member for South Cambridgeshire said, we are developing certain orthopaedic procedures.
We take the problem seriously. Indeed, it is rare, if not unique, for a Secretary of State for Health publicly to declare that the issue is one of our great challenges. It is easy not to collect data, not to declare the problem and pretend, because the data have not been collected, that the problem does not exist. I took the opposite approach—I said that the first step in tackling the problem was openly to admit that we have a problem. We have had the problem for decades, but I think that I am the first Secretary of State for Health publicly to declare it as a major priority.
The figures indicate how serious the problem is. Our surveillance shows that 7,600 known MRSA bacteraemia or blood stream infections currently exist. To put that in context, that is about one in 1,000 patients. Although we do not yet collect data from other areas, if we include the other main area of infection—surgical wound MRSA infections—the best estimate is that 23,000 incidents of infection have occurred, which is about 0.3 per cent. of patients or three in 1,000.
That is, of course, three patients too many. Some hon. Members may know a loved one or friend who has suffered pain or lost their life because of such an infection, in which case 100 per cent. of that person's life is lost. That is why we must take the matter seriously. I present the figures to put it in perspective, because some recent headlines have been so alarmist that they might discourage people from going to hospital to receive treatment for conditions that could kill them.
I accept that we do not yet have enough data on the incidence of hospital-acquired infections, but, from the data that we have, we do not believe that such infections are increasing significantly. That is not my judgment—it is the judgment given to me by my advisers—but I take responsibility for accepting it. The base data on bloodstream infections show a slight increase of the order of 5 per cent., perhaps less, over the past three years. The problem is great and the incidence of infection has increased, so we should take the matter seriously—I shall come on to how we are taking it seriously—but the magnitude of the problem is not as alarming as some stories have claimed.
If I heard the Secretary of State rightly, he said that the increase was about 5 per cent. over the past three years. How does he square that judgment with the figures from his own Department and the Health Protection Agency published in July this year, which show that the increase for blood infections with MRSA was 3.6 per cent? If one adds cases of less severe infection, MRSA, and the total number of blood infections, the increase was just more than 9 per cent.
The hon. Gentleman may have misheard me. I started with the aggregate volumes of hospital-acquired infections before going on to the specific subject, MRSA, which I admit is a problem area. The figure that I just gave is for MRSA.
The figures are wholly compatible, unless my arithmetic has gone completely mad. As 3.6 per cent. in one year is less than 5 per cent., it is entirely possible that the total was of the order of 5 per cent. over three years. It is not crucial whether the figure is 4 per cent. or 6 per cent.—I said that is of that order, because the figures are based on estimates. If the hon. Gentleman sees a contradiction, I am more than happy to check it and write to him.
I accept that we do not yet have adequate data. One of the reasons why we do not have comparable figures going back to before 1997 is that comprehensive data have been collected only under this Government. Although we have had this problem for 50 years, with the same aggregate volume of hospital-acquired infections, previously no data were collected at all. We were not only the first Government but, to my knowledge, the first country anywhere in the world to introduce mandatory surveillance for MRSA bloodstream infections. Although we may not have done everything as quickly as the Opposition would like, it is hardly fair to say that we have done nothing: we have led both at home and internationally.
Not knowing the figures did not mean that there was nothing there—all the best estimates suggest that there was. The previous Government's laissez-faire approach meant that Parliament would not have been able to have such a debate, nor would the tabloids have been able to write the headlines. No one gave them the information to alert them to the seriousness of the problem because no one collected that information in the first place.
Although we know that not all health care-associated infections can be prevented, this is an important patient safety issue on which we are determined to take action. Contrary to some of the advice that is being thrust upon us, there is no simple quick fix to preventing these infections. We need a multi-strand approach because the causal relationship between the factors is multi-faceted. It is not just a matter of cleanliness—it also depends on the patient's age, the severity of their illness and the intrusiveness of some operations.
The two most important risk factors in contracting an infection are the severity of the patient's illness and the use of devices such as catheters which provide an entry route for bacteria. Our action plans for reducing infection rates and addressing those two risk factors are set out in two publications: a public report by the chief medical officer called "Winning Ways"; and "Towards cleaner hospitals and lower rates of infection". Copies are available in the Library. Those were informed by the advice not only of the chief medical officer, but of the chief nursing officer, both of whom have played a vital role in giving me continuing advice on the implementation of our programme of action. It is the action of any responsible Government to ensure that sound, evidence-based policies are implemented.
Although we take advice from everyone concerned, Ministers are ultimately responsible. Naturally, I therefore take responsibility for any actions that we have taken to combat the problem and any failings that people perceive in them.
The right hon. Gentleman will know that one way of creating public confidence in the set-up of hospitals is to ensure that instruments are properly sterilised. He may be aware of the recent disclosure in Northern Ireland whereby endoscopic instruments were found to have bodily fluids retained within them. As a result, many hundreds of people had to be recalled to have investigative procedures carried out to check that they did not have infections. It is important that NHS staff correctly follow procedures to ensure that instruments are properly sterilised, to give confidence to people in Northern Ireland.
Yes, I am aware of the incident that the hon. Lady mentioned. We have tried to tackle the matter in several ways. At one stage, we tried to introduce disposable instruments, but they led to complications that resulted in injury, discomfort, pain and further problems. The hon. Lady is right that the instruments that are used constitute an important element of hygiene, especially since the treatments are becoming increasingly intrusive as we find more treatments that, on the face of it, relieve pain, but are so intrusive that they create a further risk.
I was trying to explain that we are considering a multi-faceted problem. Other important risk factors include the age of the buildings and increasing antibiotic resistance. It is not simply a matter of cleanliness, which I shall tackle later. Any balanced and objective assessment would recognise that the age of our hospital buildings and the fact that people have perhaps overused antibiotics, leading to the mutation of organisms, which become more resistant, are important. Those reasons are not exclusively associated with a particular Government of a particular political persuasion.
Buildings are part of a legacy that we inherited and we hope that the risks that they present will diminish, because we have the biggest building programme in NHS history. However, that cannot be completed overnight. We must also consider the design of buildings. Many countries have far more single rooms in hospitals, making isolation easy.
Of course, cleanliness is also essential. Everyone makes that point. To be fair, the hon. Member for South Cambridgeshire pointed out that we have known that since the time of Florence Nightingale, and perhaps even before then. Cleanliness is not less important nowadays, but, ironically, it and the standard of hygiene may have to be far greater, even though we have new hospitals, because the resistance of the bugs that we are trying to kill is much greater. Getting rid of them is not as simple as spreading a bit of Dettol or a few antibiotics around.
I worked in theatre in the 1970s. In my experience and that of other friends and colleagues, who have been senior nurses—call us old bats if you like—the standard of cleanliness on the wards is not as good as it was years ago, because of procedures. To give one quick example, some nurses use their hands to open pedal bins and then deal with patients. We are not considering rocket science. We simply need discipline and good management of nursing and other staff, including doctors, on the wards. That has deteriorated and perhaps the greatest proponent of explaining the reason for that is Claire Rayner.
I would not even begin to think of the hon. Lady as an old bat, a young bat or any sort of bat. Her comments are not batty—I agree with every word that she said.
Let us consider other problems that might affect cleanliness. The age of hospitals matters. In the 1970s, some of our hospitals were 35 years younger. Hospital design matters, as does the fact that we have had long waiting lists, which we are trying to reduce. Staff shortages are important because people have less time. The points that the hon. Lady made about cleanliness also matter. As she said, it is not rocket science. That is why we are trying to introduce gel and the placing of such items at the foot of the bed. We are trying to emphasise to nurses, who are better trained than ever in many matters, that the basics are important.
I dare say that some people would write to me and say that the process of contracting out cleaners that the previous Conservative Government introduced opened the way for cheapness as a substitute for cleanliness. A host of reasons exists, but I do not believe that any of us are, at heart, interested in identifying them in a party political way. We are all trying to ensure that the practical measures, which the hon. Lady mentioned and which may help us to combat lack of cleanliness or hygiene are put in place.
This morning, a meeting of NHS matrons took place on the subject. Yesterday, my right hon. Friend the Minister addressed NHS chief executives and told them that cleanliness was a huge priority. Cleanliness and hygiene are not extras in the NHS but the fundamental premise on which we treat patients.
Therefore, cleanliness is essential, and we are working to improve both infection control and cleanliness, since even in the absence of clear evidence, common sense suggests that there is a link between the two. There is not statistical and scientific evidence to show that, but my intuition and common sense tell me, as the hon. Lady tells me from her experience, that there must be such a link.
Such work is not always easy in an area in which, we believe—and the Opposition urge us to go further on this—that we should decentralise control. We are being asked to ensure the application of national standards of hygiene and cleanliness in a context in which we are decentralising power to the front line. That is not easy, but it is essential, and that is why we are doing it from the centre.
