‘which arises as a result of healthcare interventions, either in patients undergoing these interventions or in health care workers involved in these interventions.’.
Good morning, Mr. Illsley. I hope that we can now make fast progress because there is a lot to cover in the remaining six sittings, and we may not reach some issues if we do not do so. I shall try to be as brief as possible.
Amendment No. 100 relates to worries expressed by the Royal College of Nursing about the definition of heath care-acquired infections. I an interested in the basis for the definition under the Bill because it seems slightly at variance with that used by the Health Protection Agency, which states:
“Healthcare-associated infections are those that arise as a result of healthcare interventions, either in patients undergoing these interventions or in healthcare workers involved in these interventions. A wide variety of organisms can be transmitted in healthcare settings, causing in turn a wide range of different diseases.”
Did the hon. Gentleman say that we had six sittings left? I keep looking at the motion and thinking that there are four, including this one.
It is wishful thinking. The hon. Gentleman is right. There are four sittings left, so what I said was only a 50 per cent. exaggeration.
Anyway, back to health care-acquired infections. There are two definitions, one used by the HPA and one used in the Bill. Will the Minister explain why the definition is as it is in the Bill? The RCN says that we need first to understand what infections would be transmitted or spread anyway and what infections relate to health care actions. It is fair to say that members of the Committee do not want to exaggerate. We do not want to sensationalise. We do not want people saying, as they say to me sometimes, “I don’t want to go into hospital because I’ll catch something.” We do not want people to be so afraid of, or so concerned about, the national health service that they think it is bug-infested and do not want to go near it. There must be a sense of perspective and proportion.
The amendment would make the distinction between, for example, an infection brought into hospital by a patient, which becomes observed only in hospital, and an infection that is associated with a health care action. That is a relatively simple distinction, but has the Department assessed the extent to which infections that are identified on NHS premises are the cause of health care actions and the extent to which they are methicillin-resistant Staphylococcus aureus or something else that has been brought in and identified during a person’s course of treatment, but is not a health care-associated infection because the person already had it? I am not talking about health care action such as a dirty ward but about an infection that was brought into the hospital. The statistics for such infections are aggregate. No distinction is made in respect of the original source.
Has the hon. Gentleman observed the suggestion that people should be screened pre and post-admission? Does he agree that that might solve the conundrum? I suspect that the Minister will say that she does not have the information that the hon. Gentleman seeks. My suggestion would supply the information.
Superficially, pre-admission screening is attractive. We have discussed that briefly in Committee, at which time the Minister said that the cost-effectiveness of the screening processes had not been demonstrated. I am open to the suggestion. The private sector can take such action more often because it is dealing with planned admissions and elective surgery, whereas the NHS is, to some extent, the victim of having to take anyone who turns up at its door. If such action can be proved to be clinically effective and cost-effective, I shall be open to the suggestion. It would help the point that I am making.
Why is the definition in the Bill different from that used by health bodies? Can we distinguish between infections acquired as a result of health care intervention and those that are identified in a heath care setting? Can the Government give some assessment of the balance between those two sources of risk?
It is a great pleasure to serve under your chairmanship once again, Mr. Illsley.
The hon. Member for Northavon (Steve Webb) said that he hoped we could rattle through the remaining parts of the Bill. I also hope that we shall make some progress because, as he said, at the moment we are in danger of not reaching some of its important bits. Not to reach them would be a great pity, would it not?
If I may leap to the Government’s defence, amendment No. 100 seems somewhat redundant. As I read it—shortly, the Minister will be able to clarify her intentions—the Bill covers the eventuality to which the hon. Gentleman referred. Occupational health is important and the issue of the transfer of organisms from patients to practitioners, health care workers and people in general in hospital settings is important for two reasons: first, because those people may become ill and secondly because they may unwittingly transfer bugs to other people—patients or otherwise.
I understand the hon. Gentleman’s intentions. They are good ones, although, as I said, my reading of the Bill is that it covers the eventualities to which he referred; shortly, the Minister will clarify. Furthermore, the guidance notes are very good and comprehensive, although perhaps I shall regret saying that. They are helpful and assist us in this matter.
The hon. Gentleman did not mention some of the more catastrophic infections that face our health service. Last week, I raised the issue of viral hemorrhagic fever. It is important fully to appreciate the risks that people working in the health service face as a result of their occupation; perhaps we have neglected that. As we face an increasing threat from more exotic, but nevertheless devastating, infections, it seems appropriate that we should bend our minds towards how we might protect those who work in the health services in processes that are very difficult to control. In the context of occupational health, such infections create unusual circumstances for which there are no procedures. Each one of them is unique, and that means that risk is maximised.
