Thank you, Mr. Caton, and welcome to our deliberations. I propose to consider the suggestion that was made by the hon. Members for Northavon (Steve Webb) and for Westbury (Dr. Murrison) that there is not much in the Bill for hon. Members to get their teeth into and that it does not say much. They seemed to question its purpose. I reiterate that the draft code was made available and I draw the Committee's attention to the fact that in July we published the ''Action on Health Care Associated Infections in England'' document, which set out the overall strategy, bringing together all the different initiatives, including the ''Clean Your Hands'' campaign and the target of reducing the number of MRSA bacteremia. It pulls together in one sensible strategy many different facets of announcements that have been made.
In the document to which the Minister refers, the Secretary of State says that the draft code of practice builds on what has been done already, yet in ''Winning Ways'', the chief medical officer says:
''What will not work is simply continuing with the present style of implementation, which has failed to deliver results''.
The Secretary of State is saying that she wants to build on what the chief medical officer says has failed. Will the Minister clarify why the draft code of practice should build on what has already failed?
The final code of practice will lay down a standard that the Healthcare Commission will be able to use to inspect all hospitals and health care providers. Putting the code into the Bill will give statutory force to much previous guidance. That is why the draft code of practice, which was published in the July document, states:
''The purpose of this Code of Practice is to set out criteria by which all levels of management in NHS Bodies should ensure that patients are cared for in a clean environment, where the risk of HCAI is kept as low as possible.''
That will be absolutely clear. I reiterate that all the different strategies, including the ''Clean Your Hands'' campaign, are being pulled together to ensure that those who are in charge of providing care can be measured to that standard by the Healthcare Commission through ongoing inspections. Today's report was a one-off snapshot—as it was described—of that process. The intention is quite clear; the code will give statutory force to what we propose.
Will the Minister confirm that the first occasion on which a code of this kind was raised in the Department was October 2004? I recall, as will my right hon. Friend the Member for North-West Hampshire (Sir George Young), the Secretary of State being given powers in the Health and Social Care (Community Health and Standards) Act 2003 to specify standards. Why was that not used to encapsulate the codes of practice? If it was desirable to do that and the Department was discussing it, why was it not done then? That would clearly have given statutory backing to the code and would have directly informed the Healthcare Commission's subsequent publication of standards that have to be met generally, rather than this being added on afterwards.
Either way, we would have required a legislative vehicle. This is the first such vehicle with which we have the opportunity to create the statutory environment within which the code will operate.
What the Minister says is just plain wrong. I served on the Standing Committee that considered the Health and Social Care (Community Health and Standards) Bill, so I know that it contained a measure that specifically gave the Secretary of State the power to set standards for the NHS and did not say that the Secretary of State is constrained from publishing those standards in the form of a code of practice. In fact, that has been done through the mechanism of endorsing the standards framework set out by the Healthcare Commission, but it was perfectly possible to use the power in the 2003 Act.
I will want to look back at what was said and at what the considerations were in order to be able to give a more detailed answer on the dates and times. Since I took up my post in May, tackling health care-acquired infection has been one of our priorities. I was keen to ensure that we got a draft code into the public domain as soon as possible so that we could have wide consultation on the measures and standards against which hospitals should be judged when it comes to the codes of cleanliness and hygiene that the Bill establishes.
The Committee will not be surprised to hear that we want Members to resist amendment No. 104. It would serve no practical purpose since it only obliges the Government to do what we clearly intend to do anyway, so that there is no need for such a code. The architecture that we are using is not new or something that we have thought up; we have tried this route before. The hon. Member for South Cambridgeshire (Mr. Lansley) referred to the 2003 Act, and we are building on the process of establishing the standards in that Act. We have followed the model that permits rather than obliges the Secretary of State to publish standards. We are proposing an effective set of statutory obligations that can be linked to the need to take action. We should not impose a duty on the Secretary of State that may not in future be necessary or useful. I would have thought that the Conservative Members would not be blind to that argument.
Now we are hearing more of an answer to my previous question. Will the Minister admit to the Committee that the reason why we have a code of practice in the legislation is that a code of practice with which sanctions to the extent of criminal liability would be associated was originally intended, and Ministers subsequently decided not to include such sanctions but were already committed to a code of practice? In reality, the code of practice that we have in front of us is and was capable of being implemented under the 2003 legislation.
The hon. Gentleman may well have a point with his last remark; I certainly was interested in the debate about whether it was necessary to apply criminal sanctions where there was a significant failure. On reflection, given the responses that we have had and after listening to what those in the national health service were saying, and given the powers of the Healthcare Commission, my view was that it was better not to make a criminal sanction available. We believe that giving the commission extra powers to measure against a statutory code is satisfactory.
The sanctions that the Minister is describing are weak, are they not? The most severe sanction that can be imposed is the suspension of a board. [Interruption.] Well, I am not sure whether suspending a board will make a hospital any cleaner. Modern matrons were given a charter some time ago under which they can withhold payments from cleaning contractors, which is far more effective than suspending a member of a trust board or the board itself. If a charter that gives modern matrons the right to suspend cleaners' payments has not worked, how on earth will suspending an individual work?
I think that the hon. Lady is absolutely wrong. The sanctions that the Healthcare Commission has are extremely severe. The threat of removing the whole board of management of a hospital is very serious and focuses the minds of those who serve on NHS trust boards. In the first instance, that is what we are considering, and I believe that that is sufficient sanction. Also, I was persuaded by the argument that we would be criminalising system failure. It is difficult to prove criminal liability in such a case, because it is hard to demonstrate that one individual is criminally liable if a whole institution is failing.
We recognise, as do those in charge, chief executives and trust boards, that the onus needs to be at the highest level—on those who are responsible for the running of hospitals—to ensure that they are focused and that they make a member of their board responsible for overseeing the code and for taking seriously other factors affecting health care-acquired infections.
We do understand that cleaning is not the only element in dealing with hospital-acquired infections. However, the cleaning of a hospital plays a huge part in dealing with the problem, and I cannot help but cynically feel that a contract cleaning organisation is going to take far more note of the fact that its payments might be withheld than the fact that a member of the hospital board might be suspended or lose his or her position.
We are not taking away the powers of the modern matrons to do that; this provision does not replace that, but brings these together. In later clauses, we give powers to the Healthcare Commission to measure the conduct and performance of a hospital against the code. We have taken the view that it is far better to have hospitals performing well to the code of practice as a result of being regularly inspected and held to perform at those levels than to get to the point at which there is such systematic failure that individuals allow themselves to become criminally liable for neglect.
We might revisit the hon. Lady's suggestion if there is a cataclysmic failure, but I do not believe that it is appropriate. The sanctions that we are proposing are right, fit for purpose and proportionate to the problem that we face. Perhaps I can reassure the Committee by giving an undertaking that there will be no inappropriate delay on our part in issuing the code of practice once we have finalised it in response to the consultation. Indeed, the discussions during these proceedings will inform that. I am conscious of the need to activate the proposals, because they will go a long way towards ensuring a rapid reduction in health care-associated infections, resulting in significant improvements to patient safety.
It is a pleasure to serve under your chairmanship this afternoon, Mr. Caton. We have kicked off on a less than conciliatory note. I had hoped that we might be able to proceed through this clause in a more positive way. However, we are faced with a draft code of practice, the best interpretation of which is that it is a rather hastily drafted document.
Let us leave aside the typos and grammatical errors, assuming that they are simply due to the haste of the drafting, and look at the content. If we are lucky enough to have a clause stand part debate later, we might examine it in greater depth. However, it is worth recording that on reading the code one is left feeling that it is just the 24th addition to the long list of announcements that the Government have made in their attempt to tackle health care-acquired infections. There is nothing to get one's teeth into, and one is left with the most swingeing generalities imaginable.
I am wondering how I would react to the code if I were faced with it at the front line in my battle against health care-acquired infections. How would it help me in trying to reduce the toll of 5,000 deaths a year and, on top of that, to help the many people—many times 5,000, I suspect—whose recovery is delayed as a result of health care-acquired infections? I struggle to see how it would help.
My hon. Friend the Member for South Cambridgeshire (Mr. Lansley) is right to say that we already have the powers that we need under existing legislation. I, too, well remember debating it. Given that this is what we could probably call the Government's 24th bright idea on the subject, I wonder why it was not brought in before. We have not had a satisfactory explanation from the Minister. I appreciate that the 2003 Act was introduced before she assumed her current post, but she might like to give the issue some thought and write to us to clarify why the existing legislation could not be used. Importantly, why could we not use it right now, rather than wait for the provisions before us to come into force? Perhaps there will be another 5,000 deaths and an even greater number of people will be adversely affected by health care-acquired infections as a result of this procrastination and delay.
Had the code of practice been worth waiting for, we would have said, ''Hurrah!'' but it was not. It is called a draft code of practice, but it really ought to be called the rough first draft. In general, printing on both sides of a piece of A4 is a good thing—certainly in environmental terms—but the document before us at least has the utility that we can use the blank page for doodles, jottings and things; apart from that, it really does not move us much further forward.
There was obviously a proper publication, which I did not manage to make available to the Committee. I asked my private office to run off copies, so if the hon. Gentleman has a criticism of the quality, that is probably why. However, I was seeking to help the Committee.
I am grateful to the Minister. I am used to all sorts of presentation, but it was not the presentation that concerned me—it was the content.
In our amendments to the clause, which I am sure that the Minister has gone through exhaustively, we have sought to flesh the measure out and give it some real teeth. We need definitive actions to be taken as a result of this part of the Bill to address this problem in our NHS.
Perhaps I can help clarify the point that my hon. Friend is making. If we read the draft code of practice in detail and compare it with the matrons charter and other initiatives that have gone before, we find that it is incredibly similar; indeed, some sections of it appear simply to be a rewording of those earlier measures. There is lots about cross-partnership working and infection control teams and it has all been printed before in guidelines previously presented to the NHS.
Thank you, Mr. Caton. I was trying to point out that the dialogue used in the code of practice is very similar to that used in measures that have been presented to the NHS before.
My hon. Friend is absolutely right and in addressing her comments, I shall stick to the point of my amendment. I suspect that she has recognised references to ''relevant surveillance'', all NHS bodies having in place ''suitable management systems'' and ''a strategic cleaning plan'', and other such startling revelations. I am sure that those come from elsewhere. I simply do not know what that all means. I simply assume that that is what the NHS is doing already, although I do not know what a strategic cleaning plan is.
I am grateful to the hon. Gentleman for getting it absolutely wrong, as usual. The Government's own Department has admitted that there is no difference in health care-acquired infections, whether cleaning is done in-house or contracted out. [Interruption.] The hon. Member for Lincoln (Gillian Merron) sniggers, but I am sure that the Minister will be more than happy to provide her with the figures. The MRSA rate has doubled since 1997, and my constituents are worried about that, as I am sure that the constituents of the hon. Member for Falkirk (Mr. Joyce) are. Seeking to deny that we have a problem does none of us any favours, and I assume that the Minister recognises that; otherwise, there would be no point in drawing up the code in the first place. We all recognise that there is a problem, which is what we are here to debate. I am not simply going to give the Minister warm words; that is not my function as part of the Opposition.
I have worked in this sector for most of my adult life. I feel quite strongly about it, and I believe that the first duty of our health care system is to do no harm. That is part of the Hippocratic oath, as it happens. It is also incumbent on the rest of us who take an interest in health care to ensure that we maximise the prospects of those of our constituents who must unfortunately become patients. Ultimately, that will mean most of us.
I fear that I am straying from the point, although I must say in my defence that I have been tempted to do so by interventions. I hope that the Committee will allow me to deal with this simple amendment, which would simply replace ''will'' with ''shall''. [Hon. Members: ''May.''] The Minister knows that I seek to do so to try to beef up the clause, which we regard as a fairly lame inclusion. It has no teeth, it does not really say what it wants to do, the draft code of practice to which it refers is weak in the extreme, and we believe that there should be a duty on Ministers to issue the code. It is not a question of the Minister deciding on a whimsy that he or she will issue it; he or she should be doing so.
As my hon. Friend the Member for Mid-Bedfordshire (Mrs. Dorries) said, this should have been done well before now. This should not simply become the 24th latest bright idea from the Minister. We have heard about the other 23, and nothing very much appears to have happened on the front line as a result of them. If this is to be anything other than simply the 24th idea, we need to beef up the clause, and we will seek to do just that throughout our consideration of this part of the Bill.
