Clause 17

Health and Social Care Bill – in a Public Bill Committee at 9:00 am on 17th January 2008.

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Code of practice relating to health care associated infections

Photo of Stephen O'Brien Stephen O'Brien Shadow Minister (Health)

I beg to move amendment No. 17, in clause 17, page 8, line 41, leave out ‘may’ and insert ‘shall’.

Photo of Derek Conway Derek Conway Conservative, Old Bexley and Sidcup

With this it will be convenient to discuss the following amendments: No. 18, in clause 17, page 9, line 3, at end insert—

‘(2A) The code of practice must make reference to—

(a) screening for admissions,

(b) bed occupancy, and

(c) the frequency and extent of cleaning in healthcare premises.’.

No. 19, in clause 17, page 9, line 7, at end add—

‘(3A) The Secretary of State shall publish each revision of the code.’.

No. 20, in clause 17, page 9, line 7, at end add—

‘(3A) The Secretary of State shall report to Parliament in respect of those cases where—

(a) regulations made under section 16 are breached, and

(b) the Code of Practice under this section is breached.’.

No. 21, in clause 18, page 9, line 13, at end insert—

‘(c) lay the draft code before Parliament.’.

Photo of Stephen O'Brien Stephen O'Brien Shadow Minister (Health)

The amendments build on the themes that were discussed in the debate on clause 16 to ensure effective combating of health care associated infections and clarity in reporting that to Parliament. The Health Act 2006 makes provision for the Secretary of State to issue a code of practice relating to the prevention and control of HCAIs. It was updated most recently on 11 January 2007. As the explanatory notes say, the new code will replace that code and extend it to all regulated activities, not only NHS bodies.

Amendment No. 17 queries why the drafting stands at “may” not “shall”, given the Government’s apparent commitment to the code of practice. That is such an easy one that I am hoping the Minister will get us off to a flying start this morning and accept it, without any cavil. Amendment No. 18 would include in the code action particularly on screening, bed occupancy and the frequency and extent of cleaning in health care premises.

During the oral evidence sessions, Anna Walker from the Healthcare Commission noted that the extra powers given to the commission would not have prevented the outbreaks of infection at Maidstone and Tunbridge Wells NHS Trust, a point that will be important to the discussions on future clauses. However, she noted that the key was to

“get proper infection control processes in place.”

She also said:

“if we find a trust which is cavalier about putting the right processes in, then the penalties will be helpful”,

and that the reality is

“usually more fundamental than that—the team does not understand the processes it needs in place to solve that problem.”——[Official Report, Health and Social Care Public Bill Committee, 8 January 2008; c. 24.]

Hence, it is crucial that the code of practice gets matters right and that the Committee supports the amendments.

It is reported on page 16 of the current code that it makes provision for screening for methicillin-resistant Staphylococcus aureus. The policy should make provision for admission screening, which should include screening of all elective admissions by March 2009, and for screening of emergency admissions at presentation as soon as it is practical. However, as we know, the Secretary of State has axed the Prime Minister’s promise of screening for clostridium difficile. The Committee may recall that on 6 January on “The Andrew Marr Show” the Prime Minister said:

“If you go into hospital you will get screened by next year for MRSA or C. difficile”.

That was later reported on the BBC under the headline, “Brown pledges superbug screening: All patients entering NHS hospitals in England will be screened for  MRSA and clostridium difficile”. No one from the Government sought to correct that story, but two days later on 8 January 2008, in the document “Clean, Safe Care: Reducing Infections and Saving Lives”, the Secretary of State’s infection control strategy reports on clostridium difficile that

“Screening for colonised patients is inappropriate (most potential cases would not be identified, and it requires a stool sample), and colonisation without symptoms is not considered to increase risk of transmission”.

The Secretary of State is obviously admitting that the Prime Minister was wrong. The code makes no provisions for bed occupancy other than saying that on the movement of patients:

“There should be evidence of joint working between the ICT and the bed managers in planning patient admissions, transfers, discharges and movements between departments and other healthcare facilities. Where necessary, ambulance trusts may need to be involved in such planning.”