If the hon. Lady wants us to set that as an objective, and to drive it with guidelines and targets, I am with her. Her Front Benchers are not. They want such an outcome to arise spontaneously, like something out of the "Book of Revelations", but I think that we should insist on a national standard of cleanliness in our hospitals. That is why we have set a new objective for the reduction of MRSA, which is the responsibility of every member of a hospital from the top down. We have strengthened the role of the Healthcare Commission in that area. We have introduced the National Patient Safety Agency "clean your hands" campaign—the non-rocket-science, basic practice, which the hon. Lady recommended. We have introduced a matron's charter to put matrons back in charge, and ward sisters more in charge, of what happens in wards. In addition, we are prepared to learn not only from best practice at home but abroad. We are therefore bringing in experts from other countries, which sometimes have a significantly lower rate of MRSA than this country. We are also trying to improve the design of hospitals. All of that is under way, in addition to introducing extra staff and resources.
I cannot let the Secretary of State get away with suggesting that I said that there should be targets. In the 1960s and 1970s, we did not need targets to maintain good practice on hospital wards. It was achieved through management, procedures and training. That does not require the setting of targets.
I merely point out to the hon. Lady, with great respect—this in no way diminishes her contribution to the national health service at that time—that the aggregate rate of hospital-acquired infections in the 1960s and 1970s was exactly the same as today, and perhaps higher, according to the advice that I am given. The problem is that, within that aggregate total, some of the bugs that we are fighting are more and more resistant, with dreadful consequences.
Like many other Members who have participated in the debate, I have had casework involving MRSA, so this issue is also important to me. In the event that an infection control team makes a formal recommendation to close a ward because of a serious infection on it, and there is a tension in the hospital management because that may affect waiting lists, should the advice of the infection control team take precedence and the ward be closed?
I do not know the specific example to which the hon. Gentleman refers. If he asks me about general principle, clinical priorities and clinical need take precedence over everything else. That is the nature of the national health service. That is why the position on waiting times and waiting lists is determined by clinical need. That is why, on the four-hour target for accidents and emergencies, if a doctor says that a person should stay for more than four hours for clinical reasons, we allow that, and it is not counted. There should be no doubt about that. He will understand why I cannot comment on a specific example, the details of which I do not know. As a general guide, however, all of us in the House would agree with the proposition that clinical need should guide the actions of those who work in the national health service.
We agree that more needs to be done. As the recent National Audit Office report recognises, however, our work has moved infection control up the NHS agenda with a priority that no previous Government have given to it. That is precisely why there is public debate on the issue at present. In July, we introduced the new objective—the new target—on which I know that Opposition Members do not agree, although God knows how we are supposed to get rid of MRSA by removing as an objective of the NHS the combating of MRSA. That seems a perverse logic, but it is the logic of their position.
That will not improve patient safety; it will do the opposite. We know that having an objective, a target, according to which managers, staff and hospitals are judged when information is issued to the public, must ensure that the issue is given greater priority in the NHS and in hospitals. The National Audit Office report concluded that the introduction of mandatory MRSA surveillance raised the profile of infection control not just with staff on the wards, but with senior managers. We expect the new target to operate in a similar way.
Let us briefly consider the alternatives that have been put to us. I have explained to the House that the aggregate number of infections is no greater than it has been for 50 years. The first misrepresentation of the position is the claim that it is much greater than it was; the second is that the problem is entirely due to the fact that we are treating more patients in the NHS more quickly. I remind the House that the awful length of the waiting lists with which we have to deal must make dealing with them a priority—and also that they are a legacy of neglect of the NHS.
We do run the NHS at a very high bed occupancy rate. That is because it is treating more patients and cutting waiting lists. Of course increased activity means that we need to work even harder to reduce the risk of infection, and that is what the NHS is doing.
We believe that it is possible to be both clean and efficient. We believe that it is possible to achieve targets, and good infection control. The Opposition seem to be arguing—I am sorry if I have gained the wrong impression—that we should keep more people waiting longer to go into hospital, with all the distress, anguish and, no doubt, deaths that that may entail. They seem to suggest that making people wait longer than they should for treatment is, somehow, a logical, fair and effective way of combating the increase in MRSA and other hospital-acquired infections.
Let me say to the Opposition that people should not be made to choose between lingering in pain and increasing the risk to their health by remaining on a waiting list, and going into hospital more quickly than is normal and incurring a risk of contracting MRSA. As I have said, we believe that it is possible to be clean and efficient, and we must ensure that that is achieved.
We will be actively helping NHS staff to achieve the aims specified by the chief medical officer in "Winning Ways". The requirement for each trust to designate a director of infection prevention and control does not mean the creation of another bureaucrat, as the caricature suggests. No additional post is being established. What we are saying is that responsibility must be taken at the top, rather than trusts passing it down to the nurse at the bottom.
We know that health care-associated infection is a vitally important subject—an issue of great public concern. We are tackling it. We will restore patients' confidence that NHS hospitals are clean, safe environments with infection firmly under control. Our approach is the same as it has been throughout. We are increasing capacity and reducing waiting times, and we are confident that clear objectives and a sustained management focus will achieve results.
This is, however, a complex issue, which does not lend itself easily to populist, or popular, instant solutions. It is complex in medical terms, and it calls for the hard work and care that are the hallmark of NHS staff. It will only be solved by extra capacity and by newer hospitals, better design, more research into drugs, more nurses and shorter waiting lists. All those things are just as essential as the key issue raised by Mrs. Browning—that of cleanliness and hygiene.
The problem will not be solved by party-political rhetoric from the Opposition, from me, or from anyone else. I began with a long quotation from a Conservative, which I thought quite apposite and fairly balanced. Certainly the problem will not be tackled by the introduction of charges, a reduction in the number of doctors or the taking of money from the NHS. Nor will it be helped by a constant backdrop, or refrain, of criticism of NHS staff who are trying to perform a very difficult task—and, in my opinion, succeeding.
That is why the Government will reject all those options and will continue to give the support, staff, money, capacity, resources, research and guidance on hygiene and cleanliness that is required to improve all our hospitals. If we achieve a sustained reduction in hospital-acquired infections, that will be for the first time not only under this Government, but in 50 years. The project is therefore worthy of common support and effort across the House, and I thank the Opposition spokesman for giving us the opportunity to exchange ideas on constructive ways to tackle the problem.
I, too, am grateful for this opportunity to debate a very important issue. As has been suggested, much of what we are referring to in respect of controlling infection and tackling MRSA and other infections in hospitals is not rocket science. It is basic, scrupulous attention to hygiene and cleanliness—basic good practice.
Often bandied around in debates such as this, in the press and elsewhere, is a figure that has been around for quite a few years, and which was cited in the first National Audit Office report in 2000. Every year, the death toll arising from infections acquired in hospital is about 5,000. An additional 15,000 people may well die as a result of infections, but that figure is even less hard than the 5,000 figure. So since 1997, about 35,000 people have lost their lives as a result of infections that they picked up in hospital.
The Secretary of State was right to rehearse the fact that this phenomenon did not commence on the first day of the Labour Government in May 1997; it has been with us for a long time. However, that is not an excuse or reason not to do more now to address a problem that many of our constituents still feel is not under control. The truth is that we do not know the scale of the problem. The Secretary of State gave various figures, many of which are based not on the mandatory systems of surveillance that I acknowledge the Government have introduced, but on estimates. I hope that, after the debate, he will place in the Library all the calculations and the basis for those estimates, so that we can consider the figures objectively and in the clear light of day. It would be useful to see precisely how some of them were arrived at.
It is worth considering some of the research published over the last few years. I shall cite one or two examples, not least of research that was undertaken and published by the Public Health Laboratory Service, as was, in 1999. It found that patients who pick up health care-acquired infections in a hospital tend to stay in that hospital for about 2.9 times longer than a patient who does not suffer from such an infection. So those beds are being occupied by people who, had they not acquired an infection while in hospital, would not be occupying them. Those beds could be being used by other patients, so capacity is being wasted in the NHS because of poor practice. On average, the stay of a patient who has acquired an infection in hospital is an extra 14 days, according to the 1999 research. It also estimated the cost of the additional treatment required as in the region of £3,000 per patient. No wonder the NAO estimated the cost of hospital-acquired infections as being £1 billion.
In his response to the official Opposition's motion, the Secretary of State gave no indication of what the Government intend to do to address the NAO's criticism of the Government and the NHS for failing, since the NAO's first report in 2000, adequately to address the lack of an estimate of the cost of hospital-acquired infections. The figure in that report is still the only one that exists, and it would be useful to know whether work will be done on that.
The Secretary of State said that at any one time, nine in every 100 patients are likely to have a hospital-acquired infection, but that information dates back to 1996; we have no up-to-date figures. Probably the most surprising figure—again, it comes from the 1999 PHLS research—is that, after factors such as age and diagnosis have been taken into account, a person who acquires an infection in hospital is 7.1 times more likely to die in hospital than someone who is not suffering from an infection.