However—there is always a however—I have heard what the Minister has to say, and I have made my comments for the record, so I beg to ask leave to withdraw the amendment.
Amendment, by leave, withdrawn.
I beg to move amendment No. 105, in page 8, line 11, after 'bodies', insert
'within the United Kingdom and abroad'.
This is a probing amendment, and I should be grateful if the Minister would consider the addition of the words
''within the United Kingdom and abroad'' at the end of proposed new section 47A(1)(b). We understand from part 2 that the standards will apply to NHS bodies, but more particularly to NHS patients, so if an NHS body decided that a patient would be treated elsewhere, there would be a duty to ensure that certain standards applied.
We have been treating NHS patients abroad in recent years, and I suspect that the intention is that the duty that the Minister would seek to place on NHS trusts to apply standards to health care would apply in the UK and abroad, but it would be good if the Minister would confirm that. I suspect that other hon. Members may suggest similar amendments that relate to health care outwith the NHS, in that an NHS patient should presumably enjoy the same standard of treatment in the private or the not-for-profit sector as they would in the NHS. I believe that the hon. Member for Northavon (Steve Webb) intends to speak later to an amendment that relates to both NHS and private patients, so I shall not go too far down that route.
It is important to know the scope of the code of practice in the Minister's mind. Will she confirm that the standards will apply not only to an NHS hospital such as St. Thomas' over the river, but to other hospitals in the UK and particularly to hospitals abroad? Will she also say how she will monitor what is going on in those hospitals?
We are making progress. The last amendment was a time-filler. I have seen them many times before. Indeed, we used to table them when we were in opposition. It gives the appearance that we are getting our teeth into the legislation. However, I am willing to concede that amendment No. 105 makes an interesting and important point. I hope to reassure the hon. Gentleman.
If English NHS bodies or cross-border special health authorities commission health care from health care providers in other countries, including in other parts of the UK, patients should still be able to expect the same good level of infection control. The amendment is therefore unnecessary. Clause 13 gives the Secretary of State wide powers to impose requirements in the code on relevant NHS bodies in relation to NHS health care that they commission, as well as health care that they provide.
Section 47(4) of the Health and Social Care (Community Health and Standards) Act 2003 makes it clear that the Secretary of State can impose requirements on relevant NHS bodies in relation to the health care that they commission, irrespective of where the health care is provided. That would cover health care carried out on behalf of those bodies in other countries, even without the amendment. The commissioning of the health care code, and the requirement that those providing the service should comply with the requirements of the code, would be one of the considerations taken into account in the commissioning process.
It will not matter whether the health care is carried out in England or elsewhere—including, for example, in France. Those commissioning such care will be under a duty to ensure that the person providing the NHS health care—the health care that we pay for—meets appropriate standards on infection prevention and control, for example by including appropriate provisions in the contract. Patients will not fall through the net simply because the NHS body does not itself provide the care.
However, the Secretary of State cannot and would not wish to dictate the way in which health care is provided in other countries. What she can do, and what is already covered in the clause, is to set out the responsibilities of NHS bodies whenever they provide or arrange health care as part of the NHS.
I shall resist the temptation to be too political; the amendment does not justify my doing so. However, I reserve the right to respond to some of the points that the hon. Gentleman made. It is a worthy amendment, but it is not necessary. I shall therefore ask the Committee to resist it.
If an NHS body were to commission care from an overseas provider, and the contract included references to the code of practice and its content, is it none the less the case that the Healthcare Commission, whose inspectorate and enforcement is intended to buttress the code of practice, would have no locus and not be able to inspect that provider? Would the enforcement and compliance then become the direct responsibility of the commissioner?
Yes; the hon. Gentleman is right. The Healthcare Commission clearly does not have the right to inspect health care provided overseas. However, the commissioner has a responsibility to ensure that the contract provides precisely the care that is required, including care that meets the standards that we are discussing in the context of the code.
I accept that it is a probing amendment. I hope that I have been able to give the hon. Gentleman the reassurances that he rightly sought. If the amendment is not withdrawn, I hope that the Committee will resist it.
That was helpful. The Minister has more or less given me the assurance that I required. It will be onerous for the commissioner to have to police matters in the event that patients are contracted out, particularly if they go abroad. It will be quite a burden and it might act as a disincentive to place contracts with other countries; however, it will nevertheless be necessary.
Amendment, by leave, withdrawn.
I beg to move amendment No. 98, in page 8, line 15, at end insert
(c) non-NHS providers of health care'.
Good afternoon, Mr. Caton. As the hon. Member for Westbury said, the spirit of this amendment has some overlap with his previous one. It is concerned with whether, and how, the code of practice and other attempts to minimise health care associated with infections would apply, not to provision overseas or outside England, but to non-NHS providers. It would add those providers to the list in subsection (2), which mentions ''English NHS bodies'' and ''cross-border SHAs''.
Our basis for the concern is that we are in a world where, on present policies, the independent sector will provide much more health care, whether we like it or not. There is good reason to be concerned that monitoring, which is much easier to do if one not merely commissions but provides the health care might not be so effective and comprehensive in independent sector providers.
In this morning's sitting, we talked about the Healthcare Commission, which the clause deals with, and its report today on hygiene and cleaning standards in different sorts of institutions, including the private—the independent; I am sorry to use the euphemism—sector. We discuss those providers in the amendment. The Minister's response to the report, which found variable standards and serious problems with some standards in hospitals, was revealing. She said:
''Of the 23 hospitals that had serious problems with refurbishment or cleanliness, 19 were in independent or NHS mental health care settings''.
That was in a response to a report that said that there were some serious problems. The Minister's good news was that
''90 per cent. of NHS acute hospitals had high standards of cleanliness or were considered not dirty''.
It seems as if the fact that 19 of the 23 hospitals were independent or NHS mental health ones somehow made things better. Otherwise, what is the relevance of that point. The argument is that there is a kind of hierarchy, and we are most worried about NHS acute hospitals because they are where people can pick up a bug that can kill them, because operations are being done. That is what really matters.
I will not deviate down the mental health route, but clearly the outcomes for mental health patients were not very good. The Minister seemed to be saying that the independent sector almost does not matter so much because it is not in the NHS and that the Government are answerable only for the NHS. Our amendment seeks to say that that is not the case. If the Government are increasingly going to commission my health care and that of my constituents in the independent sector, it matters every bit as much.
Is the hon. Gentleman aware that the figures for hospital-acquired infections in the independent sector are negligible? In Scotland last year, one case of a hospital-acquired infection was reported in the independent sector. BUPA's statistics show that the figures are minimal in England.
I am grateful for that intervention, but I am not sure, for a number of reasons, whether the matter is quite as straightforward as the bare statistics imply. One reason is the question about reporting.
From a sedentary position the public health Minister said, as we were discussing trends in statistics, that trends and levels are sometimes masked by changes in patterns in reporting. There are issues about whether the way in which infections are picked up in the independent sector is comparable with how it happens the NHS, and whether it is as systematic. In a sense, an independent sector provider who is competing for market share has every incentive not to report hospital-acquired infections because it is bad for business.
I draw a comparison between the situation in Holland and that in independent hospitals in the UK and Scotland. The systems operate on a similar basis: there are many single rooms, single bathroom facilities and an enclosed, almost sterile, environment. The independent sector operates very much as Holland's national health service sector does. Does the hon. Gentleman not think that there is a synergy, given that 1 per cent. of the population have hospital-acquired infections in Holland and the statistic is probably similar in the UK? Such figures might be down to the way independent hospitals operate and treat patients rather than their reporting procedures.
I certainly accept that better infection control procedures such as isolation rooms are a good thing and that there are not enough of them in the NHS. I entirely welcome such procedures where they are carried out in the independent sector, either here or abroad, as they thereby contribute to lower rates. The hon. Lady's point about independent hospitals might be part of the reason for better infection control, but I do not think it is the whole reason.
We need to be sure that we are being systematic, and that we are actually identifying infections. Monitoring of infections in the NHS has not been brilliant—frankly, it is still not—and I have no reason to suppose that the independent sector is even as good at it as the currently inadequate NHS is.
I also think that the hon. Lady is not comparing like with like, because the independent sector performs a lot of planned operations on patients who can be pre-screened, and the NHS often does not have that luxury. It is unfair just to say that the independent sector is better at these things.
Surely that knocks out the hon. Gentleman's own argument. It is true that the independent sector does much more elective surgery and planned and cold surgery than the NHS does, although it has recently started taking on more emergency surgery. The hon. Gentleman was saying that the independent sector should be included, but because of the way that it is structured and the fact that it has more elective surgery and operates in sterilised environments in its rooms, there surely is no need for the amendment.
The hon. Lady touches on the very points, to do with the nature of what the independent sector is doing, that underpin my amendment. The nature of what the independent sector does is changing. If it were doing cold surgery with people who had been pre-screened for MRSA—or whatever—in single rooms and so forth, we might be less worried, but its role is changing. It is doing far more of the sorts of things that the NHS does, although it does not take people in accident and emergency, whom it would not be able to screen. Its role is becoming much more similar to that of the NHS. That is why I am asking whether there should be any difference in the way these matters are handled.
That brings me to the Minister's response to the previous amendment, because her argument in respect of that is germane to this one. As I understand it, the Minister is saying that if a health authority primary care trust, or another commissioner, commissions health care from the independent sector, that is within the scope of the code. I hope that that is true, because that is what I want, and if the Minister tells me that that is what the clause does, it would be welcome. However, I remain concerned that the whole process of reporting is not as systematic in the independent sector. I suspect we will address on later amendments the extent to which reporting should be mandatory or voluntary in respect of different sorts of infections, but my sense is that there might be different reporting practices and differences in hygiene and infection control between different sorts of organisations that will increasingly be asked to do the same thing for our constituents. Our constituents will go to independent sector providers for the same reasons that they would have gone to the NHS, yet we might have different patterns of reporting and regulation. I am worried about that.
To the extent that reporting is not compulsory, I believe that the independent sector, and, arguably, the NHS as well, these days, will be worried about the commercial impact of reporting infections. We all know what happens if there is a serious bug at a local hospital: it is front-page news. An independent sector provider who is competing for market share and trying to attract patients, under patient choice, will not want a reputation for infection problems; it will not want anybody to know about that.
I am just about to draw to a close. I seek the Minister's assurance not only that independent providers will in principle come within the scope of the code, but that once they do, monitoring will be much more proactive and at least as energetic as it is in the NHS.
Amendment No. 98 addresses two important points. First, where NHS bodies commission health care from the independent sector, the same standards of infection prevention and control should be met. However, we have already made provision for that. The Secretary of State can and will apply the code to health care ''provided for'' NHS bodies. When an NHS body covered by the code commissions health care, it will have a responsibility to ensure that it is provided in line with the requirements set out in the code
Secondly, patients of all health care providers deserve good quality infection prevention and control. The hon. Member for Northavon referred me to the comments that I made on the Healthcare Commission's report.
My hon. Friend the Member for Lincoln and I have a shared history. Before we were Members of Parliament, we worked for a trade union. We were privileged to be full-time organisers for the National Union of Public Employees. Consequently, I have worked not in the heath service but with it at different levels with different groups of people. I have a long recollection of and deep affection for the institution, as I am sure the hon. Member for Westbury does.
When I was elected to the House in 1992, the cleanliness of hospitals was a serious matter that was never treated seriously by the then Administration. I am proud that the Government have started to count serious health care-acquired infections such as MRSA, of which the public are genuinely afraid. We hope that by ensuring greater transparency and by providing information to the public, we can provide health care services better than those we inherited. It is a measure of how poor investment was in the health services that we are still tackling difficult, deep-seated problems.
When cleaning was contracted out under the previous Government, the criteria used to determine the value of the service and the amount of money spent meant that the cheapest possible service was provided. I recall being with staff, trying to negotiate in-house bids.
Let me finish my point, and I shall be happy to do so. The hon. Member for Northavon provoked this point, but it has been stewing.
I am proud of our efforts. Granted, we have had to put in a lot of money, and we are not yet at the point at which the health service is funded as it should be, but we are gradually moving in that direction. From what I have seen, where private contracts still operate, hospitals are spending and investing more money on them. We have provided the resources and enabled hospitals to do that.