The hon. Gentleman has, perhaps unwittingly, done us a service in prompting us to think not just of patients in the context of hospital-acquired infections but of those who work in the health service. For that we should be grateful. I hope that in a minute the Minister will say that she appreciates the hon. Gentleman’s intentions, but that his concerns are covered in the Bill—and, if not there, in the guidance notes.
I am tempted to say that I could not have put it better myself. I shall speak very briefly. It is worth saying that the definition is simple and straightforward. Health care-associated infections are those acquired in connection with health care; that definition is much broader than that of a hospital-acquired infection.
However, I acknowledge the concerns raised by the RCN and I understand the reason for the nature of the amendment. We acknowledge that the burden of health care-associated infections has been mainly on hospitals, where more serious infections are seen and where it is estimated that at any one time 9 per cent. of all in-patients have acquired an infection while in hospital. We are also interested in screening; I do not want to dismiss the concept out of hand. We are testing different methods of screening to ascertain whether there are ways to screen for MRSA, for example, in a cost-effective way that will produce results and reduce the risk of passing on the infection in hospital.
The amendment tabled by the hon. Member for Northavon would restrict the definition to the detriment of patient safety. For example, it would exclude infections caused by environmental factors as opposed to actual clinical procedure. Examples of environmental factors are inadequate ventilation or decontamination failures in the hospital. It would restrict the scope of the code to infections that are caused by health care interventions. As the objective of the code is to require an NHS body to carry out a risk analysis and develop systems to protect patients, staff and visitors by minimising the risk of health care-associated infections, the amendment would not benefit the Bill. I hope that the hon. Member for Northavon accepts that explanation.
I am grateful to the Minister for that response, but it raises a question. If the Health Protection Agency uses a narrower definition, similar to the one in the amendment, but the Bill proposes a broader definition, should she go back to the agency and suggest that its activities be broadened in scope because they are unnecessarily narrow? That is an interesting question.
I notice that the Minister did not offer an answer to my question about the Government evidence on the distinction between infections acquired in the health care setting and those brought in. That is an important distinction to make, because if we want effective measures to be in place to tackle infections, we need to know where they are coming from. It is interesting that the Government appear not to know, or certainly the Minister did not tell us, what the balance is on those two fronts. However, we have had a useful discussion to kick off the debate and I shall not press the point. As I said, I am grateful to the Minister for her response. I beg to ask leave to withdraw the amendment.
We have had quite an extensive debate on the clause and it would perhaps be wrong of me to repeat what has been said. Thursday’s debate was certainly an enlivening experience for me, and we covered a great deal of ground. However, I would like to put a few points to the Minister before we take a decision on clause 13.
The crux of the matter is the code, which is a bit of a mixed bag. It is a rather non-specific document; it has a lot of generalities, many of which we covered on Thursday. The question is to what extent the code adds anything to our fight against the range of infections that we are considering. We are left with the view that, as drafted, it does not do so. We hope that when the definitive document is produced in the fullness of time, it will be a little more helpful to those on the ground who are expected to carry forward the fight against hospital-acquired infections. The early draft, as I said fairly unequivocally on Thursday, does not give us a great deal of hope that that will be the case.
In debating the clause, we have proposed a number of amendments that would materially have assisted thed¤Government in producing legislation to help our fightd¤against hospital-acquired infections. The Government, having politely listened to our suggestions, declined to recommend them to the Committee, as is their prerogative, but we may well have to return to at least some of them later. I hope that when we eventually get the legislation and, subsequently, the code, it will lay out precisely what people should be doing to tackle hospital-acquired infections and that they will have something that will be useful to them and give them a sense of direction.
When I talk to health care professionals about the issue, they tend to say to me, “The Government appear to be devolving the responsibilities to us, but there seems to be little in the way of concrete guidance.” We have suggested that there should be a manual of hospital-acquired infection control. If the Minister does not want to lay all this down in the code of practice that emanates from the legislation, she should at least give some consideration to a definitive text, so that best practice throughout the health service can be pulled together. Such a document would of course have to be updated regularly, because this is a changing science, but it would be useful for people to refer to. Of course it would not have any statutory force; it would have force only as a text. As things stand at the moment, if there is a case against an individual or a hospital, standard works can be cited in defence or otherwise. The document would merely have that kind of strength, but it seems appropriate to produce such a volume to give guidance to people who are carrying on the fight against hospital-acquired infections.
