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13 Jan 2004 : Column 217WHcontinued
Dr. Ian Gibson (Norwich, North) (Lab): I thank hon. Members for attending the debate. I am sure we all agree that hospital-acquired infection is a serious subjectone that we are pleased is being discussed and recorded for posterity in Hansardand that we should move things forward. There may be differences in how we approach it, but we are all determined to ensure that we make progress. There cannot be many worse things in life than going into hospital for treatment, being there for some time, acquiring an infection and being incapacitated for even longer. That does happen and, irrespective of whether we will ever prevent it absolutely, we should do something to try to achieve that aim.
The infections can be caused by viruses or bacteria. There is plenty of evidence that infections have been occurring and that the bacteria and viruses have been identified. Such infections are bad for individuals and for a hospital's reputation. The issue is often picked up by the media. The infections are also bad for hospital workers who take good care of us and yet have to bear the brunt because of those infections, for which they cannot be held totally responsible.
I am pleased that the chief medical officer for England, Sir Liam Donaldson, has reacted to the situation and produced the document "Winning Ways: Working together to reduce Healthcare Associated Infection in England". In it, he states that such infection is
Nine per cent. of patients acquire hospital infections and that is one of the highest rates in Europe. The rate of methicillin-resistant staphylococcus aureus, or MRSA, infection has continued to increase in this country. The figures issued in 2003 show that England is one of the front runners for this kind of infection rate in hospitals. Associated with that phenomenon is the increasing problem of antibiotic resistance, as we continuously use antibiotics to treat the problems that arise. It is almost as if the thinking is, "Oh, give them an antibiotic and they will be all right." Of course, when that is done, resistance to drugs develops.
Mr. Andrew Lansley (South Cambridgeshire) (Con): Just so that I understand the hon. Gentleman accurately, when he says "front runner" in that context, does he mean that this country is boththis is slightly perverse in some respectsrelatively high in terms of
Dr. Gibson : That is true, and I thank the hon. Gentleman for raising that. It is not concomitant that, because we have the best technology and techniques, that produces the results. At the same time, we continue to use antibiotics, which increase the resistance of many different organisms. MRSA is only one organism that shows antibiotic resistance. It is a feature of all biological life, such as cancer cells that become resistant to chemotherapy and malaria when the organisms become resistant to the drug that is being used. AIDS is another such organism.
At the Royal Society today, I heard about another recorded case of severe acute respiratory syndrome in China and the measures that are being revisited there to handle the problem. Infection, and resistance associated with infection, is a worldwide problem. It is not just caused by bacteria that float around in the air and on surface tops. It often happens during surgery, where there are site infections. Data from 60,000 operations show that 12 per cent. of hospitals have reduced the rate of surgical-site infection, be that during operations on hips, knee or large bowels. However, I am afraid that 2.5 per cent. have increased infection rates. That comes from a low base and we have to worry when the figure begins to rise.
No one would say that there should not be more hip or knee replacements or bowel treatments, but the increase of infection, coinciding with the increase in activity, which we welcome, must be handled. It is interesting that that is happening across the world and we are now, as in the United States and other countries, beginning to tackle it. Perhaps I will have time to say something about the particular successes of the Netherlands and some of the procedures that it uses to bring about lower levels of infection.
The best estimates we have suggest that about 100,000 people in England get a secondary infection each year and that about 5,000 die because of it. There is certainly evidence in this country that some trusts and hospitals have a worse record than others. No doubt a league table on that will emerge before we can blink and get out of the Chamber. I hope to hear whether the Minister has that intention.
No single factor can explain the number of patients who acquire infections during the course of their treatment and care in the NHS or other health systems around the world. The factors that have driven and continue to drive the worrying increase in infections associated with health care are multiple and there may be multifactorial situations, in which more than one agent is involved.
The problem is partly to do with patients. The increase in the number of people with more serious illnesses such as cancer, which heightens their vulnerability and susceptibility to drugs and organisms when they are at a very low immune statetheir resistance and immunity are lower than they would be if they were healthiermeans that more patients are susceptible to such an attack while they are in hospital.