We are at risk of indulging ourselves. That was not my intention in my earlier remarks. The hon. Member for Northavon provokes us. For the record, the Government have been in power for eight years. It is somewhat tortured to blame everything on the Conservatives. The Minister must recognise that, as she mentioned, the MRSA rate has doubled since 1997. She might also reflect on where we are in the EU league table of hospital-acquired infections, because there is a distinction to be made. She will say, ''We are not top.'' Well, we are not top, but we are in the top quartile, which is not good. She might also address head-on the issue of contract cleaning. She implied that the Conservatives, who hired all the private cleaners, were responsible in some way for the lack of hospital cleanliness.
I would be wary of doing that, because it would take us a long way down a route that I would love to cover. There is a case for the Conservatives to answer.
I acknowledge that the evidence shows that there is little difference between hospitals where care is provided by contract cleaners or by in-house cleaning services. There has been an investment in cleaning services. It is where money has been invested in cleaning—whether contract cleaning or in-house cleaning—that we have seen the improvements in cleanliness. In hospitals that have shown that they can turn around rates of health care-acquire infection, that has often been down to greater investment in cleaning. However, that does not apply to all of them. It is a complex issue.
On the amendment, we intend, for the reasons that I have given, to set out separate requirements for infection prevention and control in the independent sector in regulations under the Care Standards Act 2002. They will be based on the requirements set out in the code to ensure that the NHS and the independent sector have equivalent levels of good practice in infection prevention and control. We plan to consult in spring 2006, and I hope that implementation will follow in October, coinciding with the issuing of the code of practice to all health service providers. By then, we will have everybody marching in step.
In the first instance, there are the commissioning powers. The first port of call in relation to an independent sector organisation that was failing because it did not measure up to the code would be the commissioner. However, the Commission for Social Care Inspection has responsibility for inspecting the social care elements of the independent and private sectors. We aim to ensure that we have a coherent inspection regime that covers all sectors providing health care to the NHS, and the code will provide us with the means of measuring all providers to the same standard.
Does the Minister agree that it might be helpful if the hon. Member for Northavon, before asking such questions, visited some independent hospitals and found out how they are inspected by the Healthcare Commission? He would see the standards to which they are examined and that the consequences for independent hospitals that fail to meet those standards are that they loses their licence and are unable to operate. The sanctions are more severe and the inspection standards more rigorous than those applied to NHS hospitals. The hon. Gentleman should recognise that before he asks such questions.
The hon. Gentleman is absolutely right. The independent sector is inspected to a higher standard. I am interested in that, as I believe that there should be a level playing field: we are not at that point yet, but it is under consideration. All health care providers should, in the context of the code, be measured to the same standard. The clause provides for that, and that is why I believe the amendment is unnecessary.
The Minister's reply offers me some reassurance. When I asked about enforcement, however, she said that the first port of call is the commissioner. The implication is that in this consumerist model of health care, if one does not like a private sector hospital because one is worried about infections, one does not buy services from it. However, in the market-driven mania of the NHS these days, that is true of the NHS as well. If the power of the commissioner to shop around were all that was needed, we would not need the code in the first place. If there were a worry about infection at a particular hospital and the Minister said, ''Well, commissioners will just go somewhere else if they are not happy with the level of infection,'' that should be sufficient. However, it clearly is not sufficient in the case of the NHS, so I do not see why it should be sufficient in the case of the private sector.
Has the hon. Gentleman spoken to anybody who has been involved in one of the choice pilots in Trent? I have, and I was told that patients are exercising some choice between the hospitals to which they might be referred. They are becoming aware that they can be referred to the local private hospital, and they are choosing it. The evidence suggests that they are choosing it because they know there to be a much lower incidence of infection.
That gives rise to two questions. First, does the hon. Gentleman recognise that it is a valuable fact that knowledge about infection should form part of the choice mechanism? Secondly, since he and his party seem not to regard choice as having value in this context, how do they propose that patients who want to be in an environment that has good controls against infection should exercise their preference, other than through the commissioners, whom he denigrates?
The hon. Gentleman mumbles—chunters, I think, is the verb of the day—but I will tell the Committee why what he says is so important. He says that people shop around between pretty-infected hospitals and not very-infected hospitals, although I accept that that is an extreme characterisation. He is saying that there is a difference, which may be marginal or may be big. Some hospitals have high levels of infection, and some low. He says that people shop around, and some, who are presumably the articulate, well informed, well advised and all the rest of it, take up capacity at the low-infection hospital, leaving the marginalised to the hindmost—that is, to the high-infection hospital. To me, that seems a classic Tory approach, which should be utterly rejected.
As the Minister said, we should try to make sure that higher standards apply everywhere. It is absolute nonsense to say that people should shop around between more-infected and less-infected hospitals instead of making sure that everywhere has the highest standard.
Perhaps it is because I was a member of NUPE, but I am about to argue the Government's case. Patients can shop around very effectively, particularly with choose-and-book, of which I do not approve, incidentally, but which is being introduced in general practitioners' surgeries. Choice is everything to patients. Knowing that they can go to the hospital that they want, when they want, whether in the independent or the NHS sectors, is absolutely everything to a patient. Having that choice is to be applauded, not denigrated.
What I think the hon. Lady does not understand are the consequences of that choice. Is the Committee saying that we should tolerate variations in infection levels? Is the response to that variation to say, ''Well, shop around; look at the infection rates, and go to the hospital with the lowest one,'' or should we say that it is utterly intolerable for NHS patients to be sent anywhere that does not have the highest standards of infection control? That is a fundamental philosophical difference.
I have no problem with people shopping around because they would like a separate room or a colour TV, or any aesthetic, cosmetic thing. But things that are absolutely fundamental to the standard of health care should not vary in that way. It should not be about those who work the system.
Jane Kennedy rose—
I am getting drawn into this; it is great fun.
Is the hon. Gentleman saying that the Liberal Democrats oppose encouraging the independent sector to provide real choice for patients? Let me give him one anecdote. The elderly father of a very dear friend of mine needed a hip operation. He had a choice of several places where the operation could take place. One was his local, large NHS teaching hospital and another was a newly established, independent treatment centre down the road. He chose to go to the independent treatment centre because it offered a swifter service. Is the hon. Gentleman saying that that choice should be denied and, furthermore, that in making such a choice, it should not be possible to consider such issues as the rate of MRSA infection? It is useful to have this kind of discussion, because I was gaining the impression that he was saying that.
A number of aspects of the Minister's question cause me concern. For example, the cost of providing the place at the independent treatment centre is money not spent on the NHS. There is a question of value for money. In other words, could the money have bought more capacity in the NHS?
I am more than happy to do that.
The amendment would create a level playing field for the NHS and the independent sector. Our discussion implies that variability in infection rates between sectors is somehow acceptable and that the answer to that is people shopping around. That is utterly unacceptable as a basis for public policy. Having said that, the goal of our amendment was to try to ensure that the independent sector was covered by the code of practice to the extent that commissioners enforce it. The Minister has offered me the reassurance that I was seeking, and I beg to ask leave to withdraw the amendment.
Amendment, by leave, withdrawn.
With this it will be convenient to discuss the following amendments:
No. 107, in page 8, line 21, at end insert—
'(za) require a person—
(i) in each NHS trust to be nominated as the Trust Director responsible for cleanliness; and
(ii) in each NHS Trust responsible for any hospital to be nominated as the Trust Director for cleanliness and hospital acquired infection control;'.
No. 108, in page 8, line 30, at end insert—
'(c) require healthcare contracts relating to NHS patients to contain—
(i) minimum cleanliness standards;
(ii) penalties for failure; and
(iii) provision for the assessment of compliance.'.
No. 109, in page 8, line 30, at end insert—
'(4A) The code will—
(a) require that a person nominated in accordance with subsection (4) (za), on the advice of the senior infection control nurse to close a ward or department for cleaning, make an immediate report to the trust board; and
(b) require that a trust board in receipt of such a report effects the closure of the ward or department for cleaning as soon as patient safety permits.'.
No. 114, in page 8, line 30, at end insert—
'(4A) The code must establish procedures for the systematic recording and reporting of all incidences of hospital-acquired infections.'.
No. 99, in page 8, line 36, at end insert—
'(5A) The code shall require the mandatory reporting of all occurrences of MRSA,'.
No. 110, in page 8, line 36, at end insert—
'(5A) The code shall in respect of acute NHS hospital trusts—
(a) require pre and post discharge surveillance for a person undergoing surgical procedure,
(i) infection control nurse requirements; and
(ii) requirements for isolation facilities,
(c) provide for the senior infection control nurse to report directly to the person nominated in accordance with subsection (4) (Za),
(d) require the availability of 24 hour cleaning services to a defined standard,
(e) require standards that are model cleaning contract compliant, and
(f) set minimum standards for the cleaning of bed spaces following the discharge of patients.'.
No. 111, in page 8, line 36, at end insert—
'( ) The code shall require hospital infection data to be recorded by clinical department.'.
No. 81, in page 8, line 42, at end insert—
'(7A) Any code of practice drawn up under subsection (7) must make provision for—
(a) hygiene standards for clothing worn by NHS staff while on duty; and
(b) the recording of infection using wound swabs.'.
At moderate length, but in detail, because they are quite complicated and lie at the very heart of what we want to do to improve the code of practice to ensure that it is worth the paper on which it is written. We make it very clear that the code is the Government's bright idea no. 24, after the long string of amendments—remarkably, there are 23 of them so far.
Despite the observations made by others and indeed the praise that the Minister has rightly heaped on efforts to address the problem, the progress that we would like to have seen made has not been made. We cite in particular MRSA rates, which have increased substantially, despite the changes in monitoring, which I admit are important, and where we are in the European batting average for health care-acquired infections, as we now call hospital-acquired infections for the purpose of including infections that have been acquired outside hospitals. It is right and proper that we should have changed that terminology.
This rather complicated set of amendments, which includes the very important amendment No. 81 tabled by my hon. Friend the Member for Mid-Bedfordshire, to which she will speak, would change this particular bit of part 2 so that the code has teeth. I make no apology for the fact that many of our amendments reflect what we have been saying for quite some time—probably for two or so years—and in no uncertain terms about what we believe needs to be done, having consulted others to improve the health care-acquired infection rate in this country.
I talked a little earlier than I had anticipated about the code of practice and where it fails. Proposed new section 47A relates entirely to the code of practice, of which we have a copy. I entirely accept the Minister's statement of her zeal to ensure that the Committee is properly informed and that the proposed new section might have been run off in some haste, but I am not at all critical of the presentation; it is the content that worries me.
I read through the proposed new section with some expectation, because I thought that it would give us chapter and verse on how we would deal with health care-acquired infections, but I was disappointed. It includes some pleasant surprises, if one can call viral haemorrhagic fever a pleasant surprise, but it also includes things that do not immediately spring to mind when we talk about health care-acquired infections. We will accept it, because the Minister has had the foresight to choose to include it in case it becomes an issue in the future, which is all to the good.
I shall briefly develop my comments on the amendments and try to set the scene to explain why they are necessary. Let us canter quickly through the draft code of practice. As I said to the Minister, it should be called the rough first draft of the code of practice, because it has very little substance. I hope that if the Minister accepts what we have to say in our several amendments this afternoon, we may be able to flesh out the code and give it some real bite so that the Government's 24th bright idea for addressing health care-acquired infections may be the one that does the trick and finally gets to grips with an issue that is of huge interest to many of our constituents.
Indeed, one of the major health service issues raised in my constituency is the fear that hospitals pose a risk. That might just be a perception, and I usually try to downplay it when constituents raise it, because I like to think of myself as a responsible politician who does not try to make too many political points. I say, ''This needs to be put in context. Your risk of going down with a hospital-acquired infection is not high.'' None the less, we must accept that one in 11 admissions will go down with a hospital-acquired infection. We need to expand a little on that, because we need to think about what is serious and what is relatively trivial. In examining the statistics on health care-acquired infections, we need to get behind the headline 5,000 deaths per year—that is more than the number of people killed on our roads—and look at the lesser infections, which are also important and which substantially delay people's chances of making a full recovery. I am thinking of things such as urinary tract infections, which are probably the classic example. I well remember—it is after lunch, so it is probably okay to mention this—catheterising people rather a lot when I was a junior hospital doctor. We were concerned about the risks of introducing a urinary tract infection.