We must show that we are taking the issue seriously, without spreading alarm and despondency, but in a realistic way.
The Secretary of State cited various figures, but we have no information on the actual number of deaths—the figure of 5,000 is based yet again on estimates. We do not have an accurate and reliable way of collecting the information, and the death certificates themselves do not include it. What plans do the Government have to commission the specific research that would be necessary to determine how much MRSA and other health care-acquired infections contribute to the likelihood of patients' dying and how many die annually? It would be useful to get a true fix on the problem.
I am having slight difficulty in following the hon. Gentleman's point. Obviously, additional statistics can always be helpful, but surely we do not require statistics to demonstrate the common-sense point that a hospital-acquired infection can hardly be conducive to a patient's health and should therefore be avoided at all costs.
I do not think that there is any dissent anywhere in the Chamber from that self-evident point, but there is concern about the rising figures and the considerable number of people who die, and it would surely be sensible to ensure that we have sound, reliable data that can be used to reassure people that the NHS is a safe place to get treatment, as sometimes it is portrayed as far from that.
The spotlight in these debates tends to focus on MRSA, but as the Secretary of State acknowledged, other bacteria can and do wreak havoc in our hospitals. The NAO rightly covered all the infections, and the motion, which frankly is a good summary of the NAO progress report from July, identifies a number of the criticisms but does not move the debate on much.
The NAO report makes depressing reading. It found that progress by both the NHS and the Department of Health in getting to grips with the infections was patchy: there was some good progress by individual trusts, and the Government had made positive responses to some of the recommendations in the 2000 report, but the picture was not consistent. The Department has issued reams of guidance to the NHS on the control of infection, and the chief medical officer, in "Winning Ways", said that the Healthcare Commission
"will be asked to make infection control a key priority when assessing hospital performance".
However, that does not mean that the commission will publish a national report on infection control and hospital infections. Indeed, there has been no national audit of compliance with infection control standards in the NHS and Health Ministers have confirmed in writing to me that the Government have no plans to undertake one.
When I undertook my own survey of the NHS a couple of years ago to find out how trusts were doing in undertaking compliance with the guidance that had up to then been issued by the Department, I was passed a copy of an e-mail sent to press officers in NHS trusts by the Department's press office. It said:
You may wish to be aware that the following is the Department of Health's 'line to take' for our press office to respond to enquiries about completing this questionnaire survey. I would be grateful if you could let me know if you are dealing with any enquiries from your professional colleagues."
It went on to say:
"A Health Service Circular which set out a programme of action for the NHS on the management and control of Hospital Infection was sent to all hospitals in England in February 2000. A revised 'infection control' controls assurance standard, issued in October 2001 and national standards of cleanliness for the NHS, issued in April 2001, together cover many of the questions in Paul Burstow's survey. In addition, both the Patient Environment Action Team visits and the Commission for Health Improvement regular review visits assess hospitals against both standards and publish their reports.
The Department is mindful that the NHS should not be overburdened by responding to requests for information"—
I agree with that—
"from a variety of sources".
What really puzzled me was that, having asked written question after written question and having been told time and again that the information was not held within the Department, it was surely not unreasonable for an MP to try to seek the information at a more local level. The message seemed to be that ignorance was bliss.
When "Winning Ways" was published last December, the chief medical officer provided a possible reason why the Department was not keen on my survey. What he had to say then was:
"Despite the extent of the guidance issued to the NHS, such data as are available show that the degree of improvement has been small."
Surely ensuring compliance with the guidance issued by the Department of Health over the last few years should be a matter of concern to Ministers. The Secretary of State says that the guidance is a key part of driving improvements forward from the centre, but how can the centre be confident that it is happening if it is not auditing compliance on the ground?
The Secretary of State also talks about a target for reducing MRSA bloodstream infections. Quite apart from our arguments about the Government's obsession with targets and tick boxes, infection control professionals are expressing some serious concerns about the Government's target. The Infection Control Nurses Association told me that the method of collecting data in connection with the target is seriously flawed because it fails to exclude patients who acquired their infections in the community—in care homes and elsewhere—or at other hospitals. It also compares infections acquired in a given year with the bed data for the previous year, which makes it hard to get a proper fix on whether or not performance is improving. If a trust already has a low infection rate, the target penalises it most unfairly—typical, perhaps, under this Government. The focus of the target is solely on one bacterium—MRSA—and it excludes all other organisms that can and do cause problems in the NHS.
Other resistant bacteria also pose a threat, which is why it is important to have information about them. Currently, however, there is no requirement to undertake surveillance and report on those other infections. The matter has already been debated across the Dispatch Box, but it needs to be repeated. Back in 2000, the National Audit Office made some very important recommendations about the need for a clear picture—not just nationally or trust by trust, but in relation to specialties. As paragraph 3.3 of the NAO progress report of July this year states, there is
"still a lack of robust information on the majority of infections at both local and national level. As a result it is still not possible to say whether there has been any tangible measurable progress."
It went on to point out that its original recommendations had made it clear that there should be
"specialty specific surveillance of bloodstream, surgical site and urinary tract infections" and that such information should be "fed back to clinicians".
I heard what the Secretary of State had to say about the advice he was given about whether moving forward with mandatory surveillance should be the first priority, but I am puzzled that in the NAO progress report of July this year, the Department's concerns and the reasonings behind its introduction of mandatory surveillance across trusts were not rehearsed. That is most puzzling; there must have been discussions at official level. Perhaps when the Minister replies to the debate, he can explain why the Secretary of State's explanation offered today was not covered by the NAO in its progress report earlier this year.
Paragraph 3.11 of the report continued:
"The main concerns on mandatory MRSA surveillance were that the denominator data was inappropriate as it was collected across the whole hospital, and as a result, clinical staff did not relate to it, and trust management considered it to be a problem for the infection control team rather than clinicians."
Surely that is the key theme: there must be a feedback loop to the clinicians so that they can identify where the problems are and start to make the necessary changes. At the moment, the system does not offer the information necessary to do so. That is why putting something along the lines of the NAO recommendations in place should surely be a priority for the Government. I have heard nothing yet about the degree of urgency that the Government attach to that.
My survey produced at least anecdotal evidence that MRSA and other hospital-acquired infection patients are often treated on wards because of a lack of isolation facilities and staff. There are Government guidelines on the management of patients with infections and they recommend the use of isolation facilities for certain infections.
However, the guidance admits that the provision of isolation facilities and single rooms in NHS hospitals is sadly lacking. It states:
"Experience has shown that many hospitals find the present allocation of isolation-single rooms inadequate to deal with the increasing numbers of infected and immunocompromised patients. Hospitals with 10 per cent. of their bed contingent as single rooms often find that this number is inadequate to cope with every infectious patients. Where this is the case, risk assessment is used to inform decisions regarding patients to nurse in single rooms."
I asked some parliamentary questions to find out where the Government had got to with their programme of expanding the numbers of single rooms so that there was more scope for isolation. Ministers have stated that NHS trusts were individually responsible
"for determining the level of provision of isolation and single rooms."——[Hansard, 19 September 2002; Vol. 390, c. 407W.]
I was told that the Government circular relevant to this matter
"required trusts to undertake a risk assessment to determine the appropriate provision of isolation facilities within each trust"——[Hansard, 2 February 2004; Vol. 417, c. 687W.]
However, surely Ministers should not be in the dark about the progress being made in this matter, or about the level of front-line preparedness to deal with hospital infections. Surely, that knowledge is essential if they are to cope with threats such as severe acute respiratory syndrome. In his strategy for combating infections, the chief medical officer stated:
"NHS trust chief executives will ensure that, over time, there is appropriate provision for isolation facilities within their healthcare facilities."
I asked Health Ministers, in questions, how that was going. I was told:
"As the creation of new isolation facilities is generally linked to local plans for rebuilding and refurbishment it is not feasible to set a national timetable. Over-time is not specifically defined but provides flexibility for chief executives to implement realistic, timed work programmes for isolation facilities."—[Hansard, 12 March 2004; Vol. 419, c. 1819W.]
The Government talk about providing more isolation facilities, but they do not have a grip on what is going on on the ground.
This is an important debate about the Government's record after seven years in office. The Secretary of State has told us that the estimates show that things have not got better, and that we still have a serious problem with infection. He has made it clear that the Government have not acted on all the recommendations in the NAO report. The case that he made on surveillance is not sufficient justification for not getting clinicians into the loop.
Reference has been made in the debate to Florence Nightingale. However, this is not rocket science. It is a question of scrupulous attention to basic hygiene, such as hand washing. It is about effective screening, robust surveillance, and giving clinicians the information that they need to adapt, and to learn from mistakes. None of that is present in the Government's approach, and that is why we must relearn the lessons that Florence Nightingale taught more than 140 years ago. In that way, we can start to reduce the death toll in the NHS.
As has been noted already, the issue of hospital-acquired infection is an extremely important topic. However, the Opposition have attempted to skew the debate to make a narrow party-political point. They want to use hospital-acquired infections to support their proposition that we should get rid of targets in the NHS, and in particular those for waiting lists.