We are concerned about the recording of data. The Government are, rightly, recording hospital-acquired infection data—MRSA data, specifically—by hospital, by institution. That is very good, but for data to be useful, they must be broken down to an appropriate level. Given the nature of large hospitals, data apportioned according to hospital may not prove that helpful. We all know that our constituents will give us mixed reports on hospitals. They may tell us that the cardiology or dermatology department is spotless, but that paediatrics is dreadful. We know from evidence that has been collected that cleanliness in hospitals can be a mixed bag. Therefore a hospital cannot be considered as a whole.
It would be expedient to break down data according to the department, ward, or unit in order to control hospital-acquired infections. Indeed, for reasons that I discussed on Thursday, we should break them down even further under certain circumstances, especially in areas in which we know there to be a risk of health care-associated infection. For example, if we attribute certain infections to an individual practitioner, one can identify and deal with specific problems. Data that are collected from a ward or department raises the question of what on earth we should do about those that are above or below average. We must decide why exactly that ward or department is an outlier. That can be done by ensuring that it is clean. If it is dirtier than the norm, one can deal with that.
We must be cleverer than that, however. I suspect that the cause of many infections is the practices of an individual. Indeed, the prevention of many infections will be as a result of an individual’s good practice. The problem can be dealt with only by collecting individual-level data. We can learn from cases in which a particular individual is performing better. By doing that, we can improve best practice.
Referring again to our proposed manual of hospital-acquired infection control, to which the Minister might wish to give some thought at some point, it would be a manual of best practice.
I am following the hon. Gentleman’s argument with interest, but I am a bit puzzled at the notion of individual-level reporting. Many health care professionals are involved in the care of any given patient. If one nurse has practised bad infection control, should everyone who has come into contact with or served the patient a meal be listed, or even blacklisted?
No, I am not saying that at all. That is an entirely predictable question from the Liberal Democrats. On Thursday, I gave the hon. Gentleman an example from my practice related to urinary tract infections. In such high-risk procedures, it is appropriate to determine why one individual produces better results than another. The hon. Gentleman furrows his brow, but he has been around for the past year or so when Ministers have presented those data in league tables. He must know what I mean.
A critical outcome is where someone contracts a urinary tract infection. That can be devastating. It is important that we know which individuals are performing well and which are performing less well. Collected data may show a high level of infection in a department in which many high-risk procedures are carried out. We are then left asking ourselves why there is that high level of infection. It prompts the question, “Who is responsible for this and what are we going to do about it?”
There is no point in collecting data for the sake of it unless those data will be put to some use. In order to do that, one must know who is involved with those data-collecting procedures. The hon. Gentleman may have a better suggestion, but I cannot think of a better way than recording data at an individual level to deal with problems or, as I have taken some pains to explain, to identify particularly good practice. That information is needed if we are to drive up standards.
I suggest to the hon. Gentleman that the worst possible thing would be to gather data that is largely useless. If data is to be gathered, it should be the right data, containing sufficient detail. That is the crux of what I am saying to the hon. Gentleman. It would be highly redundant to collect such material in respect of every clinical department; manifestly, that would be a gross waste of resources. However, in areas which are known to be high-risk, where in the general run of things there will probably be a fair number of hospital-acquired infections, it would be helpful to be more specific about the sort of data that is gathered.
Perhaps in a spirit of consensus the hon. Gentleman and I can find some common ground. I agree with him that statistical information at trust level is insufficiently disaggregated, but I struggle with the notion of ascribing things to an individual, whether the hon. Gentleman means a consultant or another individual. For example, if bad nursing practice is the cause of an infection, there is a danger that an individual consultant may, wholly unfairly, get “bad figured” and be at the bottom of a league table. Surely, we should identify where within a trust there is a problem and have a look at what is going on in the entire system, rather than just trying to tabulate and ascribe problems to named individuals. Departments and wards should be considered as a whole; it is the individual concept that I have trouble with.
I understand precisely where the hon. Gentleman is coming from. To judge from his earlier amendment, he has been discussing the matter with the organisations that represent individuals. He does not want individuals to be blamed or a blame culture to emerge, and I agree with that. However, it is individuals who provide health care, within teams, of course, but at the end of the day, individuals manage patients and, generally speaking, they do it extremely well.
We are discussing hospital-acquired and health care-associated infections and health care is provided by individuals. If there are problems or if there is good practice it is down to individuals, not to amorphous teams. I thought that I had made it clear that it would be redundant to undertake the kind of exercise suggested in, for example, a dermatology out-patients department; it would not be a very good use of resources. But in urology, the potential for health care-associated infections is quite high and it is individuals who do catheterisations, as I said at our last sitting. If there is a problem, it is down to the individual carrying it out.
Of course, but I am not exactly sure what the hon. Gentleman thinks I am suggesting. I am certainly not proposing a witch hunt against persons; I am trying to impress on him, but he does not seem to grasp, that infections are because individuals do not comply with best practice. That is precisely the problem that I am trying to get round.