Equally—it was not that long ago—I well remember that there was no real effort to audit what was going on and to compare one doctor with another, and I very much hope that Ministers would be minded to do that. Health care professionals do such procedures a lot, and it is important not only to break down heath care-acquired infection by hospital, ward or department, but to get a handle on which practitioners are involved. It is the practitioners who do the procedure, not the wards or departments; it is an individual who is expected to carry out the procedure at three o'clock in the morning under something approaching sterile conditions, but whose technique might not be good because they were not taught it properly or because they need to be refreshed, rebriefed or otherwise brought up to date. If we looked at individual practitioners who carry out large numbers of procedures, I suspect we would find substantial differences in infection rates. Of course, there is sometimes a perfectly obvious reason for that, which might have nothing to do with the practitioner and more to do with the case mix or the individuals undergoing the procedure, some of whom will be more at risk than others. Nevertheless, it is important to make such a fine-level comparison if we are to get to grips with the problem.
I would contrast that micro action with the grand, blasé strategic stuff outlined in the draft code of practice, with all its generalities and extraordinary statements about including ''relevant surveillance'' and having in place proper ''management systems'' and ''a strategic cleaning plan''. There is also the remarkable assertion that
''there should be 24 hour access to a qualified Infection Control doctor or Consultant in Communicable Disease Control''.
Does the Minister feel that such provisions are not in place already? It would be remarkable if there were no access in a particular trust area to a director of public health, who in turn would have access to a CCDC. Is the Minister saying that such provisions are not in place now? I would be extremely alarmed if they were not, particularly in respect of viral haemorrhagic fevers et al. However, I think that she will find that such provision is pretty well taken for granted and is part of what the NHS does anyway.
A lot of the code of practice is purely rhetorical, therefore. We are doing it already, so the code is repetitive and that, of course, degrades the currency. Much of the code is motherhood and apple pie, but there are good things and specifics in it, and we welcome that. However, there is a risk that all the verbiage and banal material will degrade what is important. As a working document, it is severely limited. For example, it says that there should be
''24 hour availability of infection control advice to Bed Managers''.
I should have thought that that was already available. It is extraordinary that it is not. The access is through the director of public health or others, yet the code of practice states:
''NHS bodies should ensure adequate provision of isolation facilities.''
Of course, they should, but what actually is adequate provision? As for isolation, I shall refer to viral haemorrhagic fevers. By now the Committee will have realised that viral haemorrhagic fevers have really gripped my imagination.
The draft code asserts that confirmed case are
''to be handled under full isolation measures in a High Security Infectious Diseases Unit . . . or equivalent'',
The hon. Lady clearly put the statement specifically under the code, so she must have concerns about viral haemorrhagic fevers. It would be appropriate under the Bill for her to reflect on the duty that the centre has to provide the units, because that is not something that we could necessarily expect individual NHS trusts to deal with on their own. They are highly specialist units, and few and far between. My word, they are specialist! From my reading of the draft—let us be clear that it is a draft—it is something that NHS trusts might be expected to crack on with, and that is a little unfair. It goes on to say:
''Formal arrangements are in place to fund the cost of outbreaks.''
That prompts the question: if formal arrangements are not to be in place, should the arrangements be informal? I wonder whether the Minister has in mind getting away from the position in which there is a whip round each time there is an outbreak. Words like that do not help in the context of a code, and that brings me back to my concern that the code, which falls from clause 13, is not fit for purpose. It does not say anything. It is full of words, blandishments, generalities, motherhood and apple pie.
We understand that
''isolation policy is to be evidence based''.
That is extraordinary because the converse is that isolation policy might be based on a whimsy. Of course, it is to be evidence-based. It is unnecessary to say that. What, in practice, does the Minister's assertion mean?
There is a large chunk of information on page 19 of the code about the safe handling and disposal of sharps, and the avoidance of blood-borne viruses. My hon. Friend the Member for Mid-Bedfordshire mentioned the matron's charter and that is possibly when matron raises her very pretty head. Much of that information will already be well enshrined in the practice of NHS trusts. Perhaps I have been a little unkind in my recollection of catheterising people, but the majority of hospitals with which I have been involved have advanced facilities and rules for the disposal of sharps and the avoidance of blood-borne viruses. That section merely outlines what is happening already. Simply writing it down will not get to grips with what we should be involved with, which is improving the health care-acquired infection rate in this country, improving our European position in that awful league table and bringing down MRSA and its successor, vancomycin-resistant Staphylococcus aureus, which is even worse. The Minister is probably getting the picture: we are not at all happy, which is why we have had to table this group of amendments to improve the code and give it real teeth.
On page 22, there is a paragraph entitled ''Care of the cadaver''—that shows that the NHS truly cares for us from cradle to grave. Paragraph 2.3.2 mentions reusable surgical instruments, which brings to mind an article published in the Nursing Times, to which my hon. Friend the Member for Mid-Bedfordshire may well refer when she speaks to her amendment No. 81. That article, which was published, I think, in March this year, was quite horrifying. It suggested that nurses were being expected to reuse disposable instruments. That is not a widespread occurrence, I hope, but it was clearly sufficiently prevalent for nurses to volunteer that it was going on. I am not sure why it happened—whether it was simply a logistical problem or whether it was to do with cost—but we clearly cannot allow it.
In paragraph 2.3.2, there is an assertion that
''systems should allow sets of surgical instruments to be tracked through decontamination processes in order to ensure that the processes have been carried out effectively.''
Like me, the Minister goes round hospitals from time to time; she must know that that happens already. It can happen in a sophisticated way; sterile supply departments are highly sophisticated places. It is not just a question of bunging instruments in a steriliser and telling a surgeon to get on with it; such things are tracked right through the system. That is already happening and is built into the fabric of the NHS. The document goes on to state that
''All NHS Bodies should have written local policies, including a strategic estates plan, which reflect statutory requirements and national guidelines on the provision of a good environment.''
I simply do not understand that. I do not really understand the words, or where they are leading us. All this is degrading what should be a fairly incisive and to-the-point document that should signpost us in the right direction to sort out the hospital-acquired infections and MRSA rates, and what I have mentioned does not help.
The document digresses and goes on about food services, including food hygiene and food brought into organisations by patients, staff and visitors. Most of the complaints that I get about food in hospitals are not to do with it not being safe but with its quality and appropriateness for patients—that is an issue, although it is not relevant to this Bill. I am not aware of any particular problems to do with food safety in hospitals. Indeed, as a consumer, my experience of hospital food, although we like to joke about it, is that it is pretty good these days. I am not aware that any specific food hygiene issues relate to hospital food per se—quite the reverse, although the risk to patients can sometimes be greater than to the general public. None the less, that appears in the code. Is that driven by a concern on the part of the Minister or is it simply a question of saying, ''Oh, we had better stick that in as a means of padding and because it covers us in some way''?
The document goes on to discuss the provision of linen, which, it asserts, should be
''in line with national guidelines''.
That is fine, but what are those guidelines? Surely it would be appropriate to include them in the code. Surely that is what the code should be about, yet there is no reference. All the document states is that what happens in NHS trusts will be in accordance with national guidelines, which are not referred to or laid out.
Paragraph 2.5, under the heading ''Healthcare Workers'', asserts that all staff should
''have access to Occupational Health Services'', and that is as it should be. As an occupational physician, I certainly support that; indeed, I am surprised that our NHS occupational services are often pretty well vestigial, and not sufficient by a long mile. So I support that provision; of course I do. However, there is no explanation of what those occupational health services will do, or any explanation, for example, of where locum, agency and casual staff will fall in all this. They are listed, of course, but from my experience as a locum I know that they are often hired at an hour or so's notice and off they go and do their stuff. There is no attempt to screen them in any way, to give them a health questionnaire or to conduct any other surveillance at all, other than ensuring that they are on the register.
How will the code apply to those people? We do not want Typhoid Mary equivalents wandering around the NHS spreading infections. To what extent does the Minister think that agency, part-time or locum staff might pose a risk? I assume that she has considered that and is able to advise us where part-time, casual and locum staff will fall within the occupational health framework and, in particular, how we can ensure that they pose no risk to their patients.
The hon. Gentleman criticises the code because some things are in it and some things should be in it. Is he not in danger of substituting his own judgment for that of the Secretary of State?
Perhaps I missed something; I thought that the job of the Opposition was critically to appraise measures suggested by the Government, and, where they are found wanting, to suggest alternatives. I find this provision wanting—that is probably coming out loud and clear—and I am going to some trouble to explain why it is not particularly helpful. In the course of dealing with these extensive amendments, I shall explain where I believe the code—we must accept that we will have one—will improve matters.
It is not a case of judgment. I have just been going through the draft code. Speaking as an ex-nurse who trained many years ago, I know that many things that are listed in the code have been done for many years: infection control structure, done in the early 1980s; isolation of patients, done in the 1970s; safe disposal of sharps, done; occupational health teams, done in the 1970s; specific roles for cleaning teams, done; infection control programme, done; liaison between bed managers and infection control teams, done. Those things have all been done since the early 1980s, yet they are in the code of practice. It has no teeth.
My hon. Friend makes exactly my point. I am grateful to her for expanding on and illustrating how the code is, to a large extent, redundant. It is a pity, because this is an important matter, and it would be nice to have a code. Indeed, it would have been nice to have had one before now. It appears that this will be the first one.
However, if we are to have a code, it must be a proper code. It must be helpful; it must be a signpost to enable people to achieve the outcome of reducing hospital-acquired and health care-acquired infection rates, and, as a result, MRSA rates. My hon. Friend is absolutely right. All that the document does is reiterate what has gone before. We need to move forward and try to work out how we can improve matters rather than do a sort of retrospective. I regret that, to a large extent, that is what the code is.
I may be in danger of straying into my hon. Friend's territory shortly. The code mentions linen, which is important. I remember my days a long time ago as a hospital doctor—indeed, as a medical student—and the linen services that obtained then. Perhaps it was not so very long ago. My hon. Friend may discuss nurses' uniforms. I did not wear a nurse's uniform, I wore a white coat—except at parties when I sometimes wore a nurse's uniform. If I may explain for the benefit of my hon. Friend, I was trying to be amusing in suggesting that I did not wear a nurse's uniform except sometimes at parties, and that was on the very rare occasion—perhaps only on one occasion. I ought to make that clear for the record.
The fact is that I was accustomed to wearing a white coat, and there were no facilities for laundering them. As a medical student, I was accustomed to wearing a short one, and when I graduated I got a long white coat, which was terribly grand, but neither my short nor my long white coat were ever laundered by the hospital. It was up to the discretion of the wearer to launder it if he or she felt it appropriate.
For 18 months, I worked a one-in-two rota, which fortunately is now outlawed, and I felt that there was no time to do laundry. I freely admit that, inevitably, the garment that I wore was probably not the most hygienic of items. We know full well that a lot of hospital-acquired infection is spread by individuals and their clothing and it would be appropriate for the laundry services to be provided in the NHS to ensure that the garments get laundered. There is little in the code of practice to lay out precisely how that should be done.
I suspect that one has limited control over agency, locum and casual staff, because people tend to come in for a day or so and then disappear. Sometimes they just work a shift or a few hours to fill in. One has no control over what those people wear or their hygiene. That is a real risk in the context of health care-acquired infection. I suspect that the Minister has looked into the issue of casual, locum and agency staff and will have assessed the risk that they pose. She will have given some thought to how that particular element of the risk might be reduced, and it will be interesting to hear her findings.
Paragraph 2.6.1 states:
''Support for infection prevention and control should be provided by a Microbiology Laboratory accredited by Clinical Pathology Accreditation (UK) Ltd.''
I have to say—and it is probably a failing on my part—that I am not fully familiar with the organisation, but my suspicion is that that is done in any case, which underscores my point and that of my hon. Friend that much of what is included in this wonderful, revolutionary code is in fact nothing new.
However, I commend the Minister for the reference to the Control of Substances Hazardous to Health Regulations 2002—hurrah! She will not know, because it was a matter for part 1, that I challenged the Under-Secretary on COSHH in connection with ventilation and occupational exposure standards for tobacco smoke. Although I do not want to hark back to that—you would rule me out of order were I to do so, Mr. Caton—at last I have got my wish and the COSHH regulations have appeared, if not in the Bill, in the code associated with it. I guess that I must take my pleasures where I can, and I am pleased to see that, in another context, my old friend COSHH has finally made an appearance.
I will now deal with the specifics of my amendments, which are a little complicated. I suppose that one could say that they are a bit long-winded, although I have tried to keep them as condensed as I can. However, their meaning is fairly clear. I will run through them one by one.