I have never been asked by any constituent to get rid of targets for waiting lists. They are very keen on them, because they want waiting lists to be reduced, and they need the targets to make sure that that happens. However, the logic of the Opposition's approach is that, to reduce the incidence of hospital-acquired infections, we have only to reduce the number of people treated in hospital. It is indisputable that treating fewer people would reduce the rate of hospital-acquired infections, but the consequence is that more sick people would remain untreated and would ultimately die from their untreated conditions. The Opposition's position on this matter is therefore completely fallacious.
A year or so ago, my own hospital, Milton Keynes general, had a serious problem with hospital-acquired infections. I would argue that that was because the hospital's bed-occupancy rate was incredibly high, mainly due to the fact that the hospital was too small for the population that it serves. That remains so, despite the large numbers of additional beds that have been provided as a result of funding by this Government.
Primarily, the hospital is too small because for the 10 years before 1997, when the Conservatives were in charge, no extra beds were provided, despite the fact that the population was growing by between 2 and 3 per cent. every year. It was undercapacity that added to the problems contributing to the high rate of hospital-acquired infections, rather than our policy of at least trying to use existing capacity to the ultimate to treat patients, and encouraging hospitals to do that by publishing targets that they were supposed to meet for waiting lists.
The second point in the Opposition argument was that the Government were not giving NHS staff enough freedom to take the measures necessary to deal with infection. I notice that the Opposition did not really produce any evidence for that claim—I have to say that their evidence is not strong. What they suggest is complete rubbish and, again, I cite examples from my hospital.
About a month ago, the Secretary of State visited Milton Keynes general hospital and I was able to be there, too. One of the conversations that he held was with a senior nurse about the measures that staff had put in place to try to deal with the problem of hospital-acquired infections. The senior nurse had responsibility for co-ordinating the policy and he described all the steps that had been taken, which indeed are not rocket science but had been learned from experience elsewhere. The staff did not feel constrained in the slightest in taking the initiative to implement those measures, either by the Government's policies or by our waiting list targets.
It is complete rubbish for the Opposition to suggest that removal of targets would make staff freer to act. It would make no difference to their implementing sensible policies for disease control. However, removing targets would make a real difference to the number of patients who are treated, to the service provided to my constituents and to the pressure on everybody at the hospital to continue to drive up standards across the board.
My final point is about the impression that the Opposition have tried to give that hospital-acquired infections are new and growing phenomena, and that they are somehow a consequence of the Government's policies on NHS targets. Hospital-acquired infections are not new. Indeed, I can give an anecdote from personal experience. As a very young child, which was several decades ago, I was in hospital for a considerable time and during my stay I acquired every childhood disease that one could catch in a small period of time. The advantage was that when I finally left hospital, cured of the orthopaedic condition for which I had gone in, I no longer had to worry about catching childhood diseases because I had natural immunity to every single one of them. I cite that merely as a truism that everybody knows: hospital-acquired diseases have always been a problem. In part, they are a problem because people in hospital are, by definition, not in the best of health. They are more susceptible to infection; many of them bring infection in with them and they are in an environment where infections, even with the best methods of control, are unfortunately more likely to be passed around than outside.
These days, there is an additional problem. Because more people are being treated outside hospital in the community, hospital populations are more ill than they used to be, so that in itself is likely to mean that patients are more susceptible and that cross-infection is likely to be greater. Furthermore—a reason that has been ignored completely—there has been a rise in antibiotic resistance, especially multi-drug resistance, which does not only concern practice in the UK. Unfortunately, such resistances spread between countries. There is irresponsible practice in antibiotic use worldwide. Antibiotics have been used for conditions that were not serious enough to warrant them. In this country and elsewhere, they have been doled out by GPs, possibly due to untoward pressure from patients, to treat conditions where the patient should have been told to go home because the infection would clear up. Members of the public also use antibiotics irresponsibly when they do not finish the full course.
The most extreme case of irresponsible public use of antibiotics, not in this country, is the well-known example in south-east Asia, where prostitutes treated themselves with low levels of penicillin, as a prophylactic, to try to protect themselves from sexually acquired infection. All that they managed to do was to turn themselves into incubators for drug-resistant venereal diseases, not only to the huge detriment of themselves, but to the enormous detriment of everyone else.
Such practices have led to the unfortunate situation where an increasing number of infections are now resistant to all the common antibiotics. That is the really serious problem, which has led to added pressure on our hospitals and other health resources, so we must have even higher standards of hospital hygiene than in the past to ensure that those problems do not get out of control. I very much regret the fact that the Opposition have used this very serious topic simply to make the party political point that they want to get rid of targets and waiting lists. That is a complete diversion from what we ought to be discussing, and they should be much more responsible on such issues in future.
A number of hon. Members and the Secretary of State have stressed the importance of cleanliness in the hospital environment in seeking to tackle the growing problems of MRSA in our hospitals. I certainly accept that that problem cannot and will not be eradicated overnight, but efforts naturally have to be made to ensure that more is done to minimise and reduce the incidence of the problem, and I believe that cleanliness in our hospitals is a key factor in achieving that.
During my brief remarks, I should like to highlight my own hospital, Broomfield, which is part of the Mid Essex hospital trust. The hospital was the subject of an article in the British Medical Journal earlier this summer because it has managed in a relatively short time, using excellent practice, to eradicate infections completely on the one ward—I emphasise that it is one ward, not the whole hospital—where the problem was growing. I refer to the orthopaedic ward.
In 1998, the orthopaedic unit was moved from a dedicated orthopaedic hospital to a district general hospital—Broomfield—and a dramatic increase in the incidence of patients on the elective ward who acquired MRSA was noted. In 1996, before the transfer, there were three new cases of MRSA on the elective ward. By the year 2000, after the transfer, the figure had increased to 29.
Staff on the orthopaedic ward analysed the situation and came to the conclusion that the increase was associated with elective orthopaedic beds also being used indiscriminately by emergency patients. To test their conclusions, they started to follow the British Orthopaedic Association guidelines and separate elective from emergency work, introducing an MRSA-free zone. Strict admissions criteria were introduced for elective orthopaedics. No inter-hospital transfers were allowed. All patients due to have elective orthopaedic operations were screened at a pre-admission clinic, and any positive patients were given eradication therapy and admitted to one of the trauma wards for surgery, rather than to the elective ward. The practice of admitting day cases to the elective ward was stopped.
In addition to the standard precautions, a strict code of dress was instituted so that nursing staff wore disposable aprons and gloves for each interaction with patients; alcohol hand rub was installed by every bed—and staff had to use it before and after every consultation; medical staff had to leave their jackets at the door to the ward and wore clean white coats that were washed regularly; and visitors were not allowed to sit on the beds.
The results of those procedures were dramatic. In the year before ring-fencing, 417 lower limb arthroplasty operations were carried out; in the year after, there were 488—an increase of 17 per cent.—without any increase in theatre capacity or the number of beds.
But the total number of all infections in post-operative patients fell from 43—nine of which were MRSA—out of the 417 cases, to 15 out of the 488 cases, with no cases of MRSA.
It must be emphasised that that achievement is confined to the orthopaedic ward, because there has been some confusion, to the detriment of the local hospital, about whether MRSA has been eradicated in all the wards. That is not the case. However, the example shows that if proper procedures are adopted and rigorously enacted, they can have a positive and dramatic effect on the problem. I congratulate the nurses, doctors and consultants, as well as the management of Broomfield hospital. They have introduced a positive procedure that should be studied by other hospitals in the NHS so that it can be emulated and copied to reduce the incidence of MRSA.
It is a pleasure to follow Mr. Burns, who spoke of local experience in reducing the rate of hospital-acquired infection. I found it an inspiration to hear about the work that has been done, but the most interesting point was that the reduction was achieved when targets and the other pressures mentioned in the Opposition's motion were in place.
Florence Nightingale is a personal hero to many of us, especially nurses such as myself. She has been quoted enormously in the debate. However, the issue is difficult and complex, and that is why it should never be used in a party political way. Florence Nightingale was indeed keen to ensure that cleanliness was at the heart of treating patients, but she was also keen to ensure that they had lots of visitors, so that their emotional and psychological wellbeing was properly cared for. Indeed, she believed that if patients wanted their pets to visit them, it should be allowed. She understood that patients' happiness was important when they were trying to recover from serious operations. That illustrates the difficulty that we face. It is not as straightforward as saying that everybody must wash their hands and everything will be fine. That is untrue, and it is a target that we cannot possibly achieve. It is wrong to try to give the impression that that is all that needs to be done.
Many visitors bring hospital-acquired infections with them. Visitors bring their children and they hug and kiss their loved ones—thank goodness they do—but what should be done about that? It is a complex issue that cannot be addressed in the simplistic way that has been suggested today.