The hon. Gentleman, in a way that is typical of his party, is keen on showering us with warm words; I suspect that he roundly approves the code of practice, which is full of words but has very few teeth. My constituents and those of the hon. Gentleman—we share a major hospital—are concerned about what is being done to address the infection that they or their nearest and dearest may contract when they are admitted to hospital. We need to identify where there are problems and take action to sort them out. That is not the witch hunt that the hon. Member for Northavon fears; it is identifying those who are not complying with best practice and re-briefing and retraining them.
I certainly accept that whole systems often need to be looked at, and that is why we must gather departmental data. However, I underscore the fact that, in my experience, it is a departmental, rather than a whole hospital, issue. I am sure that the hon. Gentleman will find common ground with me from his experience of the Royal United hospital, Bath. At the end of the day, it is individuals who deal with patients and individuals who implement best practice. Some of them may do less well, and when that is the case, there is obviously potential for health care-associated infection. That is my point. He may, on reflection, agree with me; if not, I suggest that he contacts the chief executive of the RUH, asks for an in-detail tour of the hospital, and views some of the high-risk procedures. He might then more fully understand what I am trying to get at. I think that we have exhausted this line of debate, so unless the hon. Gentleman wants to intervene on me to explore my thoughts further, I shall move on.
My hon. Friend the Member for Mid-Bedfordshire (Mrs. Dorries) is delayed, but I agree with the purpose behind her amendments. She described the difficulty with laundry in certain areas. I elaborated on that from my personal experience of 20 years of practice. I was fairly frank in my admission that during my time as a junior hospital doctor, hygiene standards were not what one might expect. I hope that things have greatly improved—indeed, from my observation, I think that they probably have. Certainly, the subject of hygiene in general is better covered than it was 20 years ago. I am sure that those now training in medicine, nursing and other health care professions are briefed quite well on their responsibilities to maintain hygiene and cleanliness.
However, my hon. Friend’s reference to her nursing colleague, who had spilled the previous evening’s dinner down her dress, was graphic. Many of our constituents are concerned about the cleanliness and presentation of health care staff, so my hon. Friend’s remarks were well made. On hospital laundry, it is important that the Minister understands that if uniforms are to be adequately laundered, we need some sort of central provision. It is simply inadequate to expect individuals to take care of that; they are busy people with demanding careers who lead frantic lives. With the best will in the world, and although we wish it otherwise, laundering often tends to get neglected.
If we live in the real world, as I hope that we do, it is important to investigate how we can help individuals to ensure that their uniforms are up to an acceptable standard of cleanliness. The Minister might say, “Ah, there’s another Conservative spending commitment,” but the fact is that health care-acquired infection—
Order. I apologise for interrupting the hon. Gentleman, but both hon. Members who have spoken this morning made reference to the fact that we are in the ninth of 12 sittings, and we need to make progress. We Chairmen have been generous in allowing a clause stand part debate on this clause, which has already been extensively debated in discussing amendments to it. We are less than a quarter of the way through the Bill, so I strongly recommend that Members make their speeches a little more concise.
I am extremely grateful for that advice, Mr. Illsley. Your colleague generously allowed a discursive debate on Thursday, and I promise not to test your patience too much. However, we are addressing important issues; this is an important part of the Bill. Health care-associated infections exercise many of our constituents, and we need to explore the subject comprehensively—thus the extent of my remarks. However, I am coming towards the end of them.
I hope that, even at this late stage, the Minister will consider giving some beef to the clause. If she is not minded so to do, which seems to be a real possibility, I hope that when she draws up her definitive code, it will be more helpful than the document that she has produced in draft for us. That document is full of warm words, and I accept that it has good bits, but it needs to be specific if it is to do anything to tackle health care-associated infections.
The hon. Member for Westbury (Dr.d¤Murrison) was right to question the nature and the point of surveillance. Does my right hon. Friend the Minister intend, in due course, to use the clause to impose a more comprehensive system of surveillance in the national health service for health care-associated infections, and if so, is she satisfied that the clause is sufficiently widely drawn to enable her to do that?
I have been assisted in thinking this issue through by postnote 247 of July 2005 from the Parliamentary Office of Science and Technology, headed “Infection control in healthcare settings”. The current mandatory surveillance started in 2001 when the Department made mandatory the surveillance of methicillin-resistant Staphylococcus aureus blood infections. In 2003, we also made mandatory the surveillance of glycopeptide-resistant enterococci, and in 2004 we made mandatory the surveillance of clostridium difficile. I hope that I have pronounced those conditions correctly.