That sounds like a handbook for shepherding patients. We have all heard anecdotal stories of patients being kept in ambulances to control hospital admissions and targets. In April 2001 in response to the Select Committee on Public Accounts the Government said:

“Health Authorities should plan bed numbers in order to achieve a bed occupancy rate of no more than 82 per cent, in 2003-04.”

After that, the bed occupancy rate went up. It is still at 84.5 per cent. and in many parts of hospitals it is way above that. In the past year, the Government have reduced the number of acute and general beds in the national health service by the largest proportion since 1982. We have seen a reduction of 6,000 acute and general beds, which has taken us down to a figure of 127,000. However, the NHS plan said that there would be an increase of 2,000 beds to take the figure up to 135,000.

Last year, The Independent said that the Department had conducted a review suggesting that reducing bed occupancy to a maximum of 85 per cent. would save 1,000 cases of MRSA a year. Just last week we heard that the Worcestershire royal hospital is running so close to capacity that it has had to cancel operations, send some patients home, send others to the downgraded Kidderminster hospital and enter into punitive negotiations with the independent sector treatment centre there. The hospital in Worcester runs with an occupancy rate that is consistently above 90 per cent.

The third factor that I have outlined should also be considered: the frequency and extent of cleaning in health care premises. As I have discussed on a number of occasions during the Committee’s proceedings, the Prime Minister’s commitment to deep clean appears to be something of a whitewash. Not only have fewer than 50 hospitals actually had the deep clean, but it is being paid for from primary care trust lodgements—the top-slicing that the Government imposed on local health economies to solve their own central financial crisis. The deep clean is important, but it is the maintenance of a clean environment through ongoing cleaning, particularly the search and destroy approach to HCAIs, which we have committed to, that would really bring down MRSA rates.

The current code of practice imposes processes and managerial structures on cleaning, rather than focusing on the nature of cleaning itself and the outcomes  required. Given that it is often the refrain of those who make rather obtuse points on the matter, I wish to state that the cleaning services at Maidstone and Tunbridge Wells NHS Trust were not outsourced; they were absolutely in-house.

Amendment No. 21 will formally give Parliament sight of the draft code, which hon. Members from all parties will want the Government to get right. As the points I have outlined show and as we discussed on Tuesday, that is an area where the Government are failing. Parliamentary debate will introduce a more effective strategy and a clear priority focus for parliamentarians and the legislature on one of the key problems in our constituencies at the present time.

Amendment No. 19 is self-explanatory. If the Secretary of State revises the code, it must be published. Amendment No. 20 is similarly self-explanatory and would give hon. Members an early warning of health care associated infection issues in hospitals across the country and in our constituencies.

As the Committee will be aware—it was widely reported on the news last night and this morning—Leslie Ash yesterday settled for £5 million, although there were some reports that it was just £500,000, with the Chelsea and Westminster hospital over her methicillin-sensitive Staphylococcus aureus suffering. Yesterday, The Times reported that legal arguments had begun in the Court of Session in Edinburgh. Judges are to decide whether the case brought by 71-year-old Elizabeth Miller, a great grandmother who contracted the MRSA superbug in hospital, should proceed to a full hearing. She is suing NHS Greater Glasgow and Clyde for £30,000, which could pave the way for hundreds of other sufferers to claim millions of pounds in damages.

Therefore, the key issue is whether, by virtue of these amendments, we would be able to give the necessary priority, focus and parliamentary scrutiny to the revised code of practice, which is required to be published by the Government. The Government themselves proclaim that they are focused on dealing with the matter. We would demand that of any Government given the desperate situations that arise as a result of hospital associated infections.

In looking at this group of amendments, I hope that the Minister will agree that screening, bed occupancy, and the frequency and extent of the cleaning in health care premises, in particular a search and destroy strategy, are key to effective control of health care associated infections. I hope that he will agree with Anna Walker that the problem is more often to do with teams that do not understand the processes that are needed to combat health care associated infections than a cavalier attitude towards putting in the right processes.

Also, why has the Secretary of State reneged on the Prime Minister’s commitment to screen for C. difficile? Why are bed occupancy rates still so high under this Government and why is no mention made of those rates under the current code of practice? Why should right hon. and hon. Members not be formally alerted when the regulations under paragraph 16(5) of the code are breached? How regularly would the Minister expect such breaches and, we would argue, reports to happen? I have high expectations that the Minister will be persuaded by those arguments and accept our amendments.

