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I thank my constituent, Rosemary Edwards, for allowing me to raise this matter today; I know that it is a painful subject for her and her brother. She has two major concerns: first, she wants to know how the incidence of MRSA can be reduced in hospitals; secondly, she is concerned about how St. Helier hospital dealt with her and her brother's complaint about the way their father was treated. Her father, Mr. Thomas Alun Charles Edwards, first became an in-patient at St. Helier hospital on
Methicillin-resistant Staphylococcus aureus, or MRSA, is part of a wide range of infections that can be found in hospitals. Those include methicillin-sensitive Staphylococcus aureus, which the actress Leslie Ash recently contracted. As the Minister will know, there has been a sharp increase in the number of cases of MRSA. According to a report published in The Times at the weekend, the number has risen from 114 cases in 1992 to 5,561 cases in 2003. There has also been an increase—albeit not so significant—in the number of cases of MSSA, which have risen from 4,373 to 7,886 in 2003.
The Minister will be aware of graphic headlines in the Evening Standard last week, referring to hospitals in the grip of killer superbugs. It is important that we understand that we are talking about MRSA and not—as we suspect that the Evening Standard did in its analysis—methicillin-resistant Staphylococcus, not aureus. We need to understand what the risk really is and deal with it accurately. It is important for my constituents that we get clear information.
I thank my hon. Friend for her intervention. It is important for her constituents that the information is accurate.
The UK has a relatively high level of hospital-acquired infection. The cost, in health terms, is very high. One in 10 patients has some kind of health-care acquired infection. In financial terms, the cost is estimated at about £1 billion a year, according to the National Audit Office. Infection control programmes are cheap in comparison; it is the equivalent of maintaining one hospital bed a year per 250-bed hospital. In other words, the cost of one patient suffering MRSA and being kept in hospital for a year is the same as that of ensuring that the full 250-bed hospital is kept as clean as possible.
The Government recognise the issue of MRSA. Their document, "Winning Ways: Working together to reduce Healthcare Associated Infection in England", published at the end of last year by the chief medical officer, confirms that the national health service does not perform as well as the health services of other European countries. There are evidence-based countermeasures of known effectiveness that are not being implemented consistently or rigorously in the majority of hospitals.
I said that I would concentrate on MRSA, rather than the more specific complaint, but it is worth pointing out that my constituent was made aware of her father's MRSA diagnosis from a piece of paper that was accidentally left by his bed. Clearly that is not an appropriate way to be informed of such a serious complaint. It is also important to note that according to the death certificate her father's death was not caused by MRSA, but by coronary artery disease. However, MRSA was likely to have been a significant contributory factor.
What is MRSA? It is spread mainly through hand contact, but some people carry the bacteria on their body and are not infected by it. It often occupies the skin and nose of humans and only becomes dangerous if it finds deep tissue. It is easily spread because it moves with the skin. It can be washed off with soap, but disinfectants do not rid surfaces of it. As hon. Members will know, MRSA infections are resistant to treatment.
What has St. Helier hospital been doing in response? It holds training sessions for staff. It has an awareness programme about hand washing for staff. Back in October 2002, when we first received a comprehensive response from the chief executive about the different things that the hospital had undertaken, there was talk of providing information leaflets about MRSA. I rang yesterday to check on the progress. I was told that the leaflets are now at the printers. Bearing in mind that this letter was from October 2002, I hope that being at the printers is not the equivalent of the cheque in the post. Clearly a long time has elapsed since the original commitment was made.
If a patient is found to be carrying MRSA, the hospital carries out a risk assessment. The patient is isolated or moved to an infection control ward if it is felt that a spread is likely to occur. Could the Minister tell us about the availability of such isolation areas? She may not be able to do that now in relation to St. Helier hospital, but perhaps she could tell us in general terms. Finding places within hospitals where sufferers can be isolated has been an issue. The hospital treats with mupirocin cream, but is limited to two courses because of MRSA resistance. During my conversation with the trust yesterday I was given assurances that it was making the progress that was needed against the different infection control indicators.