Amendment No. 107 inserts at the end of subsection (3) an extra paragraph, which I suppose would be paragraph (c). I fully appreciate that parliamentary draftsman will find fault with all of the amendments and will want to amend them. However, I want to press their general meaning. The amendment would insist that there is an individual who is responsible for cleanliness at trust board level. The Minister will say that there is already such a person, but that is a little unfair. We know that individuals are appointed at trust board level to look at hospital-acquired infection, but our whole theses is that there should be somebody at that level who is actively engaged in being responsible for health care-acquired infection. Somebody should be tasked with that. Unfortunately, in many trusts, directors of finance, estate directors, or even non-executive directors have been nominated as the board member responsible for health care-acquired infections. That seems to be an attempt to kick the matter into the long grass. Traditionally, if there is a duty that a board or organisation must undertake that is unpopular, it is given to the person who does not run fast enough or someone who is fairly junior in the organisation.
My fear is that that is precisely what has happened in the context of responsibility at board level. Indeed, that criticism was made by the Patients Association last month. It was concerned that so-called directors of infection control are in fact directors of other things that do not directly relate to infection control or the clinical sphere alone. Surely to goodness, if there is to be such an important person with real responsibility, they need to be engaged in the clinical sphere or at least clinically trained in some way in order to get a grip on the matter. I had it in mind that such individuals would be in charge of cleanliness and hygiene in their hospitals in a real sense. That is the purpose of amendment No. 107.
I am grateful to my hon. Friend for giving way and I appreciate the way in which he is setting out the arguments relating to the draft code.
On the point of who is in charge, he might be interested to hear of my experience of visiting one hospital where I discussed health care-acquired infections and who was responsible for what. We know that NHS hospitals are required to have a director of infection prevention and control; that is not new in itself. I asked the team there who was in charge of infection control. I was told that it was the senior infection control nurse. I then asked who the director of infection and prevention and control was, and was told that it was the consultant microbiologist. I asked who was in charge of cleaning and cleanliness on the wards. I was told that it was the director of estates, who reports to the finance director. I asked who had overall responsibility for the patient environment; there was a separate chief nursing officer, whose title was the director of patient environment, but they did not have control of cleaning or the infection control teams. One can comply with the code, but in this case none of those things would have been brought together in the hands of one person on the board with responsibility for delivering the code.
My hon. Friend is absolutely right. The amendments would ensure that that was not the case; an appropriate individual at board level would be in charge of those things and be responsible to the board. We have laid that out clearly in the amendments. I do not want to hark back too much to the code because I have more or less read it out verbatim, but it is important and interesting to reiterate paragraph 2.2, which says:
''All NHS bodies should have suitable management systems in place that define responsibility and accountability for infection prevention and control.''
It goes on to talk about relevant surveillance. That quotation is very telling. What on earth is ''suitable'' in the context of management systems? It is that vagueness, to which my hon. Friend referred, that worries me.
If there is a problem—and there is, despite what some hon. Members might like to pretend—we have to grip it and be serious about it. I know that the Minister takes it seriously; if she did not she would not have gone to the trouble of drafting part 2. We really need to flesh out in the Bill precisely what we expect NHS trust boards to do. That is not something to be left to the imagination; we need to be clear about what we expect. That is why we have tabled amendments that will make the code something useful as opposed to some whimsical document that trusts can interpret as they will. I am sure that my hon. Friend would agree that, as it stands, it has very limited utility.
Amendment No. 108 would require health care contracts for NHS patients to contain
''minimum cleanliness standards . . . penalties for failure; and . . . provision for the assessment of compliance.''
It is the first of a small set of amendments in which we lay down what we require. It gives trusts a certain scope. It is not didactic in demanding so many gel dispensers per ward and what have you, but of course were a manual of health care-acquired infections produced—there may be good argument for having such a thing—it might do just that, based upon the evidence. The amendment sets a sort of framework, and it is little more prescriptive than the code.
It seems entirely reasonable that we should do such things. We obviously need to establish what the penalties might be for failure, and we could debate what they might be. We heard the Minister's and the hon. Member for Northavon's respective views on what would constitute a proper penalty, and my hon. Friend the Member for South Cambridgeshire mentioned that in the context of the independent sector. However, if the provisions are to have teeth, and if we believe that we should take the matter desperately seriously—I think that we all do—we need to have penalties. We need to know what penalties may accrue in the event of a shortfall in the outcomes that we desire for health care-acquired infection and MRSA rates and in hospital cleanliness, however we choose to define that.
It is reasonable to set out minimum cleanliness standards. We hear a lot about targets and standards, and I shall speak about targets a little later, but I believe that they have contributed to the problem that we have now. The Minister launched into a polemic about how things have improved since 1997, and how dreadful they were before then. However, I lay at the Minister's and the Government's door the fact that targets have contributed to the problem. I firmly believe that to be the case. For example, the targets for high bed occupancy have certainly contributed to some of the present difficulties. We will doubtless come to that in a little while.
It is important to be realistic about what has happened over the past eight years and perhaps avoid the more obviously partisan points, some of which the Minister has mentioned. I hope that we are singing from the same hymn sheet. We are all constituency MPs and we all have people coming to our constituency surgeries every week—those who run weekly constituency services—to say that they are concerned about hospital cleanliness; we also receive correspondence and emails on the subject, so it is obviously a big issue. We need to take it extremely seriously.
Amendment No. 109 would insert a new subjection (4A), which would read:
''The code will . . . require that a person nominated in accordance with subsection (4) (za), on the advice of the senior infection control nurse to close a ward or department for cleaning, make an immediate report to the trust board; and . . . require that a trust board in receipt of such a report effects the closure of the ward or department for cleaning as soon as patient safety permits.''
I know that trust directors and chief executives are under real and intense pressure. The average working life of a chief executive is about 19 months. In a sense, the amendment lets them off the hook. In the event that the infection control nurse goes to see the director for infection control and says that there is a problem, the measures that they will have to take will be pretty well laid out. If the Minister was minded to accept something along those lines, she would doubtless change it to take account of all sorts of eventualities. The amendment is deliberately concise to give notification of where we are coming from. For sure, it seems that it would put an onus on the trust board; but it would remove any doubt about the correct course of action.
The amendment has the capacity to allow for patient safety. We cannot simply say that we have isolated a bug, so we must close down the unit, close the doors and get everybody out right now. That would be ridiculous and laughable, so we have included the caveat that it should be done when patient safety allows. The amendment introduces an element of discretion.
Borrowing from the Dutch model, we must be clear that we shall not tolerate health care-acquired infections. That is the purpose of amendment No. 109. When there is a problem, we need to be more willing to close down wards so that they can be properly cleaned to a recognised standard. My concern is that there may be instances in which that does not happen, owing chiefly, I think, to the target culture and the undoubted pressures that apply to senior health care managers.
In line with what my hon. Friend was saying about there being a lot of existing NHS practice in the code of practice, I have an interesting case. If one goes back to the working group composed of representatives from the Public Health Laboratory Service, the Infection Control Nurses Association and other bodies that I think published a report—from memory, I am afraid—in 1998, it is clear that a substantial aspect of that document, which was about the guidelines for infection control, was geared to the question under discussion and to the mechanisms that should be gone through in order to conduct a proper risk assessment prior to the point at which a recommendation is made to close a ward for disinfection.
Given that over the years that document has been a statement of best practice, I find it curious that it has not been reflected in the code of practice. Given that we and the National Audit Office have emphasised that closure recommendations have been overridden to meet waiting time targets, there is a real opportunity to give the NHS clear guidance that prioritises patient safety. However, the code of practice appears to be rather limited: it does not even reflect current best practice, which was in fact best practice before the introduction of waiting time targets. It is a great pity that that has not happened.
My hon. Friend is right. Although I spent a great deal of my time describing how the code simply reflects what one should in any case expect as part of the fabric of the NHS, there are even omissions in that. My hon. Friend has clearly laid out one such example. It seems extraordinary, does it not, that the code of practice does not refer to the crucial issue of the assessment of wards and departments for cleanliness, when closure may be necessary for cleansing. I share my hon. Friend's concern, and I hope that the Minister has heard his remarks and will address them when she makes her remarks.
Amendment No. 110 is rather lengthy. In essence, it inserts in the code measures that will allow better surveillance of health care-acquired infections than exists now.
The Minister rightly touched on the surveillance that has been put in place, and I think that another Labour Member might have done so too from a sedentary position. It would be churlish of me to say that it was not a good thing—clearly it was. However, in 1997, surveillance was voluntary. Surveillance was subsequently based on orthopaedic cases only, and then only for three months of the year and in selected hospitals. Since then the focus has largely been on blood-borne MRSA, which is by no means the whole story. It is important to disentangle MRSA from health care-acquired infections. They are largely part of the same thing, but they are quite separate. Arguably, although health care-acquired infections—minus MRSA—are less Daily Mail, as it were, they are just as important, if not more so, to the sum total of human happiness, as they are so prevalent.
The 5,000 a deaths a year from health care-acquired infections represent the tip of the iceberg. If we consider the impact on morbidity of health care-acquired infections that fall short of death, the whole thing gets bumped up into an even higher league of importance. Therefore, we must assess the problem adequately, and pre and post-surgery surveillance seems to us a reasonable measure. It would allow the Minister to crow about any successes that she might have. In a quiet moment I would celebrate with her, if the surveillance that I am suggesting showed an improvement. It might give her something to celebrate in public health terms. However, we cannot do so unless we know the extent of the problem.
Therefore, although we welcome the developments in surveillance over the past eight years, reflecting advances and no doubt also international comparisons, we must move on—
That is very naughty of the Minister; it tempts me to expand my contribution.
Before I was rudely interrupted by the Minister, I was merely trying to be helpful by suggesting that she might like to expand her surveillance in a way that enabled her to record some good news in the not-too-distant future when things improve and infection rates are shown to have declined.
I am grateful to be allowed to interrupt my hon. Friend less rudely. The Minister might find some things in the amendments that will improve the code, because we are trying to say, ''If we're going to have a code, let's make sure that it not only ticks boxes on all the things that people are doing already or on processes, but gets to the heart of what current evidence increasingly suggests is effective.''
Here is an interesting case—it is astonishing. The regulatory impact assessment for part 2 of the Bill contains a perfectly good reference to what has been done at University College hospital to reduce MRSA bloodstream infections. One of the key things that UCH did was post-discharge surveillance after surgery, for two reasons: first, to identify where practice inside the hospital was deficient and to remedy it, and secondly, because there is good evidence that those who have subsequent MRSA infections are on re-admission likely to be carrying MRSA and to be at risk. I have searched through the code of practice and it contains no reference to post-discharge surveillance, yet it is perfectly obvious from the good evidence of that and other cases that it should form part of the work in hospitals. In what sense does the code of practice take matters forward and encourage the adoption of best practice?
As ever, I entirely agree with my hon. Friend. I add to that the need for post-discharge surveillance of those who are, for example, going to other forms of health care. I am mindful of my hobby-horse, community hospitals. When I visit community hospitals, the staff invariably start by saying, ''We don't do MRSA; we don't have it. The only time we get it is when it has been imported with people who are having step-down care.'' They mildly resent that happening, because they regard themselves—I firmly believe that they are right—as exemplars in cleanliness. That is certainly my experience in the NHS—I would digress were I to eulogise for too long on the subject, but it would be useful if the Minister considered why community hospitals might be such exemplars for cleanliness in the NHS. It has to do with management of cleaning staff, the ethos of the place and so on. I shall not go down that route, because you will quickly call me out of order, Mr. Caton.
Such institutions say that the only cases of MRSA that they get are those that come from, in my area, the Royal United hospital in Bath. That is not to denigrate the RUH—it just happens to be the largest hospital that serves my population. It would be useful to know which of the large number of people who have step-down care in the course of a year from the RUH to the community hospitals have that particular strain of Staphylococcus aureus, so that provision can be made for them, they might be treated for it and it can be controlled. We are considering a vulnerable population, because those who have step-down care in community hospitals tend to be elderly, sometimes coming towards the end of life, when they are most susceptible to that range of infections. My hon. Friend is correct; I am sure that if we bent our minds to it we might think of a number of other good reasons for having pre and post-discharge surveillance for those organisms.
Our amendment goes on to seek to include in the code requirements to set out how many infection-control lists there might be, or the bearing of them, and requirements for isolation facilities. That harks back to the bit in the draft code that I mentioned earlier in the context of serious infections, and the fact that at the most serious end there seems to be little recognition in the code—it is probably not intentional—of the strategic national nature of the requirement for ordaining high-level units. I hope that Ministers do not regard that as a matter for localities. Although, as a party, we are increasingly localist, we recognise the need for a national strategic oversight in a number of particulars, and this is one of those.