Photo of Sandra Gidley Sandra Gidley Shadow Minister, Health

I understand the motivation behind these well-intentioned amendments. I want to query a few points on amendment No. 18 because it attempts to detail what should go into the Bill. I have some concerns about the list, not because of what is in it but because of what is not. I do not believe that the list is comprehensive. For example, new paragraph (c) refers to the frequency and extent of cleaning in health care premises, but there is no mention of personal hygiene standards or the responsibility of the individual health care workers or even the antibiotic policy which, if we are talking about C. difficile, is just as important, if not more so, as cleanliness. At the moment, I feel that if those aspects are in the Bill, undue emphasis could be placed on the procedures and processes outlined in new paragraph (c), and we might not be able to tackle the overall picture. With the emerging nature of resistant infections, situations may arise which require a change in practice. We need to retain some flexibility so that we can face existing and future challenges.

Photo of Stephen O'Brien Stephen O'Brien Shadow Minister (Health) 9:15 am, 17th January 2008

I accept the hon. Lady’s fair question. In principle, I think that she is very sympathetic to what we are trying to achieve here. It is clear that a Bill that does not contain anything of this nature would look rather weak because it leaves everything for others to decide. It would be far better not to seek to be comprehensive, because things will move on and change. At this stage it is absolutely clear that the three things cited are fundamental and unlikely to change, and therefore, rather than have a comprehensive list, it is important to identify a focus of activity to allow for prioritisation. At the moment, in terms not only of the Bill but of the way in which the Government are dealing with the matter in general, this issue is not sufficiently high on the agenda, and this an attempt to raise it. I accept that the amendment could have been more comprehensive, but the danger of that is that one then ends up trying to include everything, rather than prioritising.

Photo of Sandra Gidley Sandra Gidley Shadow Minister, Health

I thank the hon. Gentleman for his explanation. I am still not entirely convinced. His timing was impeccable, as I was just about to sit down and draw my remarks to a close.

Photo of Ben Bradshaw Ben Bradshaw Minister of State (Regional Affairs) (South West), The Minister of State, Department of Health

The hon. Lady is right. As the hon. Gentleman says, it is important that we get these codes right, but as the hon. Lady pointed out, scientific advances and knowledge change continually; we are constantly developing new ways of tackling the challenges, including health care acquired infections. We all hope that some way down the track, if we continue the welcome, significant and sustained fall in health care acquired infections that the Government have achieved in recent years, we will not be worrying so much about this issue, but there may be something else that poses challenges to the health service.

The problem that I have with the amendment tabled by the hon. Gentleman is the same as that expressed by the hon. Lady. The terms of the amendment would place us in a straitjacket, which in the medium and long term could be unhelpful. I expect that it was tabled as a means for having a run-around on some of the Opposition’s old chestnuts about health care acquired infections.

Photo of Ben Bradshaw Ben Bradshaw Minister of State (Regional Affairs) (South West), The Minister of State, Department of Health

I will give way to the hon. Lady in a second; I just want to put one or two things on the record to correct errors made by the hon. Gentleman. The figure on the deep clean is 80 per cent. of hospitals, and it is already well under way. The £57 million sum for the deep clean is new money for hospitals, out of the £270 million of new money announced in the comprehensive spending review. One example of the unhelpful straitjackets that the amendments would create for the health service concerns bed occupancy rates. As I am sure the hon. Gentleman is aware, the latest research on bed occupancy shows that, although up until 2003-04 there may have been a correlation between high bed occupancy rates and MRSA, since then bed occupancy is “statistically insignificant.” That is a good example of how changes in practices and experience show that putting ourselves in a straitjacket, as the Conservatives are asking us to, could be quite unhelpful. That is true of the guidance and the issues discussed on Tuesday, such as the requirement for the Secretary of State, rather than the independent Healthcare Commission, to report to Parliament about every single little thing that is going on. As the hon. Member for Romsey rightly says, such an approach would mean putting oneself in a rigid system of being required to do things that are no longer important.