The hospital clearly has a responsibility here, but so do the Government. The Government's actions are set out in the "Winning Ways" report, to which I have referred. It is worth considering some of the progress that has been made in relation to the report. For instance, according to action area one—"Active Surveillance and Investigation"—the chief medical officer will publish on his website a listing of rates of health care associated infection in each area of the country. The availability of information and people's awareness of MRSA levels are of concern to my constituent.
I am perhaps no longer an expert in IT terms, having left the industry seven years ago. However, a cursory search of the chief medical officer's site yesterday did not reveal an area-by-area listing of rates. The Minister's officials may say that it is there and that I was looking in the wrong place. I should be interested to know whether that information is available. Another key point in action area one was the requirement to carry out a national audit of deaths from health care-associated infections. Until we have carried out that audit, it is impossible to say how many deaths are associated with such infections.
Action area six on management and organisation described key points to which the different trusts needed to respond. It stated that the chief executives of the trusts will
"designate the prevention and control of healthcare associated infection as a core part of their organisations clinical governance and patient safety programmes", that
"a Director of Infection Prevention and Control is to be designated within each organisation", and that the Department of Health will publish further guidance. I accept that "Winning Ways" was published at the end of last year and we are only in May, but I hope that the Minister can reassure me that progress is being made on these matters and that she is starting to receive information from different trusts confirming that these action points are in hand.
My constituent raised other issues about her father's treatment in hospital, such as poor communication with doctors, hostility of staff in certain instances, and the deterioration of his health while in hospital, but I want to focus on MRSA. To avoid MRSA becoming an even bigger problem, we should examine new techniques that might be more effective at addressing it. Can the Minister say whether the Government have looked at the Bioquell system? I understand from Bioquell's briefing that it was first deployed during last year's severe acute respiratory syndrome crisis, when it was used in three hospitals in Singapore. It has also been used in an intensive care unit in a Paris hospital that was infected by another superbug. According to the company's research, the system achieves significant levels of decontamination or removal of the MRSA infection. According to the research results, after cleaning the MRSA level was reduced from 90 per cent. to 66 per cent., and after the use of the Bioquell system the level fell to 1 per cent. If its research is correct, there is a significant improvement in cleaning and decontamination. I hope that the Minister can comment on that.
My constituent also highlighted the issue of the availability of information. She felt that patients and their families and other relatives should be informed of the level of MRSA infection in hospitals. Can the Minister give the Government's view on whether it might be appropriate to make more information available not just at an area level, which is being proposed, but in the hospital environment, and to do so more publicly? I understand that risks may well be associated with that in terms of the level of concern or fear that people might have, but has the Minister weighed the pros and cons of that argument?
According to reports in The Daily Telegraph, there is an issue relating to doctors not wanting to put MRSA on death certificates because of concerns about possible litigation. Has the Minister considered that? What advice would the Government give to doctors in that situation? Should there be a separate category for MRSA so that we can get a better handle on what levels of infection there are?
It is clear that MRSA is far too prevalent in English hospitals. "Winning Ways" is a good start in our fight against it. However, it is not too soon to start to review whether the action points that it identifies have been put in train, although I acknowledge that it is too soon to assume that everything has been dealt with—that is not possible within the time frame.
I congratulate Tom Brake on securing this Adjournment debate on a very important subject. I express my sincere condolences to the family of Mr. Edwards. The hon. Gentleman will appreciate that because of patient confidentiality, I cannot comment further on his case. However, he has kindly spoken largely about general issues so I can respond to much of what he said.
We recognise that MRSA and other hospital-acquired infections are a serious problem for the NHS. They are difficult and expensive to treat and affect patients by causing illness, pain, anxiety, longer stays in hospital, and sometimes death. This country is not alone, as these are a major concern for many health services worldwide. The European antimicrobial resistance surveillance system shows that some countries—the Netherlands, Finland, Sweden and Denmark—have maintained low levels of MRSA bloodstream infections. Although this country has a relatively high level of infection, other countries—for example, Austria, Belgium, Germany and Ireland—have also been experiencing increasing levels since 1999.