I wish to talk about my experience of working as a nurse. I spent many years nursing patients who needed to be isolated, so I know the difficulties and pain that hospital-acquired infection causes to them. Nurses also suffer pain and anguish when such cases occur. They provide 80 per cent. of care and if they discover that a patient is infected they are desperately sad and unhappy about it. Nurses want to do something about the problem.
The empowerment that is being delivered to nurses hands them the challenge of deciding how a ward should deal with an outbreak of a particular infection or ongoing outbreaks of infection.
Any hon. Member who is involved in nursing organisations or their local hospital will see some of the initiatives that are making a difference not only to how nurses deliver, but to the way in which they feel empowered to take their initiatives forward and deal with problems. It is my suspicion that many of the initiatives are nurse led. After all, as they are delivering most of the care, they see what is going on and can bring the whole team together. I stress that it is the whole team. There is little or no infection among those who are treated in the community, with the exception of those who have gone into the community with hospital-acquired infections. It is in hospitals that we need to be most worried. We need to ensure that nurses are at the heart of getting teams together. We need collective decision making, from the cleaner to the consultant, on how staff deal with the ward. That is how we will truly make an impact on hospital-acquired infection.
A hospital trust close to me ensures that staff have time to sit down with the consultant on a weekly basis, in the protected lunch hour when patients eat their meals quietly without interruption—another Government initiative that is immensely welcome in hospitals. The cleaner can say to the consultant, "But I saw you move from one patient to another without washing your hands." It is difficult to empower someone like the cleaner, who is part of that team, to do that, but if that atmosphere and ethos runs through the team on the ward, that is how we can make an impact on infection.
I was slightly worried to hear the derisory comments of Mr. Lansley. He made it seem as though hand washing was a new initiative and something that we could laugh at, but we are introducing a new ethos, which asks patients to be involved in the campaign. When did we ask patients before to challenge the staff around them and to participate in their own care to ensure that their treatment was of the highest quality? Why should not patients be able to say to a nurse, "I'm concerned that there was no hand washing between one patient and another"? Empowering our patients, staff and visitors is the way to tackle the problems.
I see genuine improvements in hospitals. The pressures are different. I wish I could put on my rose-coloured spectacles. I started my training in 1970, when we did not collect figures on hospital-acquired infection, and honestly wish that I could go back to those days and pretend that such infection does not exist, but there is a new atmosphere—the pressure is on. We have to ensure that patients are properly treated. The way to do that is to fund our NHS properly so that we can use new devices and technologies, such as silver alloy urinary catheters, which reduce infection. The only way to make that happen is to sustain investment and develop our empowerment of nurses, especially in hospitals. That is how we will get genuine improvement on hospital-acquired infections.
As many hon. Members, including the Secretary of State and my hon. Friend Mr. Lansley, said the problem of hospital-acquired infection is not new. It is a decade-old struggle, which was temporarily masked by the advent of effective antibiotics. My father worked at Great Ormond Street hospital before we had antibiotics. We can understand why an emphasis on nursing discipline, cleanliness and hygiene was imperative in those days. If patients acquired an infection, there was in many cases no way of treating them.
However, the development of MRSA antibiotic-immune infections is new, as is the much greater intensity of utilisation of hospitals, particularly by higher-risk patients, which creates a higher-risk environment and therefore calls for an intensely greater emphasis on cleanliness and standards of hygiene. That is the challenge we face.
We should not accept the development of MRSA, or the level of hospital-acquired infection—which has sat at about a level of 9 per cent.—as inevitable. There are hospitals with much lower levels of infection. BUPA reports, in a very different context, that occurrence of MRSA in its hospitals is negligible; I do not know whether that is true. As the Secretary of State has acknowledged, we know that there are differences, particularly in instances of MRSA as opposed to those of hospital-acquired infection. We have a high level of MRSA, but in Scandinavia and Holland the rate of MRSA infection is much lower as a percentage of total infections.
Equally, there is a wide dispersion of outcomes among NHS trusts carrying out similar types of operation. That suggests that some are doing well, and some are doing less well. The trust in my constituency comes 19th out of 45 in terms of MRSA incidence. In other words, it has a high level of incidence. It is an old hospital that urgently needs rebuilding and—perhaps not coincidentally—has had serious problems with cleaning.
There has been widespread recognition—and I think that the Secretary of State will acknowledge this—that Government and NHS initiatives on MRSA have produced patchy results. In some cases there has been evidence of effective results. My hon. Friend Mr. Burns made a point about a hospital in Chelmsford, to which I shall return later.
What does all of this tell us? Solutions are not just related to what can be done from the centre. I do not want to get into a debate about central targets. Clearly, the Government have to take initiatives, but they cannot just consist of poster campaigns and leaflets—we all acknowledge that. Fundamentally, it is a matter of getting back clinical management control of the ward environment. That means total control that can derive only from a level of culture and discipline from all those who work in the ward environment, which must run through the organisation from top to bottom.
The struggle to contain MRSA cannot be entirely divorced from the question of how we manage hospitals and their leadership. The debate I have had with the Secretary of State in the past about the balance between central control and targets can become slightly vacuous, but the question is how much emphasis we place on creating the right level of leadership in our hospitals, and giving that leadership—the chief executives and clinical management—the time to create the culture and organisation we want in the wards. I believe that investment in quality local management, and giving it the time and wherewithal to apply the right critical judgments, is critical to making progress.
At the heart of the problem—this sounds simple but it is not—is a failure of cleaning, hygiene, discipline and training. It is in the culture of the people, and we should not forget that. In turn, those factors derive from the quality and motivation of chief executives. I ask the Secretary of State to think about how much time a chief executive in an NHS trust has to patrol the wards, acting as a leader on the ground, as opposed to sitting behind his or her desk dealing with administration of one kind or another.
The problem is also concerned with the fragmentation of accountability for the ward environment, which we have debated before. The Government have sought to address it with the appointment of modern matrons, but we still have a far more fragmented control of the ward environment than we had 20, 30 or 40 years ago, when the ward sister was in absolute control, not only of cleaning but of admissions into the ward environment—I know that it would not be practical to do that today. In many cases, she would control whether doctors came on to the ward, and at what time they did so. That has all changed, and with it there has been a decline in the ethos of cleanliness because so many different people have uncontrolled access to the ward.
The nature of nursing care has changed. Nurses increasingly regard themselves as specialist health care professionals and are less dedicated to total care and, in some cases, less inclined to regard themselves as responsible for hygiene and cleanliness. In many cases, they rely on unqualified nurses to do the job.
I shall give a brief illustration of factors that lead to loss of control. We have talked about cleaning contractors. Sub-contracting can create a problem, but that depends on how it is managed. No one knows when cleaning will be required—it may be needed, for example, if there is an incident on the ward—but ward sisters should have the discretion to call for it whenever necessary. They must have absolute authority over when cleaning is required or when mess has to be cleared up. A system in which cleaning is determined by a rota, outsourced or is the responsibility of a modern matron on the other side of the hospital simply will not work.
Hand washing facilities in many of our hospitals are woefully inadequate. Physically, they are in the wrong place. Laura Moffatt mentioned doctors who moved from bed to bed without washing their hands, but in many cases hand washing facilities are 100 yds down the corridor. It is impractical to use them, so we must contemplate that design problem. Incidentally, they fall far short of the amenities in many other highly sensitive facilities. Most food manufacturing facilities, for example, have much better hygiene and access controls than our hospitals. Our hospitals are open buildings with free visitor access and no security. Visitors come to the ward and, in many cases, are not invited to wash their hands. They touch the patients and the facilities, then leave.
Staff uniforms are another problem. Gone are the days of crisp, white, starched uniforms. Many staff go home in their uniform and return wearing it unwashed the next day. It is therefore not surprising that we have a problem, but substantial change is required to tackle it. A total change in culture and management is needed, but it will not be easy to effect. We need a change in attitude to the way in which the ward environment is controlled, who is allowed access and what they are allowed to do while they are on the ward. There is a balance to be struck between change and the pressure to achieve targets on, for example, occupancy rates. On the ground, line managers should have the authority to make clinical judgments and should not be burdened with the weight of national targets by top management. I am not making a party political point—it is not a question of targets or no targets—but we must allow people to exercise discretion locally.
In conclusion, I shall cite the article in the British Medical Journal mentioned by my hon. Friend the Member for West Chelmsford. At Chelmsford, in a single, small location, there was a dramatic reduction in MRSA and the rate of hospital-acquired infections. At the same time, there was a 17 per cent. increase in the number of operations undertaken. Cost savings and increased productivity were achieved because infected patients were not occupying beds, so the experiment merits serious consideration. The article says:
"Staff, patients, and visitors had to undergo a major change in culture in order to implement the changes. The senior medical and nursing staff acted as role models in the implementation of new policy, as described by Ching and Seto."
In other words, improvements were achieved not just by guidelines or a new framework, but by a change of culture and policy and the creation of a completely controlled ward environment.