Photo of Angela Browning Angela Browning Deputy Chairman, The Conservative Party

I am somewhat shocked to hear the Minister use the expression “old chestnut” in respect of hospital-acquired infections. I am a member of the Public Accounts Committee. On two separate occasions, his permanent secretary appeared before it and if he had used that expression to it, he would certainly have been put in his place. The permanent secretary will return to the Committee within the next year on this very subject. It is far too serious a subject for the Minister to describe as an “old chestnut.” He has the option of bringing the contents of the amendment back on Report, redrafted by his officials. If he feels that this issue will disappear in a few years’ time—I hope that he is right—something approaching a sunset clause would be appropriate. In other words, let us put it in the Bill because it is important, not an “old chestnut”, and if in five or 10 years it is no longer regarded as necessary, the wording of a sunset clause would mean that it would die a natural death as the need for it disappeared. This issue is serious, and I hope that the Minister will talk to his permanent secretary about his experience before the Public Accounts Committee. I doubt that he thought that it was an “old chestnut”.

Photo of Ben Bradshaw Ben Bradshaw Minister of State (Regional Affairs) (South West), The Minister of State, Department of Health

The hon. Lady, inadvertently I am sure, misunderstands my point. I was not saying that the issue of health care acquired infections is an old chestnut—it is an extremely serious issue and that is why it is in the Bill, and why the Government have a £270 million programme to tackle it. It is why I welcome the significant and sustained falls in health care acquired infections that we have achieved in recent years, and I hope that that continues. However, it would be wrong to issue guidelines that are so specific that they are inflexible with regard to the new, independent Care Quality Commission, which we are setting up to help us continue to drive down infection rates.

The “old chestnuts” that I referred to are some of the issues that are regularly raised by the Opposition, based, I believe, on a misunderstanding or an out-of-date understanding of our progress on health care acquired infections. I gave the example of bed occupancy. I am not suggesting for a moment that it is not a serious issue; it is. The Government are tackling it, and we are making welcome progress. There has been a 10 per cent. reduction in MRSA in the last year, a 7 per cent. reduction in C. difficile, and a 32 per cent. reduction in health care acquired infections overall since the base year of 2003-04. I want that progress to continue, but it will not be helped by putting the new independent body into the straitjacket provided by these amendments.

Photo of Anne Milton Anne Milton Shadow Minister (Health)

I welcome the Minister’s reference to the science, and I would be grateful if he gave us the source of the information about bed-occupancy rates. One of the problems with the treatment of health care acquired infections is that precious little science is used. It will be interesting to see what happens next year—when there will not be £270 million, and when PCTs and trusts will have to make their own decisions on where they spend their money—and whether it is felt that the deep clean was worth it and should be prioritised.

Photo of Ben Bradshaw Ben Bradshaw Minister of State (Regional Affairs) (South West), The Minister of State, Department of Health

The research that I referred to is a public document published in December—the McCormick report. However, the hon. Lady is absolutely right. I do not want to detain the Committee by going through the entire list of things that have been happening and are happening to help us make this progress, but it is important that we have sustained investment. That is why we welcomed the comprehensive spending review settlement, which is very good as far as our Department is concerned and constitutes a 4 per cent. real increase in spending in the health service for each of the next three years. I am not sure whether the Conservative party is still committed to meeting that spending.

Returning to the substance of the amendments, I do not think that they would be helpful. I understand why they were tabled—to give the Opposition a chance to repeat the inaccuracies that were presented to us on Tuesday—but they would be unhelpful in our efforts to continue the sustained progress.

Photo of Stephen O'Brien Stephen O'Brien Shadow Minister (Health)

I suspect that the rest of the Committee, if they would wipe the smiles of their smug faces, would be equally disturbed and appalled by the Minister’s performance. We could do without smug party points. We are dealing with the deaths of 270 people at Maidstone and Tunbridge Wells that could have been avoided with better procedures. That was a disgraceful performance by the Minister, and I am shocked.

Photo of Judy Mallaber Judy Mallaber PPS (Rt Hon Baroness Ashton of Upholland, President of the Council (Leader of the House of Lords)), Privy Council Office

Is the hon. Gentleman seriously suggesting that it is disgraceful to try to promote part of what is being done to deal with this very serious issue? Every member of the Committee agrees that is a very serious issue; is it really disgraceful to point out where we have made, and are committed to continuing, improvements, and to put that on the record?