I shall talk about decontamination later, but there is no single solution to preventing hospital-acquired infections, and not all infections can be avoided. We need to remember that medical science is improving the quality of, and is prolonging, life, which means that patients are more vulnerable to infection as they become older, more vulnerable and are still being treated.
The control of infections, such as MRSA, is complex. It is affected by factors such as the number and type of patients treated, patients infected in other countries, trusts or in the community, the design and layout of the building, and appropriate prescribing. As the hon. Gentleman has acknowledged, we are committed to tackling those issues. In recent years, we have actively provided the NHS with advice and information on MRSA. The mandatory surveillance of MRSA bloodstream infections started in 2001, and for the first time provided data by individual named trusts. We now have two years of that data to show the national position, and to enable trusts to investigate their own performance and act as appropriate to improve patient care. The MRSA data are available by individual named trust on the Department's website. That information is for a wide audience to consult and be aware of.
The hon. Gentleman also mentioned our major initiative, "Winning Ways", which ensures that we tackle the issues. We already have standards to ensure that there is a managed environment, which minimises the risk of infection of patients, staff and visitors. Although progress is being made on, for example, increasing attention to hand hygiene, which is demonstrated by a 35 per cent. increase in the amount of alcohol handrub that has been purchased through NHS logistics, we recognise that further action is needed. That is why the chief medical officer developed "Winning Ways", our action plan to fight health care-associated infection. The report recognises the need for infection control to be everyone's business, and not just the concern of specialists such as infection control teams.
To improve senior manager commitment at a local level, a director of infection, prevention and control will be designated by every organisation providing NHS services. That individual must report directly to the chief executive and the board. The director of infection, prevention and control is not a new post, but an extra responsibility for an existing senior health professional. Designation of the new director is a local decision, but we expect that the individuals concerned will have the appropriate expertise and authority to challenge inappropriate clinical hygiene practice and antibiotic prescribing decisions. The majority of trusts have now designated a director of infection, prevention and control, and the directors will be able to pull together the prevention activities required to control the infections and bring about fast, effective change to improve practice.
We expect the trusts to act on the recommendations. Obviously, we do not audit every piece of advice and information that is sent to them. They would be overwhelmed with bureaucracy and we must keep that to an absolute minimum to ensure that trusts can concentrate on taking the required actions and trying to give patients the best possible care.
To complete the point that I was making, we are assisting the NHS to develop a consistent approach to help identify training needs. Guidance on the competencies required for the position will be published shortly. "Winning Ways" reinforces good clinical practice, but there are a number of new measures included in it—for example an investigation of new systematic approaches to the identification, evaluation and control of infection hazard. A new audit of deaths from health care-associated infection will investigate a proportion of the deaths that occur to identify avoidable factors and lessons to be learned. There is a high-quality research and development programme on health care-associated infection, on which £3 million will be spent over the next three years in addition to the Department's antimicrobial resistance research programme, which accounts for more than £2 million and includes work on MRSA.
There is also a rapid review process to assess the new procedures and products for which claims of effectiveness are made over their ability to prevent or control health care associated infection. A range of activities is underway to help the NHS control MRSA. Of particular relevance is the toolkit to improve compliance with hand hygiene. That has been piloted and the results are being evaluated. In addition, professional guidelines on preventing and controlling MRSA in hospitals are being reviewed.
In relation to the issue of prevalence, I want to ensure that the hon. Gentleman and anyone else following the debate is aware that Staphylococcus aureus is carried by about 30 per cent. of the population, normally with no problems.
Staphylococcus aureus is carried by 30 per cent. of the population without a problem. Of the patients admitted for elective surgery, between 2 and 5 per cent. are carrying it but are not suffering from it in any way. MRSA is less common. Patients having elective surgery have been surveyed fairly frequently, and rates of 2 to 5 per cent. are cited. Most of those patients have been in a hospital or nursing home in the previous year. However, rates are believed to be lower in the general population with no hospital contacts. Rates will be higher in certain patients, for example, diabetics with foot ulcers.