The problem is not new, as hon. Members have said. As well as being resistant to certain types of antibiotic, MRSA in particular has an intrinsic propensity to spread. Hospital-acquired infection, like many serious problems, has various causes, and there are many strands to its solution. It deserves our serious consideration, and is far too important an issue to become a political football. I pay tribute to the Government for their work in taking it seriously and some of their initiatives are listed at the beginning of "Winning Ways".
It is an impressive list, even at that time, before our right hon. Friend the current Secretary of State took over, and includes circulars on management and control of infection and a controls assurance standard. In 2003 the National Institute for Clinical Excellence issued guidelines for the primary care and community care sector.
"Winning Ways" reflects the deep-seated nature of the challenges. It analyses and sets out how to tackle infection at all levels, from establishing a culture of surveillance and investigation to achieving a sharper focus on high quality research, which is needed to underpin best practice in information sharing, monitoring and action. Mr. Burstow, one of the Opposition spokespeople, said that we did not want rocket science—we wanted common sense. However, we need both. We need common sense, as I shall discuss in a moment, but we need rocket science to establish which common-sense solutions are working.
"Winning Ways" also sets out some aspects of hospital management and organisation for action, including the need to appoint a director of infection control. Peter Jenks has recently been appointed to that position in Plymouth Derriford Hospital Trust and is bringing a fresh impetus to the programme that our local hospital established. He described to me the open approach that the trust takes and some of the issues associated with achieving an open culture of reporting. That has considerable challenges attached to it.
The outcome of an infection is a balance between the intrinsic virulence of the organism, the susceptibility of the host, and the skills and resources available to treat the infection. A benign infecting organism may kill a seriously ill 80-year-old and not so much as raise a fever in a fit adolescent. Likewise, a virulent pathogen is likely to be much more harmful to more vulnerable patients.
I hope that the Minister of State, my right hon. Friend Mr. Hutton, will agree that it is important for effective, active surveillance and investigation that the recording of these issues is of a high standard and that we are able to compare like with like. He will be aware of the concerns that Plymouth Derriford Hospital Trust has expressed about the recent publication of non-standardised data by the Office for National Statistics and the way in which that sparked some pretty ill-informed coverage in the national press.
As part of the surveillance systems that have been put in place, all hospitals in England and Wales must report every time an MRSA is grown from the blood of a patient. This is the most accurate national MRSA data and provides a standardised basis on which to make fair comparisons. I hope that my right hon. Friends the Secretary of State and the Minister will do all they can to ensure good practice in the use of statistics to inform not only our debates in the House, but the action that needs to be taken in all our local hospitals.
I turn now to what I know many of my constituents, whether they are patients, their relatives or people who work in the health service, as well as hon. Members consider to be a crucial aspect of bringing hospital infections under control. Although eight out of 10 Derriford patients rated care in the past year as excellent, patient perceptions of cleanliness remain much lower than I, they and the hospital would like. Through the Derriford cleanliness task force, matrons, members of the infection control team, the cleaning contractor, the unions and patient representatives are all engaged in tackling this key issue.
As others have described, matrons and ward sisters will take more control over the cleanliness of their wards. They are encouraging domestic and housekeeping staff to be valued as key contributors to patient treatment and welfare. Matrons will have direct accountability for cleanliness standards. I understand, and my right hon. Friend may be able to confirm, that if all else fails, that includes the ability to withhold payment for cleaning services.
People have rightly said that it is not appropriate for staff who clean toilets to serve meals. The tasks will now be separated in Plymouth Derriford and staff uniforms will identify staff who only serve food. Patients and visitors, as my hon. Friend Laura Moffatt mentioned, will be encouraged to ask staff questions about cleanliness and report things that they are unhappy with.
That is all good common sense, and it should never have been anything other than common practice. As the Secretary of State suggested, however, some in my constituency say that the fact that that was not the case stems from privatisation and fragmentation. That has been a particular issue at Derriford, as it has been at hospitals up and down the country.
I hope that my right hon. Friend the Minister has seriously considered ending the two-tier work force in our hospitals sooner rather than later. I also hope that he is examining how contracts can specify outputs that guarantee a minimum quality. That would certainly solve many of the problems that we have experienced in Plymouth. Strong scientific evidence proving a link between cleanliness and health care-associated infections does not exist, but common sense suggests that every care should be taken to achieve the highest possible standards of cleanliness, and patient and public confidence demands that too.
The debate has generated more light than heat, which is good and not something that the motion might have encouraged. The motion does not do justice to the depth and breadth of the problem and what is and what can be done. Much mention has been made of "Winning Ways". Playing on people's fears in the run-up to an election should have no place in anyone's strategy. If it occurs, we can expect the great British public to rumble it.
It is a pleasure to follow Linda Gilroy. I agree that the debate has been good, and my hon. Friend Mr. Lansley, who introduced it in his normal measured and rational way, set the right tone for a constructive exchange.
Along with other hon. Members who have spoken, I am, of course, anxious that my constituents should not acquire an infection when they go into hospital. Some signs are already apparent that fear of MRSA is beginning to affect people's willingness to have operations. I want to approach the subject not from the point of view of a patient with the infection, but from the point of view of a firm in my constituency that may have a solution, and I shall develop an argument that my hon. Friend the Member for South Cambridgeshire touched on in his opening remarks.
I welcome what the Government have been doing and the progress that we have heard about in this debate. I want briefly to share the frustrations that both the company in my constituency and I have had in communicating with the Government and their agencies, and gently contrast the rhetoric of urgency and of rapid reviews with the leisurely progress that has been made since last December.
Bioquell is a firm based in my constituency. It is a quoted company with a market capitalisation of some £60 million, and it has invested heavily in research and development over the past five years. I have been round it, and I was impressed by the professionalism of the operation and the commitment of the staff. It has a long record of developing bio-decontamination technology, and last year the US Government selected it for priority research into anthrax decontamination. In the health care sector, it secured contracts to bio-decontaminate three hospitals in Singapore during last year's severe acute respiratory syndrome outbreak. In July this year, it was awarded a contract by a French hospital to sterilise two intensive care units that were contaminated with a super-bug.
Progress at home has been tougher. On
"assess new procedures and products for which claims of effectiveness are made of their ability to prevent or control HAI".
In areas of the hospital where MRSA patients had been treated, 74 per cent. of swabs tested positive for MRSA.
More surprisingly, in a so-called non-MRSA ward, 43 per cent. of the bed frames were positive for MRSA. St Thomas' is probably a good proxy for all the tertiary hospitals in the UK.
Secondly, his research demonstrated that conventional cleaning does not work. In one experiment, 90 per cent. of 124 swabs were positive for MRSA before cleaning, but after cleaning the MRSA level reduced only to 66 per cent. The fact that conventional cleaning does not eradicate the superbug is highlighted elsewhere in scientific literature.
Thirdly, in another experiment the use of new technology reduced the level of MRSA dramatically. Prior to the deployment of the technology, the research team found that 74 per cent. of swabs were positive for MRSA. Use of the technology reduced that to just 1 per cent. That technology, which basically uses hydrogen peroxide vapour with high kinetic energy to decontaminate a room, equipment or furniture has been developed by the firm in my constituency.
The research that I have described was published in the "Journal of Hospital Infection" earlier this year, and it was referred to in the National Audit Office report. Lord Warner, to whom I wrote in December, neither agreed to my request for a meeting nor, indeed, answered my letter. Two months after I wrote, I got a reply from the chief medical officer that simply referred me to the rapid review process. However, that rapid review process was certainly not rapid. On May 24th, the CMO wrote to Bioquell to say that
"unfortunately, it is taking longer than anticipated to establish the rapid review process to assess new procedures and products which make claims of effectiveness against HAI. We will let you know when this has been agreed but we hope to start the evaluation before the end of the year"— that is, one year after "Winning Ways" was announced.
That frustration is also reflected in the NAO report. One of its recommendations is that the Department should
"As a matter of urgency, define how the rapid review process of new procedures and products is to be implemented, and how the findings will be promulgated so that they can be translated into practice at trust level with minimum delay."
The rapid review process is now set up. It had its first meeting at the end of August, some nine months after "Winning Ways" was published. I hope that the Minister will agree on reflection that that is a disappointing response to a matter that we are told is urgent and right at the forefront of the Government's priorities.
We have heard a lot about cleaning in this debate. Of course, common sense dictates that cleaning is important, and I welcome the emphasis that the Government are placing on that aspect. Cleaning is a necessary but not a sufficient condition, and the Government are in danger of misleading themselves if they believe that improved cleaning alone will combat MRSA and the superbug—it will not. I am sure that if any of us were about to be operated on we would like to be treated in a room, ward or operating theatre that had been sterilised as well as cleaned.
There has been ground-breaking research in this country into superbug eradication, but the first hospital to put it into practice is in Paris. I hope that the Minister will understand that from the point of view of a company that genuinely believes that it has a contribution to make, the response is one that can lead only to frustration.