It is reasonable to give some guidance on how many isolation units and how many infection-control nurses there should be. We know that the number varies considerably from trust to trust. We have had a report—from memory, I think it was from the Public Accounts Committee—pointing out the profound difference in those numbers. There has to be a reason for that. In some cases it will be obvious, perhaps to do with the case mix or the nature of the hospital and what it does. Arguably, it would be ridiculous for a hospital dealing in elective orthopaedic work to have the same bearing as one dealing in what one might call the heavy stuff—a lot of bowel surgery, for example. It would be extraordinary were the bearing to be the same. However, trusts need to see rational benchmarking, so that they can determine whether they have the correct bearing in terms of infection-control resources. That is what the amendment would achieve.
Proposed new subsection (5A) would
''provide for the senior infection control nurse to report directly to the person nominated in accordance with subsection (4) (Za)''.
That person would be the trust board director who had been tasked with the responsibility for health care-acquired infection. In other words, there would be no intermediary. To be fair to the Minister, in a tortured sort of way there is some reference in the code that would vaguely lead us in that direction.
It is important that a senior member of the nursing staff should have direct access to that trust board member, for the reason that I have already laid out. The form of approach by the chief infection-control nurse to that trust board member under our proposals has a direct significance, because it will potentially lead to the closure of a ward or department. We must not, of course, do that lightly. There has to be good reason, because it has opportunity cost implications for the health care that is provided. It is important that a senior nurse has direct access to that individual so that the procedure can be carried through rigorously.
There should be a requirement for 24-hour cleaning services to be available to a defined standard. Clearly, the nature of that defined standard is what is important. It is extraordinary that there should not be 24/7 access to cleaning and I hope there would be in most NHS trusts. It seems reasonable to set in the code of practice the requirement for 24/7 access to cleaning.
We would accept the minimum of standards for the cleaning of bed spaces following the discharge of patients. That stems from the article I referred to earlier from Nursing Times that reported a survey showing that 40 per cent. of nurses felt that they did not have time between patients to clean a bed space adequately. The Minister might say that that is anecdotal, but it chimes well with reports from our constituents. Most of us draw a lot of our thoughts from what we experience in our constituencies. The evidence in my area is certainly a little more than anecdotal. A number of people have come to me and said that they have observed that their bed space was not clean—more particularly, it is usually a relative or visitor, because they sit by the bedside and observe what is going on. That tallies well with the report in Nursing Times published in March this year, which said there was not sufficient time or resource to clean between patients.
The Minister might say that it is all very well my saying that, but where will the resources come from? In all of this we have to bear in mind the cost to the NHS of health care-acquired infections, which is substantial. I suppose we could say that a large amount is uncosted, because it is borne by patients and their carers. A substantial proportion would, of course, be directly borne by the NHS. In making a call for proper resources I do not think I am being unreasonable. I do not think that I will upset those who keep a tally of the figures and the pledges made by political parties in asserting that money spent on such preventive measures is probably money well invested when it comes to pounds, shillings and pence available to the NHS.
It is important that standards are cleaning-contract compliant. We have had reference to contracts. The hon. Member for Falkirk (Mr. Joyce), who is not present, made a party political point on the privatisation of cleaning services. I hope that I was able to reassure him that there is no evidence that contract cleaning results in less clean hospitals than in-house cleaning. Nevertheless, it boils down to the contract and how tight it is. There is no excuse for drawing up a contract that is sloppy and allows the party to which it is offered to get away with things. My experience of contract cleaners is that they are fairly dedicated. They are human beings; they want to do a good job. They usually live in the community served by their hospital. It is wrong to lay into contracted cleaners and to say that they are not doing a good job; the Department of Health's evidence suggests that that is not the case.
It is important that contracts are drawn up rigorously. If they are not, the fault lies at trust board level and not necessarily with the contract cleaner, who merely works to that contract, as any other operator would. I promise you that I am coming towards the end of my contribution, Mr. Caton. I apologise for having waxed lyrical, but this is a long string of amendments, and it is important to put the amendments in some sort of context in order to explain where we are coming from.
Although amendment No. 111 is short, the Committee—or rather what is left of it—will be delighted to know that it is probably one of our most important amendments, so I hope that hon. Members will permit me a few minutes to explain what it is about. A range of data is available to us on health care-acquired infection. The Minister rightly said that we have more data than we did in the past, and that is to be welcomed. However, what we do not have—this is the burden of what I was trying to say in my story about the catheter and the individuals doing catheterisation—is the kind of micro-level data necessary for people to make choices. Those data are needed for hospitals to make choices, so that they can assess where things are going well and where they are going less well.
Unless we really drill down, we will get a very crude measure of where things are okay and where they are not good. We need ward-by-ward data and clinical specialty data. In the fullness of time, we should look more closely at data relating to individual practitioners. I was a practitioner 10 or 15 years ago, catheterising people at 3 o'clock in the morning—to a good standard, I hope, but I had no way of telling, really. There were no figures attributable to me to tell me whether my infection rate was worse than that of the person who did my job when I went off shift, which was not particularly helpful. I could have done that procedure for two or three years and not known whether I was doing it poorly. There was no way for me to know. We can all improve our techniques and, looking back, I have to say it would have been nice to know whether one was doing things in a conscientious way and in a manner that was technically correct, and whether the results from our patients were good, bad or indifferent, so that we could improve our results.
My point is that the data that we collect are far too broad-brush; we need to drill down to a much finer level to produce material that will be useful. I suspect that the Minister will say, ''You Conservatives are all about reducing the amount of bureaucracy and administration'', but I do not believe that the measure would vastly increase the amount of data we have to acquire. We live in an age in which it is relatively straightforward to record, analyse and audit things; it is far easier than in the old days, when such procedures required little check-off cards and things that made the task much more laborious. Now, that is not a particularly big issue but, in the context of trying to improve the standard of our health care and our outcomes, the measure would be really quite revolutionary.
Amendment No. 111 would require hospital infection data to be recorded not by hospital—although that of course is good in the context of patient choice—but by clinical department. The hon. Member for Northavon has gone, in a flurry of Bolshevism—
For whatever reason, the hon. Member for Northavon has gone, but he appears to be against choice, so, sadly, he probably will not be interested in the amendment because it would allow our constituents to exercise choice. Our constituents are not—and should not be—interested in the cleanliness of X, Y or Z hospital; they should be interested in the cleanliness and results of particular clinical departments, because that is where they go for a coronary artery bypass graft. They want to know what the standards are like in that department, not what they are like in gastroenterology.
As this morning's Healthcare Commission report was at pains to explain, many of the hospitals that it assessed had good and less good areas. That tends to be the case right across the piece. Evidence of a systemic lack of cleanliness in hospitals is limited, but there are problem areas. The report laid that out. The amendment would address that problem. It is therefore timely that the report came out this morning. We recognise that this is a department-by-department problem. That is why we want the data to be collected by department rather than merged into the generality of cases in a hospital. Otherwise, the significance of the data will be lost in the noise of all the cases going through a large, district general hospital. I very much hope that the Minister will smile on the amendment and that she will comment on the others in the group that I have tabled.
I have almost forgotten what I was going to say. The Under-Secretary said on Tuesday that she likes to know where Members are coming from when they table amendments, and that she likes to know the spirit behind the amendments. For the benefit of the Minister of State, I declare an interest in the amendments.
I suppose that I was in the parliamentary intake that would be known as the class of 2005, but 30 years ago I was in what was known as the class of '75, along with 39 other student nurses who were commencing their nursing careers. The hospital in which I trained must have been very different from that in which my hon. Friend the Member for Westbury trained, because in those days our hospital laundry was all done for us. We each had eight uniforms, four of which went to the laundry together and four of which we kept. We would go to our day or night shift and speak to the man behind the locker, who would go and get our uniforms for us. If he did not have it because it was not back, we would be given one with ''surplus stock'' written on the label. Nobody travelled home or to work in their uniform. Indeed, it was known, although it was not written in any code of practice, that to do so would be a huge offence.
In addition to nurses having their own uniforms, the hospital was immaculately clean. Again, there were no codes of practice, but when a patient was moved to another ward or discharged, everyone automatically knew what had to be done: the bed space, windowsill and locker—the whole patient area—had to be cleaned before the next patient arrived. Anyone would do that: if the ward cleaner was there, she would do it; if not, an auxiliary would do it; and if there was no auxiliary present, a nurse would do it. Everyone mucked in with the cleaning because it was known that hygiene was everything.
My hon. Friend the Member for Westbury talked about taking the Hippocratic oath. We, too, took an oath, which was based on the oath laid down by Florence Nightingale. No one knew more about hospital cleanliness and the importance of hygiene than she did. She halved the number of soldiers' deaths in the first hospital that she went to by improving the hygiene standards.
However, we are talking about different and much more sophisticated bacteria to those that Florence Nightingale had to deal with in her day. Let us consider the behaviour of Staph. aureus, which is the main bacteria in MRSA, which is becoming VRSA. Staph. aureus treats hospitals like five-star hotels; it loves them. It colonises and takes residence in them. It loves warm, sticky places, but is not very particular and will live anywhere. It loves hands, clothes, plastic and floors, and will go anywhere. Its main route of transfer is through touch. Half a dozen of us in this room will have Staph. aureus on us now, but it will not harm us. Neither will it harm the nursing staff who take it home and bring it back on their uniforms. The Minister will probably say, ''Oh, it's been proven that a 60° degree wash with a good rinse cycle gets rid of Staph. aureus.'' That was discussed in the House of Lords last week.
Looking at the code of practice, I recalled that of my class of 40 nurses most of us are no longer in the NHS, which is sad, given the training that we undertook and how enthusiastic we were about what we were doing. Those who have remained in nursing, however, are at the top of their profession, and one is a modern matron in a London hospital. On Monday we chatted about the code of practice and the modern matron's charter, with which she was issued about 18 months ago, and we came to the same conclusion.
The issues about the code of practice and the matron's charter were similar. We agreed that if there were some robust, strong practical measures for dealing not only with MRSA but all hospital-acquired infections, that would give the code of practice teeth and make it popular with the public, the Minister's party and her supporters outside, and everyone else, including hospital staff. One such measure might be a robust code stating that nurses and all medical staff who come into contact with all patients should wear clean uniforms.
I went with my friend to the hospital where she is a modern matron; I shall not name it. My hon. Friend the Member for Westbury will understand what I am saying. When inserting a ventflon and so on, there is a distinctive spray of blood on the front of one's uniform. My friend and I were talking to a nurse who had that distinctive spray of blood. I happened to say, ''You have blood on your uniform.'' I know that what I am about to say will shock people in the room, because it shocked me. The nurse said, ''No, that's not blood; we had spag bol last night.'' I was horrified that she had gone home in her uniform and not only had she not washed it, but she had eaten her supper in it, returned to work wearing it the next day and was operating on the ward. That bore out what my friend the modern matron, who is the same age as me and was in my intake, was talking about.
I am glad that my hon. Friend the Member for Westbury trained when he did and is not training today. I have seen the inside of his car—one would not voluntarily travel in it, believe me. He has five daughters and a labrador and if he were training now and throwing his coat in the car, going home in it and going back into a hospital, it would not bear thinking about. His labrador has no discipline and no discretion.
If people stand in any hospital car park, they will see doctors leave hospitals, throw their coats in the back of their cars and drive away. I have no doubt that they will come back next morning and take their coat out again. If their cars are anything like my hon. Friend's car, what wonder is it that we have hospital-acquired infections?
The Minister may think that laundering hospital uniforms and those of staff who come into contact with patients is a difficult procedure, but it is not. As a nurse I benefited from that procedure and saw it in place. Let us consider the sums that are being spent on tackling hospital-acquired infections. Some £12 million has been given to pharmacists to research antimicrobials to look at cleaning solutions that are used in hospital. That would go a long way in laundering nurses' and staff uniforms.
The procedure for laundering uniforms is simple, standard and uniform, for want of a better word. The uniforms go to the hospital laundry and return. Two people operate the changing rooms. Staff are not allowed to go out in their uniforms and they must come into work in their own clothes. I fail to see, as do lots of other nursing staff, why that is not the position now.
The nurse with the spag bol, whom I will never forget, provides an extreme example. However, even if none of us has seen nurses with food stains on their uniforms, we have all seen nurses, physiotherapists and other hospital staff leaning over fruit and vegetable counters and food counters in supermarkets, or popping in to do a little shopping on their way home or on their way to work. I have seen nurses who have come straight from work to the school gates to pick up their children or other people's children, who bundle them in the car and take them home. All those people carry Staph. aureus, which is not harmful to them or to us, but it will live on the uniform and it is carried back into the hospitals. If the Minister really wants the code of practice to have a solid bite, I ask her to think about the linen aspect and the staff uniforms.