Some interesting research has been done at St. Thomas's on the use of vaporised hydrogen peroxide, or the Bioquell system as the hon. Gentleman referred to it, which casts some doubt on the conventional view that the environment is not an important source of MRSA in patients. We will consider those results during the development of our research strategy on health care-associated infections, which I mentioned earlier.
Guy's and St. Thomas's is to be commended for taking a positive approach to investigating new techniques to tackle MRSA, which is a problem throughout the NHS. The next stage is to investigate the effects on infection rates of improving the environmental decontamination, sound scientific data which will help the NHS to decide whether to implement those methods more widely. That decontamination method requires empty facilities that can be sealed.
Routine mortality statistics cannot provide information on the number of deaths where MRSA is the underlying or contributory cause of death. That is why in implementing "Winning Ways", we will establish an audit of deaths to identify avoidable factors and the lessons to be learned from them. It is difficult to produce statistics on MRSA, because there currently are no codes for antibiotic resistance in the international classification of diseases. However, codes are being introduced from 2006, and they will help to ensure that better data are available in the future.
Many of the patients who die with MRSA are already seriously ill with another medical condition, and it is difficult to say with any certainty whether they would have recovered from their underlying condition if they had not acquired the infection. At present, the death certificate is designed to obtain the first underlying cause of death. It is up to the doctor to decide how many conditions in the sequence, other than the underlying cause, should be recorded. MRSA may contribute to death, but it is unlikely to be the first event in the sequence. Requiring that it be mentioned on post-mortem reports under the present system would be unlikely to catch most deaths following MRSA infections. Most deaths in hospital are not subject to post mortem. Indeed, most post mortems normally involve little microbiology.
However, we are on the verge of fundamental changes to the way in which deaths are certified. The proposed changes should enable death certification to be done electronically and information from patient records to be linked electronically to the registration, with the consent of the family member registering the death. That will help identify cases in which MRSA or other hospital-acquired infections played a role.
New guidance has been commissioned to cover design and cost standards for different types of isolation facilities in general acute hospitals. It will include a new approach to ventilated isolation, which will improve flexibility, value for money and safety. We are undertaking modelling work to establish how many isolation rooms the NHS needs, and we will undertake an economic evaluation of the cost of meeting the shortfall. Since 1997, our advice for major hospital redevelopment has been to aim for a minimum of 50 per cent. single bedrooms. Clearly, fewer issues are likely to arise as that provision under our big hospital programme becomes more extensive.
I believe that the hon. Gentleman's point on leaflets was about the St. Helier trust leaflet. I cannot explain why the leaflet is still at the printers if the trust was working on it in 2002. The Health Protection Agency has produced a leaflet that is available to trusts, although several trusts also produce their own. I hope that rapid progress will be made on that.
Cleanliness in hospitals is an important issue, although we do not have evidence to show that MRSA and similar infections are associated with a lack of cleanliness. We are working to improve infection control and cleanliness. The clean hospitals programme demonstrates a major improvement by the NHS in creating the right environment for patients, staff and visitors. It is not, and we have never claimed that it should be, a technical inspection of hygiene; rather, it assesses the hospital from the patient's perspective. The Government have invested an additional £68 million in a nationwide clean-up campaign and have initiated a programme of unannounced visits by independent teams. Every hospital in England now provides a patient environment that is good or acceptable. Nevertheless, we accept that there is still room for improvement. Revised national standards of cleanliness for the NHS were issued in August last year, and a cleaning manual was issued to the NHS in April this year.
What about the point about more information in hospitals on MRSA infection rates?
The hon. Gentleman himself said that this is a difficult and sensitive issue. I have discussed prevalence in the general population, which would impact on the provision of information.
We believe that "Winning Ways" will result in real change and will significantly benefit patients. The new director of infection prevention and control will be key to that change and will have the appropriate expertise and authority to challenge poor practice. The process will also be helped by other changes in the NHS such as our major programme of creating extra capacity and the increase in public expenditure on the NHS, which is set to rise to £90 billion. We have also implemented major recruitment drives for qualified health care personnel and increased the number of training places for doctors and nurses.