Many hospitals also continue to use the nosocomial infection national surveillance scheme—NINSS—which was established by the last Conservative Government in 1996. NINSS is a voluntary scheme, using standard surveillance methods in hospitals in England to provide information on all health care-associated infections. However, there is still no national mandatory surveillance scheme for all infections. The different surveillance schemes that exist do not present comparable data. Also, a lack of information technology in some trusts means that surveillance sometimes cannot be carried out. Therefore, the overall extent of health care-associated infections remains difficult to gauge. The Public Accounts Committee has looked into the matter twice, and has recommended that there should be a national surveillance scheme, perhaps building on NINSS, and that it should be mandatory. In response to that, the Department has commissioned a national survey of all infections that is due to report in 2006.
Problems associated with the diagnosis of these infections can also compound issues associated with the surveillance of them:
“when a patient’s sample is sent for diagnosis, different laboratories use different methods for detecting HCAIs. This means that what might be reported as an HCAI by one laboratory might not be reported as such by another. Experts are calling for regulation to be introduced, recommending the use of certain tests over others.”
Does the clause allow the Minister, when the survey is completed in 2006, to say that a more robust national mandatory system of surveillance can be brought in, and that, under the code, it can be enforced by the Department? According to my reading of the clause, that will be possible because it addresses itself to all English NHS bodies—to any body that carries out surveillance for the Department. Proposed new section 47A(5) states that the code may
“operate by reference to provisions of other documents”.
Therefore, if the Minister has introduced a new scheme for surveillance, that could be referred to in the code, and thus be taken into account. Is my right hon. Friend the Minister satisfied that if that is what she intends to do in the future, the clause will allow her to do that?
We have had a thoughtful clause stand part debate. In response to my hon. Friend the Member for Stafford (Mr. Kidney), I tell him that the clause does not need beefing up. It is beefy enough, and will do what the Government want to do about surveillance at this time. The way we are taking it forward will allow flexibility, so that if we decide to go down the route that he mentioned, we will be able to do so.
The clause is the cornerstone of the Bill’s health care-associated infections provisions. It adds three important new sections to part 2 of the Health and Social Care (Community Health and Standards) Act 2003, chapter 2 of which is concerned with, among other things, the quality and standards in NHS health care. The power to issue a code of practice on the prevention and control of health care-associated infections involving the NHS is extremely important.
While my hon. Friend the Member for Stafford, the hon. Member for Westbury and others have urged us to consider the surveillance of all infections, we must resist the temptation to do that just because we could. We must not overburden the health service with an overly bureaucratic structure that is not necessary for the purposes of patient safety.
On the point that the hon. Member for Westbury raised about a manual, as a result of some research we concluded that professionals did not want a manual as such. We have set up a web-based national resource for infection control. As with all things in the health service, it has an acronym, which is NRIC. It is a simple way to access all the infection control advice and guidance that is available to the health service.
I do not recognise the description “chaos” in relation to the Connecting For Health programme. I undertake to ensure that the website is a robust one, which will be the useful tool that we intend it to be for health service professionals.
We are beginning to break down the MRSA data that we are getting by clinical department. More detailed analysis can be done at hospital level, but for the purpose of improving patient care locally it would not be appropriate for us to require the health service to provide the information nationally, given our current IT systems.
The code will bring together the best practice that has been developed in tackling health care-associated infections. Through the statutory nature that we are giving it, we will ensure that best practice becomes embedded at all levels of the NHS. The clause places a duty on everybody to observe the provisions of the code as part of their duty of quality in health care under the Health and Social Care (Community Health and Standards) Act 2003.
In our debates last week and in this morning’s one, much consideration has been given to the central part of the health care-acquired infections measures in the Bill.
The Minister seems to have contrasted the position of the current requirements on mandatory surveillance, as illustrated during the debate, with the proposition that every infection should be the subject of mandatory surveillance.
There are significant areas of infection. The Government have started the process of mandatory surveillance of orthopaedic surgical site infections. It would be possible, and probably not onerous for the NHS, but helpful for it, for surgical site infections to be the subject of mandatory surveillance. I believe that my hon. Friend the Member for Mid-Bedfordshire raised this point. Will the Minister undertake to consider whether to extend the mandatory surveillance at least that far?
I am always willing to listen to sensible proposals. I am currently content that the mandatory requirements are all that is necessary. However, I am willing to examine the points that have been raised, including those made by the hon. Gentleman, and take them into consideration. Although the consultation period has ended, over the Christmas break I shall consider what has been said about the code today and last week, to see whether improvements can be made to it. I am grateful to all the members of the Committee for the contributions that they have made.