I am sorry if I am anticipating anything that my hon. Friend was going to say, but I thought I detected that she might be heading towards a conclusion. I know from my conversations with staff in hospitals that they have no choice. Does she agree that they have nowhere to go to change, as the changing rooms and lockers have all disappeared? Many staff do not have them.
Earlier in the year, I talked to a senior nurse in a hospital who said that she now had four uniforms. She would, as my hon. Friend said, need twice as many uniforms and ready access to a laundry service to be able to comply with the code of practice, but such a service is simply does not exist.
As my hon. Friend the Member for Westbury said, the Nursing Times earlier in the year illustrated the fact that many nurses do not have access to the uniforms, the laundry services or the changing facilities to enable them to do the things that they want to do, as described by my hon. Friend the Member for Mid-Bedfordshire.
My hon. Friend is right. I have only to think back to the Royal Liverpool teaching hospital where I worked. The changing rooms were in the basement, so that was the first place one went on arrival and changed for work. We all had lockers and changing cubicles. I fail to see why we cannot have them today.
More generally, we all know that cleaning is not the only weapon in the fight against MRSA. There are many procedures for dealing with it, such as cleanliness of the staff and staff uniforms.
Sitting suspended for a Division in the House.
I was about to refer yet again to something that my hon. Friend the Member for Westbury said—it is hard not to do so, as he has said a lot in this debate and imparted a great deal of information. He was talking about how people who sit at a bedside can become experts in what happens at a particular hospital; that can happen not only in respect of the cleaning aspect, but in general.
Throughout November and December of last year, I was in the unfortunate situation of having to sit at a bedside for two months; that started off at a general hospital for a few hours a day, but after a while the location moved to the community hospital, where I sat for up to 16 hours a day. Many people go through the sad process that I went through then. I sat and watched things. I thought I knew how hospitals worked and were run, but sitting at the bedside watching staff and the way they worked for such long periods of time was incredibly informative.
There were phenomenal differences in the standards of nursing and cleaning in the two hospitals. The staff at the community hospital where my father ended up said, ''We don't do MRSA in this hospital'', and it was clear why they did not. The uniforms of the nurses and staff were immaculate. The same cleaner was on the ward every day, knew everybody by name, and was almost a supplementary nurse—as opposed to nurses being supplementary cleaners. The community hospital was immaculate; one could not fault it. However, that was not my experience of the general hospital.
If we are seeking to reduce MRSA, we have good examples to follow of where it is very low in the UK. I appreciate that emergency procedures did not need to be undertaken in that community hospital, and that there were no dirty operations or emergency operations, but the differences in the standards of cleanliness between the two hospitals were great. I am sure that the Minister has been to community hospitals herself and seen that; there is a lot to be seen.
If the nurses at the community hospital had their laundry laundered on site, its MRSA rate would probably not be much different, because everything else that was done at the hospital was done so well, and everything was so clean—to say that is almost to shoot myself in the foot in respect of the nurses' uniforms argument. However, that laundry procedure is needed in general hospitals because of the way they work—with so much traffic on the wards, and extended visiting hours, and ward sisters not in control of their own environments, and complexity of operations.
The other part of amendment No. 81 is about wound-swabbing. I had wanted to raise the issue in any case, but it has been reinforced by the case of a constituent. We measure MRSA in this country by measuring blood-borne infection, but MRSA or Staph. aureus is not always present in the blood and is frequently present only in wounds. That is particularly true of wounds that are difficult to heal because they have a poor blood supply and are not oxygenated well. Staph. aureus is sometimes happy colonising on the tissue surface and on the surface of the wound, producing some very unpleasant results.
The issue was recently reinforced for me by the case of a constituent who, unfortunately, had a road traffic accident some time ago. He was discharged from hospital on oral methicillin, but it is having no effect, because his wound swabs show that Staph. aureus is present in the wound. He is awaiting re-admission into hospital to have his wound de-sloughed and cleaned under general anaesthetic, and he will probably go on to intravenous Vancomycin, because that is the next port of call in such a case.
What concerns me is that my constituent is at home with a wife and four-month-old twins, but he has a very unpleasant discharging wound and the wound swabs are showing that Staph. aureus is present. Furthermore, he will go back into hospital as an infected patient. He has been desperately hoping to have the procedure done before Christmas because of the babies and the situation at home. I was actually hoping that he would go into hospital before today so that I could see how he was treated and where and how he was nursed. Unfortunately, as of this morning, he was still at home.
That brings me to the issue of post-discharge surveillance, which my hon. Friend the Member for Westbury mentioned. My constituent is at home with Staph. aureus present in a wound. He will go back into hospital and I assume that his operation will go on the end of the operating list as a dirty operation. I suspect that he will then go back into a main ward with a discharging wound with Staph. aureus, where he will be nursed by staff; he will not be barrier nursed or put in an infection-control unit and he will probably stay in a ward with other patients.
In the UK, we assess levels of MRSA simply by means of blood-borne surveillance. Would the Minister consider including a wound swab in that surveillance to attack MRSA in hospitals and bring down the number of hospital infections? As a nurse, I know fairly quickly, as I am sure does my hon. Friend the Member for Westbury, when a wound is going to break down or not repair in the way that it should, and including a swab in the surveillance would mean that we would be able to detect MRSA that was present not only in the blood, but in wounds.
To return to the code of practice, I do not say that it has no teeth out of facetiousness or to attack the Government. I am probably what one would call a consensual politician and I come at the issue purely as a nurse and as somebody who wants MRSA and all hospital-acquired infection rates to be reduced. I come at the issue as somebody with personal experience of it and as somebody who had a friend who was admitted into hospital with MRSA last year and who died of it—he was one of the recorded statistics, and those statistics need to be reduced.
This is a draft code of practice, and the Minister has the ability to go back, look at it and to put in some really solid, practical and pragmatic clauses that will do something to attack the problem. We need a strong attack to bring the figures down. We need to look at how the problem is dealt with in countries such as the Netherlands, where there is a very strong attack on hospital-acquired infections. There is also a strong code of practice, which talks about how bed spaces and wards are cleaned, the procedures for hospital linen and who is in charge of cleaning on wards, but there are no huge infection-control teams of the kind we have here. Perhaps there is just too much rhetoric and too much talking in this country and not enough people with a bucket of antimicrobials, dealing with what is causing infections on the ward.
I shall speak to amendments Nos. 114 and 99, which are in my name and that of my hon. Friend the Member for Northavon, who I am afraid has had to depart to business elsewhere. It has been interesting to listen to the contribution made by the hon. Member for Mid-Bedfordshire, who is a colleague on the excellent Education and Skills Committee, to which she has been able to bring the professional experience she had before she became a Member of this House. I was a tax consultant before I became an MP, so I confess that the issue that we just left the room to divide on is probably more within my professional expertise than this group of amendments. I shall do my best none the less.
I mentioned some of my parliamentary responsibilities. The Liberal Democrat Whips have an odd sense of humour; they have also made me a member of the Public Accounts Committee. It is interesting to look back at its past reports. The 24th report of the 2004–05 session, ''Improving patient care by reducing the risk of hospital acquired infection: a progress report'', was published on 6 April 2005. It was the Committee's last report before the general election. I will refer to a couple of points from its recommendations, which are directly relevant to the amendments that we tabled.
The members of the Committee at that time referred to the Department of Health's decision in 2001 to adopt a more limited approach to mandatory national surveillance than a previous report of the Public Accounts Committee had recommended. That would suggest that the issue has been around for a long time. Many parts of Parliament and other Committees have examined the issue of MRSA and other hospital-acquired infections, and have made many recommendations.
During my Select Committee membership it has been interesting to hear the Chairs of both Committees refer to current issues that are before Parliament and to say, ''If only the Government had taken more notice of our previous reports, Government would be so much better.'' The issue of children's food, before Jamie Oliver made it popular, would be another such example. The PAC also said that the statistics that we currently have on hospital infections are rather old in their basis. The estimate of 5,000 deaths a year is based on 1980s American data. Evidence from the review of death certificates which mention MRSA, where a 15-fold increase from 1992 is involved, is also clearly old data.
I would like to mention a final point from the PAC report. I would be interested to hear an update from the Minister on this, as we are now six months on. At the time of the report's publication, the Department of Health had still not implemented the National Audit Office's recommendation from 2000 to publish a national infection control manual, despite four years of research and consultation having been done at that point.
The clause brings forward a code of practice. I mentioned my professional expertise before I came here.
There is no reason why the hon. Gentleman should know this, because most of it happened before this year's election, but the story of the national infection control manual is a long and tedious one. The short version is that the issue was raised in the original report in 2000—not in the past six months. The progress report from the NAO in July 2004 criticised the Government for having failed to act on it.
I had meetings with the previous Secretary of State in the summer or autumn of 2004—probably in December—and tackled him on this precise question. The answer I got was pretty much, ''Well the Government and the Department have been looking at producing a national infection control manual for a long time and have found difficulty in securing a consensus on what should be in it and, in particular, on whether it should be published in written form or online. Their answer is that it should be published online. Technically speaking, such a thing virtually exists online, but certain additional material is needed. It is the very sorry story of a failure of work in response to recommendations that have been around for years. It is that lack of urgency for which we and the Liberal Democrats criticise the Government.
Amendment No. 99 calls for the code to require mandatory reporting of all occurrences of MRSA. The hon. Member for Mid-Bedfordshire effectively spoke to the amendment when she pointed out that MRSA is not just a blood-borne infection but that it can be found elsewhere. The simple purpose of the amendment is to ensure that all instances of MRSA are reported and that the data are captured.
This has been a lengthy and interesting tour de force. We have covered a number of areas and spoken widely about the code. However, one unifying theme of this large group of amendments is that, on their own or as part of the group, they would have the effect of putting inappropriate detail in the Bill. I am surprised that the Conservative party should take such a tack. I am not sure whether the amendments are probing or whether hon. Members seriously wish them to be written into primary legislation. It is not appropriate for primary legislation to set out that the code must make specific provision in certain areas, and there are several reasons for that.
First, the code needs to be flexible in order to keep its provisions in step with best practice on infection control. Priorities may change over time. Secondly, setting out the content of the code in the Bill would make it more cumbersome to revise it to take account of advances in best practice. That would increase the time that it took for patients and the general public to see the benefits of such advances. Thirdly, putting in the Bill requirements for hygiene standards for staff clothing and the recording of infection using wound swabs would be seen as an indication that we consider those measures to be more important than others such as hand hygiene and the decontamination of instruments. I use amendment No. 81 as an example, but all the amendments have that fault to a greater or lesser extent. Such an approach is not appropriate, because the essence of the proposals is that the code should be free of such legal prescription but should instead be informed by expert advice and, when appropriate, consultation.
We have never—I am certainly not guilty of it—sold the code as a miraculous set of new provisions. On the contrary, in her foreword to the draft code, the Secretary of State says that our plans are designed to give a firm statutory footing to accepted best practice. The hon. Member for Mid-Bedfordshire is right: the code is pulling into one what should already be taking place throughout the health service, ensuring that health care organisations put that best practice into effect. For me, the key clause in the draft code is 2.3.1 in which we say:
''Appropriate written policies should be in place where relevant for infection prevention and control in clinical settings. These should reflect national guidelines (where applicable) and evidence based practice and be monitored via the clinical governance system. There should be documented evidence of a rolling programme of audit, revision, and update.''
We then go on, as the hon. Member for Westbury pointed out, to list those areas in which we believe protocols are already in place. We do not spell out the protocols in the code; we expect those who are carrying them out to have the detail available. It is those protocols that will be updated in the light of new advice.
I do take the point, and it is kind of the Minister to give way. Yes, the details would be written into the protocols, but would not the funding for such measures come from a Government source? Would not the requirement for uniforms to be laundered in central hospital laundries have to be a Government directive written in a statutory code and funded as such?
Not necessarily. I shall come to hospital uniforms in a moment when I deal with the amendment. Guidance and circulars set out the way in which the Department of Health believes, based on what we know to be best practice, that standards of cleanliness, hygiene and infection control should be maintained in all the different areas. Having been provided with the resources to do that, we expect the trusts to ensure that they comply with those standards.
I want to deal with the specifics of some of the amendments.