Behavioural factors are always an issue. That means poor compliance by health care staff with hand washing and other hygienic practices. I do not want to condemn health staff. Having looked at the male toilets in Portcullis House and around the Palace of Westminster, I think that it does not befit any of us to say that the hygienic habits of individuals in hospitals are any different from those of people in august environments such as our own.
I am attracted to the idea of a device, often seen on the continent, whereby a toilet is flushed out from top to bottom before the door opens. I would also be happy with the device that stops people from leaving the toilet without flushing ita little voice says that there is a mess on the floor and asks for it to be swept up. That happens at Schiphol airport, so the Dutch are ahead of us in that kind of technology. I long for the day when those things happen, especially in male toilets. Everyone knows exactly what I am talking about. Those are sites of infection that need some fix, perhaps technological, because people cannot always be trusted to wash their hands when they are in a desperate hurry to do their important business.
There are, of course, some structural problems. In the Netherlands, where they put someone who is being monitored and has an infection in a single room, they have a structural set-up that enables them to prevent an individual mixing in a ward. Hand basins are important. There are several types. The best is the one that people hit with their elbow so that they do not put their hands on the tap, which can transfer organisms to the next person who uses it.
There are also environmental problems, such as dirty instruments, floors, walls, and clinical areas. The Government have seriously addressed cleanliness in hospitals. They have tried to improve hospital food and standards of cleanliness, and they have tried to modernise the environment. The dear old modern matron has returned and stamps her way around the wards putting the boot into people who practise dirty habits. That is welcome and was one of the major reasons for bringing matrons back. Hattie Jacques lives on, and I am sure that that will improve the cleanliness and infection controls at one level. The annual inspection of hospitals takes into account the cleanliness of wards, and serious consideration is being given to whether the organisation to do that should be the Commission for Healthcare Audit and Inspection or the Commission for Health Improvement. Cleanliness is being given serious consideration.
The cost of hospital-acquired infections is high. The National Audit Office estimates that it is about £1 billion a year. The United States has lived with the problem for a long time and has found ways to assess the savings. It says that the cost of maintaining one hospital bed for a year would support a full hospital infection control programme in a 250-bed hospital. As one in 10 national health service patients suffer some kind of infection,
The real issue, however, is not always MRSA. The problems of SARS and terrorism have helped to focus the public's mind on getting control of infection, and having systems not just in hospitals, but across the nation. The public will be demanding much stricter regimes in hospitals because of the pressure of potential infection from those different sources.
The commonest sites of health care associated infection are the urinary tract, the lungs, wounds and the blood. Medical devices that are employed are associated with urinary tract infection. Catheters can be inserted which have a record of reducing the amount of infection, but things are still at an elementary stage. Technology needs to be pushed and examined to ensure that catheters, which can be in place for some time, do not lead to large reservoirs of infection. The situation is similar for blood infections. Such infections can occur when intravenous feeding lines are used. Patients who are being ventilated can get pneumonia through various ventilation systems, and patients can also endure infection when they have complex surgery.
Those are the kind of things that happen. Every newspaper loves the single story that enables it to ridicule the hard work that people put in. However, contamination still takes place in operating theatres and we must recognise that. A reservoir of bacteria and viruses can cause the infection. They are transmitted from one person to another via table tops or other sources.
We need to start talking about what we can do to improve infection rates, and, as the Secretary of State for Health recently said, to wage a war on the infection process. The public are concerned, and unless we take up the cudgels now, infection will become an increasing problem. The chief medical officer has identified some areas of concern, and we should consider whether we can do something about that, but we need to push the argument much faster. For example, it is clear that every hospital trust needs a director of infection control, as is now the case, but where are those directors in the hierarchy? Do they have that Alex Ferguson managerial determination to put the boot in where it is needed, to show that the savings resulting from a hard-line policy are worth taking? It is not always seen to be like that. The directors do their bitthey tell people to wash their hands, they issue leaflets and so onbut the matter is much more serious than that, and we must give managers with that responsibility some clout.