I want to conclude on a broader but related point. The Government constantly promote the benefits of the knowledge-based economy and urge us all to adapt accordingly. As Dr. Starkey said, MRSA is a global problem that requires a knowledge-based solution. However, the Government should understand that in practice a British technology company has found it almost impossible to get any meaningful action from the Department of Health on testing and adopting its technology, although it clearly needs a domestic base to win export orders. The Department's document, "Towards Cleaner Hospitals and Lower Rates of Infection", which was published in July, says that it will
"bring the best expertise from abroad to tackle the worst problems at home".
But the best practice may already be in this country.
If the Government are really determined to drive forward their agenda on MRSA, I urge them to deal with the rapid review process with more rapidity than they have so far been able to apply to it and to get on with introducing this technology, when it has been tested, into hospitals with the biggest MRSA problem, then, subject to satisfactory tests, rolling it out. I hope that the Minister will make some commitment to faster progress on that particular aspect than we have had so far.
The first maxim in medicine is that one should do no harm. That is important to bear in mind in the context of today's debate. Our constituents go to hospital expecting to get better and many do not understand why they or their relatives get worse. Although we fully accept much of the data that have been exchanged across the Floor of the House, we must also accept that there is a problem of hospital-acquired infections, especially MRSA. We must therefore decide how we will improve matters for our constituents.
I welcome the Secretary of State's comments that the issue is not party political. It is not our intention to make it so, and we accept at face value his welcome for today's debate as a non-political issue.
There have been seven contributions from Back-Bench Members. They were all of high quality and constituted a genuine contribution to the general debate on such an important matter. Mr. Burstow did us all a great service by reminding us that much of the data on which we depend is somewhat dated. He made a good point about lack of surveillance of organisms and bugs other than MRSA. The headlines are full of MRSA, but we must remember that the majority of hospital infections have nothing to do with staphylococcus aureus or any related organism and are nevertheless important.
Dr. Starkey encouraged us not to make the debate party political. Indeed, up to that point, it had not been. My hon. Friend Mr. Burns made a series of good points, drawing on his experience at Broomfield hospital. He discussed sharing best practice, which must lie at the heart of our battle with infections.
Laura Moffatt made some useful remarks about nurse empowerment and developed them to include cleaner empowerment. I hope that I can agree with her in some of the comments that I intend to make shortly. My hon. Friend Mr. Norman spoke about differentials and the reason for different results in different areas of the country and different sectors of health care when tackling hospital-acquired infections. We need to determine the reason for that and, again, spread best practice and learn where we can.
Linda Gilroy suggested that our approach should be an amalgam of common sense and rocket science, a term that was repeated several times in the debate. My right hon. Friend Sir George Young made an extremely important point about the rapid review process of innovative products. The Secretary of State did not adequately cover that, so I hope that the Minister will say a little about it in his remarks.
If we criticise the Government's outcomes, we cannot fault their capacity to launch and relaunch initiatives, guidelines and various circulars. At the last count, we had touched on 12 today. The latest that I can remember dealt with the provision of individual hand-washing facilities for hospital beds—a tub of cleanser for every bed. The target date for that is April next year. That shows poverty of ambition; we need such basic measures straight away—we cannot wait until April next year. Otherwise, the findings of the National Audit Office's recent report, which suggests that we lose 750 people through hospital-acquired infection, will continue to be borne out. We cannot afford to let hundreds more patients die in the interim. The latest announcement is perhaps simply a repetition of that lack of ambition by Ministers to get on top of such a pressing problem. I revert to my initial maxim: that we should do no harm in our health service. That must be our first priority.
On Friday, I had the great pleasure of touring a new primary care centre in my constituency, which happens to be an Army primary care facility. Above all, the one thing that struck me, other than its obvious newness and the enthusiasm of the staff, was the impressive number of hand-washing facilities. I am sure that that was due to the energy of the nursing sister in charge, and that she will do her level best to make sure that all her staff—cleaners, doctors, nurses, medics—use those facilities. Certainly, it is not rocket science, although there is rocket science in relation to innovations, some of which we heard about today from my right hon. Friend the Member for North-West Hampshire. Fundamentally, however, this issue is not rocket science.
My constituent, Mrs. Burton of Warminster, who trained as a nurse several decades ago—I am sure that she will not mind my saying that—wrote to me that, sadly, she has recently become a patient in the hospital in which she trained. She gave me a 20-point list of improvements that might be made to standards in hospitals, about which she learned when she was a student nurse, and which, as a patient, she unfortunately observed were not being carried out today. I would be happy to send the Minister Mrs. Burton's list if he would be interested, and I am sure that it would be useful to him.
Above all, Mrs. Burton was worried about leadership in the NHS. We have heard a lot about that, and we have rightly heard Florence Nightingale mentioned in that context. We have heard about nurse empowerment, and about the recruitment of matrons—3,000 since 1999—apparently with the power to withhold payments to contractors and departments in the NHS that are not cleaning to a satisfactory standard. When the Minister responds, I would be interested to know how many incidences there have been of payment being withheld by matrons as result of that empowerment.
We must avoid the idea that cleanliness is somebody else's business. That has come across clearly this afternoon. Cleanliness needs to be woven into the fabric of the NHS. The NAO is rightly worried about the balkanisation of the issue—making it someone else's problem, whether the infection control team or the cleaners. I trained in the NHS, and I know full well that I was never given any instruction on hygiene during my years as a medical student. I dread to think how much infection I caused during that time. I know for a fact that, in those years, white coats were never taken from medical students for laundry. Basic measures, such as free laundry for white coats and uniforms, need to be considered. That may cost a bit of money, but as the National Audit Office points out, such infections cost us £1 billion a year, so there are savings to be made. We must not be afraid of investing money, perhaps to save some, if we want to reduce it to crude pounds, shillings and pence.
Training is exceptionally important. I am pleased to hear that training has now improved, and that medical students and nurses are being trained to apply proper hygiene. That must be fundamental to what they do, and it must go further than the ward. It is no good expecting nurses and doctors to put up with shoddy accommodation which is dirty and grimy. We need total quality management in hospitals—everything needs to be clean, including accommodation, which is often not the case. It is no good having "think clean" days, as Ministers seem to want, as in "Towards cleaner hospitals". That balkanises the problem, which the NAO is worried about. We need 365 clean days in a hospital year.
I part company from those who identify cleaning and ancillary staff as being part of the problem. It is easy for the tabloids to do that. Cleaners often appear to be marginalised—they seem to be shadowy figures in the national health service, and are often not seen as part of the mainstream NHS team. I suspect, from the remarks of the hon. Member for Crawley, that she would probably agree with me on that. Those staff need to be led, managed and made to feel that they are part of the general hospital effort.
It is no good expecting them to do their job effectively if people ignore them. It is no good saying to them, "You only shift dirt from one corner to another", if no one really takes an interest in what they are doing, and if they are not being managed properly. We hear a lot from the Government about empowering matrons, but we need to be assured that matrons and senior nursing staff have the capacity to lead and manage everyone and every activity on the ward if we are to control this problem. They must be able to lead and manage cleaners, doctors, everyone.
We have talked about differentials. It is important to compare and contrast what happens in different parts of the country. We know that hospital-acquired infection rates, particularly MRSA rates, vary dramatically. We need to learn lessons from that. Why is it happening? It is clearly not happening just by chance. Why do other countries have a far better record than ours? We need to learn from that as well, and apply best practice.
Different sectors of the health care system in this country produce different results. There may be many reasons for that. I suspect that Labour Members, in particular, will make the obvious suggestion that it has to do with resources. With respect, that would be the scoundrel's way out. Although it may have to do with resources, I am sure that it has a great deal more to do with management factors. We must be prepared to learn from that too, and decide why parts of our health care system outside the NHS appear to be doing better than the NHS in this respect. We need to establish, for example, why community hospitals seem to be doing very well. I suspect that some of that has to do with leadership. Perhaps leadership is rather better in community hospitals, owing to the sense of togetherness and teamwork, than it is in some of our larger establishments.
The Secretary of State said he felt that things had been achieved over the past few years, and none of us suggest that it is all bad news. There are people working very hard in this field. Nevertheless, we clearly have a problem. MRSA was first detected in 1960, and declined to almost zero in the 1970s. It has obviously been better managed in the past, and it is our task to ensure that it is better managed in the future.
I congratulate all who have spoken in this short debate. They spoke with considerable passion and conviction. I am glad to say that we have all recognised the clear need to reduce the incidence of health care-acquired infections, especially MRSA: that, at least, is common ground.
This is one of the most extraordinary debates in which I have had the pleasure of taking part. The background was intensely party-political. Last week the Leader of the Opposition made his attack on the Government's stewardship of the NHS, entirely focused on our record on hospital-acquired infections. We were blamed for the incidence of such infections because we had introduced a range of national targets for the NHS.