I understand the Minister's point. We are using the amendments to try to make clear ways in which the code of practice should be reformed and, in certain respects, to identify issues that would arise even if it were to be changed, such as the circumstances under which wards should be closed for disinfection purposes and how that relates to the wider requirements placed on NHS trusts. The way that the Minister is responding implies that there have not previously been national guidelines and best practice. What happened after December 2003 with the chief medical officer's document, ''Winning ways''? Was it not incumbent on the Government to say, ''We've published 'Winning ways' and it should be acted on''? Here we are in December 2005, two years on, reinventing a process of setting out guidelines and asking the NHS to respond, which I thought was precisely what the chief medical officer did in 2003.
That quite useful intervention allows me to answer a point that we discussed earlier: why are we doing this now instead of in 2003?
The proposal for legislation to strengthen arrangements to tackle health care-acquired infections was originally made after Royal Assent had been given to the Health and Social Care (Community Health and Standards) Bill. I shall not argue with the point that the hon. Member for South Cambridgeshire and his hon. Friends have made about that Bill being an appropriate vehicle for it, but the proposal did not come forward until after it had been given Royal Assent. The chief medical officer at the time advised us that legislation should be prepared, and that advice came to us in 2004.
We have moved as quickly as practicable, promising action in our manifesto and introducing this Bill as soon as we could. If there are criticisms of the drafting of the code, the fact that it is still a draft indicates my willingness to listen, certainly to the points that are being made today. Although the consultation is closed, I am firmly of the view that parliamentary scrutiny is as important as the scrutiny given by stakeholders, to whom we circulated the draft in the normal way. Therefore, I shall read the comments that have been made and, in a spirit of being helpful, I shall consider some of the detail and see whether the code can be strengthened in some of the ways that have been proposed today.
In the spirit of being helpful, I just want to say that we are trying to help make the code better. However, that does not detract from my question. I am not talking about October 2004 and the chief medical officer's saying ''Let's have a code'', because between December 2003 and October 2004 there was the NAO report and a major effort by Opposition parties and the public to persuade the Government to do something urgent about this matter. The issue is this: why were the guidelines set out in ''Winning ways'' not acted on more urgently? Let me give the Minister one example—I raised it on Second Reading, so she should know about it.
''Winning ways'' said that one of the requirements would be to consider risk assessment and the use of hazard analysis and critical control point technologies derived from the food industry to inform NHS practice. That would be piloted and then extended across the NHS. Two years on, there is no reflection of that in the code of practice, and I have not been able to find evidence of it having been done anywhere. I am not going to let Ministers off this hook; the code of practice is not going to become year zero. We shall go back time and again to the things that the Department was told should be done and were not done. Frankly, some of them are still not being done, and the Minister will have to answer that point as well. She has said, ''Let us all work consensually on making a code that includes all the best practice'', but I repeat: this is not year zero.
Let us pause before we get too consensual. I hear the point made by the hon. Gentleman. I have listened to the comments made, and I shall read them through, more slowly, in Hansard. I shall consider whether we could include in the code aspects of what has been suggested, to strengthen it. However, we believe that the code is, to a large degree, correct. I know of the criticism that it is too infection-control focused, but that is appropriate, given why the code is being introduced. I want to turn to some of the detail of the amendments. I do not think that we are going to agree. I shall need to look up the particular example raised by the hon. Gentleman, because I am not aware of it. I know of the issue, but I am not au fait with the specific reasons why that was not considered at the time, and I want to consider the matter.
I turn to amendment No. 106. The code will certainly set out the measures that the Secretary of State considers appropriate for the NHS to take with a view to safeguarding individuals from the risks of exposure to infection. Consequently, it is not necessary to impose the requirement that the amendment would introduce. In so far as the amendment applies to subsection (4)(a), it is hard to see what effect it would have.
Subsection (4)(b) simply makes it clear that the Secretary of State has more general powers in respect of the code to enable her to set out the good practice that should be observed whenever any organisation is providing health care under the NHS. I am absolutely sure that if all the protocols were applied all the time, to the appropriate extent, in all the areas providing health care, the number of health care-acquired infections would be lower. That is why we have to have the code.
Subsection (1) of the clause allows the Secretary of State to make provision for the code to cover health care commissioned by NHS bodies; we covered that in our discussions of earlier amendments. We plan that the code should apply to such health care. If an NHS body to which the code applies commissions health care from a non-NHS body, it will have a duty to ensure that that health care is provided in line with the requirements set out in the code. Again, we are discussing that issue now, although we also discussed it earlier. We plan to ensure an equivalent level of good practice in infection control in the independent sector by using the code as the basis for new regulations under the Care Standards Act 2000.
Amendments Nos. 107 and 109 were intended to be considered in combination with and in the light of amendment No. 106. The issues raised by amendment No. 107 will be covered in the code. NHS trusts already have directors of infection-prevention and control and those posts will continue. The code will also require the appointment of a lead manager with specific responsibilities for a strategic cleaning plan. However, amendment No. 109, which builds on amendment No. 107, not only places an inappropriate level of detail in the Bill—as I have said, most of these amendments, if not all of them, do that—but introduces an inappropriate level of prescription.
Decisions on whether or when to close wards involve a wide range of considerations involving patient safety and clinical effectiveness. It is not practicable or sensible for the code to prescribe a course of action, as is proposed, in the absence of the considerations that must be taken into account. It is quite possible—indeed, probable—that such a level of prescription would endanger, not improve, patient safety. It would be irresponsible to include such requirements in the legislation.
Amendment No. 108 is another amendment that we must consider in the light of amendment No. 106. It is unnecessary. New section 47A (4)(b), inserted by clause 13, already allows the code to include provisions that will require NHS bodies to impose particular requirements relating to the control of health care-acquired infections on those from whom they commission care. Those will be able to cover a range of measures. They will not be limited to minimum standards of cleanliness, as envisaged by the amendment.
For example, we envisage that the code will refer to the—[Interruption.] Bless the hon. Member for Bristol, West. It will give guidance on cleaning, which will include advice on how to contract for cleaning services. It would be normal good practice for any contract for NHS services to include provisions for monitoring compliance with the contract, and for taking appropriate action in the event of a breach. That aspect of the amendment is also, therefore, unnecessary.
I apologise, because I might be jogging slightly backwards. The Minister says that amendment No. 109 gives an inappropriate level of detail, but it is a very important detail that is not presently covered by the code. She will know that there has been the most intense debate about the fact that the recommendation of an infection control team following the appropriate risk assessment that a hospital bed or ward should be closed should not be overridden by trust managers for reasons that are extraneous to patient safety. I put it that way because the Government have relied on the idea that, somehow, the risk assessment will not have properly incorporated all the patient safety factors that might arise from an inability to effect admission to the hospital.
Waiting times and waiting time targets should expressly not be regarded as a reason to override such a recommendation except in so far as the requirement to admit individual patients demands that the beds should not be closed. I am putting this as consensually as I can. Under those circumstances, Ministers must accept that such things have happened out there and should not happen in the future. The code should be clear about that.
I take the hon. Gentleman's point and I accept that there is a tension between the target, for example, to reduce A and E waits—because that, in some cases, leads to higher bed occupancy—and the good management of beds. However, a large number of hospitals are able to keep the waits in A and E low, and at the same time have good clinical practice in place, and good protocols that are properly observed by staff to keep cross-infection at a low level. At the same time, they are able to make sensible decisions based on clinical need at the time when an outbreak of infection is considered. It can be done.
We want it to work like that in all cases. That is why we want the code. It is no good our putting into the Bill the requirements specified in the amendment—that would be too prescriptive, as I have tried to explain. I do not disagree with the hon. Gentleman's point. There is a tension out there, and when I have visited hospitals I have discussed the requirement to keep bed management in mind when dealing with good cross-infection procedures, how those two things work together and how each hospital copes with such pressures—they are able to do it.
I am told that in this context the hospitals very much welcome the role of the modern matron, who can speak with a voice that carries weight within the organisation, who has an impact, and whose role can include, for example, balancing the needs of a busy orthopaedics department and an equally busy hospital. Such a person can ensure that the needs of the orthopaedics department, which might have to keep close control of the number of beds that are in use at any time in order to reduce infection, are met.
On amendments Nos. 99, 111 and 114 and the surveillance of MRSA and health care-associated infections, our expert advice is that surveillance should be targeted and proportionate. We do not believe that collecting information on, for example, simple MRSA colonisation or minor skin infections is appropriate. I am afraid that that is my response to the hon. Member for Bristol, West.
The hon. Member for Mid-Bedfordshire asked me about wound-swab screening. It has been suggested and we have thought about it. Bloodstream infections were chosen as the measure because information on them could be extracted from computer systems; that process did not place an extra burden on staff delivering care. Wound-swab screening is difficult to organise nationally, but it is used locally in some hospitals. It can be valuable in improving patient care, but we do not believe it is an effective way of improving surveillance.
The purpose of surveillance is to identify potential problem areas that should be investigated, which is why our reporting system concentrates on infections that cause serious illness. We do not aim to record all cases of MRSA or other health care-associated infections, but we seek to provide a consistent baseline from which to monitor trends, assess the impact of interventions and reduce infection rates. For example, we have recently enhanced MRSA surveillance data to collect information by specialty, which the hon. Member for Westbury welcomed.
Amendment No. 114 would require mandatory reporting of all hospital-acquired infections. I have already given a hint as to my view on that; in fact, I stated it fairly bluntly. The Bill does not define hospital-acquired infections, but in considering the amendment I have made what I consider to be a fair assumption: a hospital-acquired infection is intended to mean any health care-associated infection acquired in hospital. As I said, surveillance should be targeted and proportionate. The surveillance system proposed in the amendment would be neither appropriate nor desirable as the benefits of it would be grossly disproportionate to the costs and bureaucratic burden imposed on the NHS.
Amendment No. 110 would introduce a large raft of detail into the Bill. We aim to introduce a systematic approach to infection control, and setting ad hoc requirements of the kind envisaged in this amendment is not the way to improve performance. Decisions on staffing levels and facilities should be made on the basis of a local risk assessment to ensure local ownership and commitment.
I shall just quickly touch on the point raised by the hon. Member for Mid-Bedfordshire concerning the risk of infection from uniforms, about which I spoke to her briefly in the corridors. Generally, nurses and other staff would use aprons, gloves and so on to prevent the soiling of their uniforms when they are practising invasive procedures. We are not aware of any evidence that uniforms per se are a significant source of hospital infections, but we expect trusts to keep their policies under review. I agree with the hon. Lady that a nurse who came to work the following day with spaghetti bolognese on her uniform would cause me, if I were her manager, to ask whether she should have washed it or brought another one.
Generally speaking, I strongly believe that the group of amendments misses the point of the code, which, as conceived, allows for expert advice to feed through speedily and clearly to front-line staff so that real improvements can be made expeditiously. Furthermore, where the amendments attempt to clarify, they actually have the potential to confuse the intention of the Bill.
The hon. Member for Westbury asked two questions. He asked how many high-security infectious disease units there are. There are two: one at Coppett's Wood hospital in north London, and one at Newcastle general hospital. He made a point about consultants and communicable disease. The consultants, who are part of the Health Protection Agency, would be contacted by trusts when outbreaks occur. The best way to answer his question is to say that, generally, hospital doctors already employed by the trust would provide advice and care in the first instance in the event of an outbreak.
Does the Minister know how many beds there are at the two units? Also, the code states that there will be 24-hour availability. My point in mentioning that was that of course there is 24-hour availability. It is arranged by the directors of public health and cascades down to hospital doctors.
The honest answer is that I do not know the number of beds. I can find out and advise the Committee at a later date or write to the hon. Gentleman, if that would be preferable.
The code is still subject to discussions between the officials and experts who have been involved in drawing it up and the Healthcare Commission, which will have the job of assessing compliance with it. I am confident that the process will lead to a code that is effective, clear, targeted and proportionate in its approach to tackling health care-acquired infection, and I undertake to review it in the light of the conversation today and the representations that have been received. If the amendments are pressed to a Division, I call on the Committee to reject them.
I am pleased that the Minister has undertaken to review the code in the light of the extensive comments that have been made in Committee. That is the best that we can hope for. Therefore, with that in mind, I beg to ask leave to withdraw the amendment.
Amendment, by leave, withdrawn.
Further consideration adjourned.—[Gillian Merron.]
Adjourned accordingly at eleven minutes past Four o'clock till Tuesday 20 December at Nine o'clock.