We should also take a leaf out of the United States' book. At great expense, having cleared it through the US Department of Health and Human Services, Tommy Thompson has given me permission to have a document. Such documents are hard to get hold of in the United States these days because of the vetting procedure. A friend of mine did the work. I am not breaking any confidences; it is a published work. Hospital-acquired infections in the United States affect 2 million people a year. The US Department of Health
the patient, the public and so on. The data are published on websites, for instance, so that people know what the infection rates are at their local hospital. That approach by the Americans in the 1980s brought about an improvement in their hospital infection rates. In other words, they are saying, "There is no secrecy. We recognise that it is a problem. We will do our best to get it down to zero. We will never quite get there, but at least we are taking stringent measures to try to make it happen." The Centre for Disease Control and Prevention in Atlanta, Georgia produced that work, and we should attempt to mirror it.
That is one important matter. I have mentioned the technologies, which we must consider. I have also mentioned hand washing and disinfection. When hospitals bid for star status, infection control will become as important as other criteria. Until it does, it will not have the clout of some of the other parameters that give a hospital its grading, unless we intend to do away with the current grading system and produce a new one. If we do not intend to do that, we must take the matter seriously and show that we are doing so. We must encourage every hospital to publish its figures on a website and to boast about improvements. There is no doubt that hospitals would be pushing at an open door. We cannot simply teach individuals and leave it to them. We must give them back-up, such as hand-washing facilities and catheters.
Who can take control of the problem? I understand that the National Patient Safety Agency is collaborating with the NHS Purchasing and Supply Agency on hand-hygiene projects, but such work is piecemeal. We need an organisation to take control of all the things that cause hospital-acquired infection. Either the NPSA or the new Health Protection Agency, which is now finding its feet and becoming dynamic, should take on that task, because their remit is to look at new research and technology, and the results could be fed into solving the problem. It is always better to have one person running the show than two, each of whom has to be asked, "Do you ever to talk to one another or do you just send each other a Christmas card?" I look forward to the Minister telling us about that.
It is time to declare war on this process, which we are doing. Now that the Government have a policy, this is a great opportunity for them to be resolute and determined, and to ensure that the policy benefits all those who go into NHS hospitals and that every trust makes hospital-acquired infections a priority.
Mr. John McWilliam (in the Chair): Order. Before I call the right hon. Member for Hitchin and Harpenden (Mr. Lilley), may I say that the point of these debates is that the Minister has time to respond adequately to the hon. Member who was fortunate enough to secure the debate? I impress the need for briefnessthen everyone will get in.
Mr. Peter Lilley (Hitchin and Harpenden) (Con): I will do my best to observe your very wise recommendation, Mr. McWilliam. I pay tribute to the hon. Member for Norwich, North (Dr. Gibson) for securing a debate on this very important subject, and I make no apology for returning to it, having spoken on the matter last Wednesday on the Floor of the House. Indeed, I have raised the issue on several occasions in recent weeks and months because it is immensely important.
Sadly, despite the undoubted dedication of the men and women who work for the national health service, we suffer from a poor record of hospital infections in this country. Nearly one in 10 people who go into hospital acquire an infection that they did not have when they entered. In most cases, those infections are not due to the superbug but, according to the National Audit Office, between 5,000 and 20,000 people die wholly or partly because of infections acquired in hospital. Not only is that level of infection worse than in most of the European Union, but it is getting worse faster. The last report of the European Antimicrobial Resistance Surveillance System stated:
There was a burst of publicity when the Government announced what we were initially told were new policiesalthough we later learned they were not. Shortly afterwards, I was speaking to a French friend, who asked what issues I was taking up in Parliament. Before I could answer, he said, "What you should be doing is pursuing this superbug issue. It is a scandal that you calmly take the fact that around 5,000 a year may die from it." Although there is such a problem in French hospitals, it is treated very seriously and, in his view, much better controlled. There was a recent scandal in northern France, where 14 people had acquired infections in hospital. The President of the Republic had been brought in, and the story was on the front page of all the newspapers. We should be taking the matter seriously, and I am glad that we are doing so today.