One of the extraordinary aspects of the debate is that it rapidly lost most of that party-political dimension. The longer it continued, the more that happened. On one level this is very encouraging: it shows that we can have a mature, grown-up debate across the Chamber, which is very important. I shall pay tribute to a number of speakers shortly, but let me say first that on another level that aspect is disappointing, because I shall have to junk most of the speech that I had prepared. There we are; that is part and parcel of the life of a Minister, and I will receive no sympathy.
Actually, I may have to inject just a little bit of party politics later—[Interruption]—but, obviously, in a mature and sensible way. I agree with my hon. Friend Linda Gilroy—and with Dr. Murrison and his hon. Friend Mr. Norman—that we should not treat this subject as a party-political football, and we have seen plenty of evidence today that that is not happening.
Mr. Burstow spoke for 17 minutes in his customary style, without—I think—making a single positive suggestion about how we might deal with the problem.
[Interruption.] Perhaps I missed it. I am afraid that when he started to read out the e-mails, I may not have given his speech the attention that I normally give. I found it slightly odd that he constantly complained that the Government are not being prescriptive enough and should be collecting more data. Having heard many of his previous contributions, I am not sure how that fits with his standard critique that we are being too prescriptive and collecting too much data.
Indeed. My hon. Friend Dr. Starkey brought a very sensible balance to our debate, particularly on the question of cutting waiting times and whether abandoning targets would make sense. She is of course right, and that theme underpinned many of the Opposition's contributions. Mr. Lansley found himself on rather lonely ground when he suggested that we should abandon waiting times targets. Mr. Burns made a very helpful contribution, pointing out that it is possible to make progress in reducing incidents of MRSA infections in particular, while also making progress in reducing waiting times. In fact, that was very much the theme of the speech by the hon. Member for Tunbridge Wells.
The hon. Member for West Chelmsford successfully anticipated my own speech, as he always does; it is deeply irritating when he does that. Perhaps he and I need to go into a quiet corner and discuss where we are on these issues. I was going to refer to the success of Broomfield hospital, which is an outstanding example of people on the ground dealing with this difficult issue at local level. There are capacity constraints in Chelmsford—the hon. Gentleman knows about the problem, and so do we—but as examples such as Broomfield hospital show, it is perfectly possible to raise awareness and promote best practice across the NHS. Such efforts are a tribute to the local NHS, and I am delighted to hear that the hon. Gentleman endorses the work of his constituents, who are making such a success of that policy.
As the hon. Gentleman knows, on a much broader strategic level across the service, we have been trying to separate out more elective and emergency work. Our treatment centres will help to accelerate that trend, so, coupled with the approach adopted in Broomfield hospital, we are entitled to be optimistic about the future.
My hon. Friend Laura Moffatt spoke, as she always does, with a great deal of common sense, borne out of her extensive nursing experience. I agree strongly—this was a theme of her speech and no one else's—that nurses have a critical role to play in tackling MRSA and other health care-acquired infections. She was right to highlight that aspect of the problem.
I agreed with just about everything that the hon. Member for Tunbridge Wells said. That is a problem for me but probably not for him—a fact on which I need to reflect. He is right: performance is of course variable across the NHS, and there are indeed limits on what the centre can do. My right hon. Friend the Secretary of State and I, the chief medical officer and all my colleagues in the Department of Health do not actually treat patients. Our job, as always in these cases, is to establish the right direction and to invest in the quality of local leadership. Ultimately, that is where this problem needs properly to be located, as the hon. Gentleman rightly said.
Far be it from me to add anything to what my hon. Friend Mr. Norman said, but surely one inference that can be drawn from his comments is that it is not central directives, guidelines and targets that deliver performance in the NHS, but leadership and local clinical teams. Indeed, Broomfield hospital is an excellent example of that. The initiative was specialty specific and on the elective orthopaedic ward; it was not hospital-wide or done on the basis of Government guidance.
The hon. Member for Tunbridge Wells will speak for himself; he is perfectly capable of saying what he intends to say in his contributions. I am simply saying that there is a sensible balance to be struck. In fact, the hon. Gentleman rightly said that there should not be an argument concerning targets versus no targets. There is a proper place in the NHS for strategic targets, and that is what we have established. The Conservatives referred today to having fewer targets, yet the Leader of the Opposition has been talking about scrapping all targets. Perhaps—
I shall not give way to the hon. Gentleman, who made a long speech. The hon. Member for Westbury was not interrupted, and I have one or two other points that I want to make.
I also agreed with the description that was given of fragmented responsibilities for ward cleanliness. In terms of management and leadership, such fragmentation is not acceptable, yet as we know, it has happened. I do not want to inject an unnecessary element of party politics into the debate—I know that some of my hon. Friends want me to—but things started to go wrong when the Conservative Government introduced compulsory competitive tendering, thereby fracturing the responsibility of ward sisters and nurses for cleanliness on their wards.
I do not want to dwell on that historical point, which we are now moving away from, but we are entitled to point out some of the inconsistencies.
The hon. Gentleman rightly referred to another important issue: open wards. Open access to NHS wards is a problem, but none of us wants to lock down our hospitals and make them a prison where no one can see a patient until they come out. There has to be a balance. We have been saying to the service—the issue needs to be taken up locally—that we should be concerned not only about the cleanliness and hygiene standards that we operate but about how we share information with patients, their families and the public about the contribution that they, too, can make. I agree, however—this is probably the most important thing—that to get on top of this we will need a total change of culture, leadership and management in the service. Ministers have a responsibility to the House and the service, as well as to taxpayers, to set the tone for that change, which is very much what my right hon. Friend the Secretary of State has been trying to do.
My hon. Friend the Member for Plymouth, Sutton expressed support for the work that we are doing, for which I am grateful, and rightly stressed the need for accurate information and the importance of data on bloodstream infections.
Sir George Young broadly welcomed the progress that we are making, for which I am grateful, but he raised some concerns about companies in his constituency. He did not ask me to meet him to discuss those concerns, but I will be happy to do so if he will find it helpful. He referred, as did others, to the rapid review process, which is now under way, and I am advised that the team of officials steering that work is now considering six products. His criticisms are not entirely unreasonable, but the most important thing is that the work has now started.
We have covered a lot of ground in the debate, but here I am afraid I must part company with some Opposition Members—I cannot avoid it. In these debates, we are entitled to compare and contrast what they say now with what they did in office. They had the opportunity to do something about this problem in the 18 years of their stewardship of the NHS, and what did they do? First, they refused to take any action to establish the scale of the problem, so none of us, in the House or outside, had any way of knowing how many cases of MRSA occurred in our hospitals. Collecting the right information is an essential precondition for developing the appropriate responses, but they never did it.
Then, the Conservatives forced hospitals to contract out their cleaning services to the private sector. Quality did not come into it: it was the lowest bidder who always won. CCT did not lead to an improvement in overall standards of hospital cleanliness—quite the opposite. They issued two pieces of policy guidance to the service and, interestingly, if hon. Members get the chance to read it, they will see that their advice is entirely consistent with the direction of travel that we have set. That is not an impression that anyone listening to the contribution of the hon. Member for South Cambridgeshire today could reasonably have formed. There were, however, some important differences: there was no follow-up—they introduced no means of monitoring progress; and neither was there any effective accountability or any requirement to implement the guidance.
The Conservatives' approach can best be summed up in this way: first, they turned a blind eye and denied that there was a problem; for ideological reasons, they then pursued actions that made it harder to get on top of the problem; and then they took no action at all to enforce their own guidance. They gave the matter no real priority, so very little changed.
When it comes to dealing with the problems of MRSA and hospital-acquired infections, consistency and a credible track record are not the Opposition's strongest cards. In direct contrast, my right hon. Friend has made tackling MRSA a priority for the NHS, as has been acknowledged by the National Audit Office. We have introduced mandatory reporting, which the Opposition always declined to do. We have set out a clear programme of action that we expect every NHS organisation to take in order to—
Question accordingly agreed to.
Mr. Deputy Speaker forthwith declared the main Question, as amended, to be agreed to.
That this House welcomes the Government's commitment to ensure that patients can have confidence that National Health Service hospitals are clean, safe environments with infection firmly under control; congratulates the Government on its action plans for reducing infection rates, 'Winning Ways' and 'Towards cleaner hospitals and lower rates of infection', which include the new target for a year-on-year reduction in MRSA, and the designation of directors of infection prevention and control to bring about local change; notes that the National Audit Office report concluded that the introduction in 2001 of mandatory MRSA surveillance raised the profile of infection control with senior managers; expects that the new target will act in a similar way, and deplores therefore the suggestion that the target be abolished; acknowledges that improving patient safety is a difficult medical issue that calls for the hard work and care that is the hallmark of NHS staff; welcomes therefore the 77,500 extra nurses and almost 19,400 extra doctors that have become a part of patient care since 1997; and therefore congratulates the Government on a comprehensive programme of investment and reform that has equipped the NHS to deliver improvements in patient safety, and to reduce hospital-acquired infections.