Photo of Stephen O'Brien Stephen O'Brien Shadow Minister (Health)

We all wish to see the best measures to tackle this. What we do not like is the smug approach taken by a Government who know that they have an  inbuilt majority, and who therefore think that the entire procedure of scrutinising the Bill is a waste of time and rather wish that they were not here. Far from it. We are absolutely committed and very sincere about the amendments and we shall be voting on them. This is not a game to get some happy little comments on the record. It is a serious question of trying to get the best performance and prioritisation for dealing with this issue in parliamentary terms. This has become serious because of the tone and attitude of the Minister in responding to a matter of this seriousness. We should recognise, on the record, that that should be repelled.

Photo of Richard Burden Richard Burden Labour, Birmingham, Northfield

May I clarify the hon. Gentleman’s intentions? If I understood his reply to the hon. Member for Romsey, he acknowledged that his amendments may well be defective.

Photo of Richard Burden Richard Burden Labour, Birmingham, Northfield

Ah—so the hon. Gentleman thinks that the list in amendment No. 18 is complete and comprehensive, and that is why he wishes to press it to a Division. If the amendment is defective, he should withdraw it; if it is not, he should press it to a Division. Which is it?

Photo of Stephen O'Brien Stephen O'Brien Shadow Minister (Health)

I am sure that the hon. Gentleman was listening when I responded to the hon. Lady. I said that the purpose of the amendment was not to be comprehensive, but to highlight and prioritise matters on which Parliament must focus.

Of course, the amendment would give flexibility. We have the Report stage and the Bill will be scrutinised in another place, so the Government could recognise that they can tweak it. If they do not tweak it, and if they choose simply to resist and to make the measures generic and unspecific, that raises questions about the prioritisation of, and focus on, the requirement for accountability to Parliament. There should at least be a tie-in with the Public Accounts Committee, as my hon. Friend the Member for Tiverton and Honiton so ably pointed out, so that there is annual scrutiny, not least in the person of the permanent secretary. We need to tie-in the prioritisation of parliamentary accountability rather than relying, as we will under the Bill, on an Executive who seem not to take the measure with the seriousness that it deserves. They seem to think that the intention behind the amendments is partisan point scoring, which it quite patently is not. I rest my case.

Photo of Sandra Gidley Sandra Gidley Shadow Minister, Health

I think that the hon. Gentleman would be best advised to rethink the matter on Report. I am concerned about unintended consequences. For example, if we are too prescriptive about bed occupancy regulations, we could create a conflict. When a person is in an emergency situation, will a hospital official say, “We cannot accept you because we would be in breach of the bed occupancy regulations”? That person could die not because of MRSA, but because they had to be moved to another hospital. Whatever capacity any Government build into the health system, those situations will arise. The hon. Gentleman must think through all the consequences of the amendment. It is well intentioned, but we need to ensure that the situation I described does not arise.

Photo of Stephen O'Brien Stephen O'Brien Shadow Minister (Health)

I am grateful to the hon. Lady, but the amendment states:

“The code of practice must make reference to”.

So the measure would not be exclusive; rather, the intention is to draw attention to prioritisation. Furthermore, if the science says that bed occupancy rates are indeed leading to MRSA, she cannot surely be suggesting that a hospital should accept a person if that would lead to their getting MRSA. On the contrary, the whole point of the science is that it should be a matter of judgment if someone who should otherwise obviously be accepted into a hospital is almost certain to contract MRSA.

Photo of Stephen O'Brien Stephen O'Brien Shadow Minister (Health)

I am not going to give way because the principle at stake in the amendments is clear. They would prioritise what the code of practice refers to. They would not provide an exclusive or comprehensive list, and they would not restrict flexibility, but we do not want the Government to feel that they can simply be trusted to do the right things at the right time, because their track record so far is deeply disappointing.

I am disappointed with the tone and substance of the Minister’s reply, so I shall press the amendment to a Division.

Question put, That the amendment be made:—

The Committee divided: Ayes 5, Noes 10.

Division number 6 Nimrod Review — Statement — Clause 17

Aye: 5 MPs

No: 10 MPs

Ayes: A-Z by last name

Nos: A-Z by last name

Question accordingly negatived.

Clause 17 ordered to stand part of the Bill.