The main reason to be worried about the problem is the impact that it has on the mortality of those in hospital, but there are also cost implications. As the hon. Member for Norwich, North said, estimates of the costs incurred of more than £1 billion are credible and,
What do we need to do? As a result of expressing an interest in the matter, I have done a lot of interviews in the newspapers, on radio and in other media. I have often shared time on discussion programmes with medical people far more knowledgeable than myself, and subsequently received e-mails from them. They say that there are medical things that need consideration, which we should examine because they might help us tackle the problem.
I did a series of radio interviews with a representative of the Academy for Infection Management, a worldwide body of experts in the sphere. It says that there must be a change in the use of antibiotics in tackling infections in hospital. We must do the reverse of what we have done until now. When a case has been discovered and samples are being sent for tests and identification, which can take several days, we begin treating with the mildest of antibiotics and slowly build up through the range of increasingly intensive treatments. As a result of its work, the academy believes that it would be better to zap the infection initially with something strong, rather than waste several days on checksallowing the bugs to take root and transmit in a hospitalbefore finally applying broad-spectrum antibiotics. That approach would save lives and money and release beds in intensive care, so it would be fully justified. I am not a medical expert; all I can do is put forward the suggestion and hope that the Government give it the consideration that proposals from such a source deserve.
The practice has been quietly dropped by NHS trusts, with no explanation."
I received correspondence from others about the potential in the long term for the use of bacteriophagesbacteria-eating viruses that have been developed in other countries. There is some literature in this country about their potential. They can be highly specific and geared to particular resistant microbes, and once they have eaten them they themselves die and have far fewer side-effects compared with microbiotics. It is another area in which we should consider whether research is appropriate. As a politician, I make it quite clear that I am not saying, "This is right; this is the
Another doctor wrote to me and criticised the impact of targets, which were impinging on his success in largely eliminating infections from the unit of which he was controller. Due to a target to move people from one unit to another at a certain speed within a certain time, people were being moved before they had been properly cleared of infection. It was then likely to spread in the hospital.
The over-rigid application of targets is an issue that came up time and again as one factor that contributes to the prevalence of bugs and various infections in our hospitals. I will not repeat the other case histories that I cited on the Floor of the House last Wednesday.
Above all, we must restore a consistent, rigorous and meticulous regime of personal cleanliness among staff. We must restore the Florence Nightingale culture that is the ultimate barrier to the transmission of infections within hospitals. That will be achieved only if we restore authority to clinical staff and medical personnel and take it away from management, bureaucracy and rigidly imposed targets. Unless and until we make the patient supreme, and medical staff have the authority in hospitals, we will not secure any change or improvement. I will not be satisfied until we have, not the worst record of any major country in Europe for the treatment and prevention of hospital-acquired infections, but the best.
Barbara Follett (Stevenage) (Lab): I congratulate my hon. Friend the Member for Norwich, North (Dr. Gibson) on securing this timely and necessary debate. I should like to echo a great deal of what he and the right hon. Member for Hitchin and Harpenden (Mr. Lilley) have said.
The right hon. Member for Hitchin and Harpenden and I share a health trust. As he will know, that trustwhich has a specialist renal unit and can therefore expect to have higher than average rates of infectionis rated sixth highest in the country. He and I are dedicated to reducing such infections, as is the trust, which has implemented a number of recommendations from the chief medical officer's welcome report. I was shocked to see England's position in the league tables. As the right hon. Gentleman said, we are the worst, with an infection rate of 9 per cent. France may be worse, but its figures do not appear to be able to tell whether it has an infection rate of 6 or 10 per cent. We can assume that we are the worst, with France somewhere alongside us. That is bad news, because the infection rate is going up.
I will focus on what is happening in the East and North Herts NHS Trust and on what I have concluded from my discussions with the chief executive at the Lister and the Queen Elizabeth II hospital. An infection control officer has been appointedAlex Ferguson. I do not know whether he has any of Sir Alex Ferguson's qualities; I hope that he has. The hospitals are taking the issue seriously and screening at-risk patients. They are training staff as hard as they can in infection control, in
Due to the use of catheters, there are particularly high rates of infection in renal units. What measures will the Government take on the provision of better or disposable catheters? They are a fact of life for many people and we must ensure that they are not also major sources of infection.
Areas of risk have been identified in each clinical area in the East and North Herts NHS Trust, and staff are being made aware of them. A decontamination centre has been established and the new cleaning contract contains new specifications. Some £500,000 more a year will be spent on ensuring that the hospital is cleaned. During a stay there about a year ago, I got up and cleaned the windows and the window ledge with baby wipes. I had a drip in my arm, but I could not sit there looking at those windows. I also got up and hooked the curtains back on the rails. My children say that I am obsessive-compulsive and I plead guilty to that. However, we need a bit of obsessive-compulsive behaviour in hospitals. I should be interested to hear how the Minister will introduce that. A care about detail and about dust on window-sills is necessary.
I am glad that there are ward housekeepers in the East and North Herts NHS Trust, and that there are modern matrons, although I fear that they need a bit of Hattie Jacques's weight and ability to inspire fear. I regret her passing, but I am sure that no matron was ever as terrifying as she was in the "Carry On" films.
East and North Herts NHS Trust has also increased the number of infection control teams in two hospitals from four to five. The director would welcome a recommendation or a guideline from the Government on the optimal number and size of such teams, because those details are somewhat haphazard at the moment, and are left to chance.
Finally, my trust put in a big plea for specialist "surgicentres". My trust is one of those that will get such a centre, but more are needed and we desperately need to consider some of the outdated buildings in which we are asking our constituents to work and be treated.
Brian Cotter (Weston-super-Mare) (LD): I am pleased that the hon. Member for Norwich, North (Dr. Gibson) has secured this important debate, as many MPs are coming across such issues increasingly often. Those issues need to be tackled for the sake of the health of our constituents and the reputation of the health service. I am glad that the hon. Member for Stevenage (Barbara Follett) is so obsessive; I only wish that she was
The issue of MRSA is particularly relevant to my constituency, which, unfortunately, last year achieved the worst record in the country for prevalence; that is why I am speaking on the issue today. As a result of that disclosure, I contacted the local hospital and wrote to the health authorities generally and the Minister. I also achieved some press prominence.
Following that publicity, I had a number of disturbing contacts from my constituents. It is only fair to say that the local hospital replied to my letter, saying that it has in place an extensive range of measures related to improvements in hand hygiene. It goes on to list the various measures. So often when such issues arise, authorities have great lists of things that are being, or should be, done. They seemingly give some answers, and send us away saying, "Everything's okay; don't worry about it."
It is early days for this issue, and people are contacting me about it increasingly often. There are many elderly people in Weston-super-Mare, and we have a number of residential homes. Local health authorities have claimed that much of the problem relates to those residential homes and to people from those homes bringing the infection into the hospital. That needs to be looked into further. I have before me a quotation from one of the very reputable residential home owners in Weston. He says:
Another constituent told me that the furniture in the intensive care unit at the local hospital was torn. Surely that does not make it easy to ensure that cleaning is carried out. It could be a source of infection. When I visit hospitals overseas, I often notice how clinical they look. As the hon. Member for Norwich, North said, it is easier to clean smooth surfaces.
Naturally, I am basing my argument on reports that have been relayed to me. I have not seen such conditions for myself, but the reports are disturbing. I am calling into question not whether procedures to control infection are in place, but whether they are being followed. I very much accept that our nursing staff are of high quality, but we all know that they are under considerable pressure. Many issues come to mind but, owing to the short time available, I shall not rehearse them. However, a nurse has expressed concern about nurses going to and from work wearing their uniforms. She spoke about the laundering of the uniforms. In the old days, they were laundered in hot conditions, but nowadays they are often laundered at home.
Since there is clearly a need for hospitals to take action, will the Minister say whether there is a stream of funding available so that special measures can be taken when they are considered necessary?
Dr. Julian Lewis (New Forest, East) (Con): My short contribution to the debate dovetails well with the contribution that we have just heard from the hon. Member for Weston-super-Mare (Brian Cotter). Much of what he had to say was anecdotal, but that does not mean that it was not true. The more true anecdotes we hear, the more we realise that something is wrong with the system. I do not have the expertise of the hon. Member for Norwich, North (Dr. Gibson), but we are all in his debt for pursuing not only the subject under discussion, but many other causes on behalf of NHS patients since he has become an hon. Member.
I know that my right hon. Friend the Member for Hitchin and Harpenden (Mr. Lilley) has made such a vital cause one of his own. However, it was the contribution of the hon. Member for Stevenage (Barbara Follett) that reached the nub of the problem. She referred to the system that is operating in wards now compared with the system that used to operate when there was a sort of quasi-military discipline in the administration of the management of patients.
Both my right hon. Friend and the hon. Lady referred to Florence Nightingale. It is surely astonishing that, so many years after her basic lessons of hygiene were put into effect with such dramatic results, we are having to learn them all over again. The problem lies in the fact that people who might have accepted her philosophy had the ability to put it into effect, which meant having a serious hierarchy of power on a ward, a serious chain
I was struck by an article published in the The Daily Telegraph on 29 November 2003, which was based on a Centre for Policy Studies pamphlet by Harriet Sargeant. I shall enter a number of quotations from her article into the record of this debate.
Whether you enjoy attentive nurses, a proper diet and clean wards is simply pot luck."
She goes on to examine in some detail how, since nursing has largely become a graduate profession, there has been a movement away from the fundamental duties on which patients rely if they are to be kept in a clean and safe environment. Here is another anecdote, which is true. She records:
I shall give three examples, which refer to three cases about which people sent me letters in a 24-hour period. That is not typical, but it is extremely worrying. In my letter to the chief executive in February 2003 I raised the case of a person I shall call patient C, whose wife wrote to me listing in detail
To balance the picture, I am happy to acknowledge that the son of patient A told me that the attention given to him in F1 ward after he had to have part of his leg amputated was first class, and that the standards of hygiene and cleanliness were very good. The attention given by consultants was also warmly praised. However, what is the point of having high standards in one part of the hospital when the patient has already been made seriously ill by low standards in another part? I do not know whether the difference is the result of changes in cleaning practices, the disappearance of matrons, the politically correct reduction in standards of discipline and training or a lack of practical experience by trainee nurses, but I do know that things cannot be allowed to go on as they are.
I had a good response from the chief executive of the Southampton University Hospitals NHS Trust. He faced up to the criticisms in a straightforward way. He said that my comments would be raised at the next trust cleanliness group meeting, and that
Mr. Paul Burstow (Sutton and Cheam) (LD): We have had a useful debate, and I congratulate the hon. Member for Norwich, North (Dr. Gibson) on securing it and allowing us to turn the spotlight on this important issue. Some hon. Gentlemen who have spoken today took the opportunity last week to raise a similar subject: performance measurement. This is a good opportunity to explore some of the issues that were mentioned then.
The hon. Members for Stevenage (Barbara Follett) and for New Forest, East (Dr. Lewis) and the right hon. Member for Hitchin and Harpenden (Mr. Lilley) referred to the teachings of Florence Nightingale. It is right to say that some of the hard-learned lessons that she taught have been forgotten and need to be relearned, and I cannot go without quoting one reference from her notes on health care:
The hon. Gentleman made several points that I want to pick up on. He referred to the availability of antibiotics that are able to treat MRSA infections. That picks up on a point made by the right hon. Member for Hitchin and Harpenden. Will the Minister tell us what assessment the Department has made of the pipeline of antibiotics research and development work? How many projects are coming through that will continue to offer the NHS, and others, forms of antibiotic that are able to deal with the resistant strains of bacteria that are increasingly encountered in health care settings?
The hon. Member for Norwich, North referred to catheter care, which was also touched on by the hon. Member for Stevenage. It would be helpful if the Minister would describe the Government's position on the work that has been done to develop catheters that are much less likely to be agents for the spread of infection.
The most important point, among many, that the hon. Member for Norwich, North made was about who should take the lead responsibility for driving forward best practice and ensuring that it really is the norm across the national health service. He referred to collaboration on hand washing between the National Patient Safety Agency and the purchasing authority. Where do responsibility and leadership lie? Is it with the chief medical officer, the Health Protection Agency or the Minister? We must be clear where responsibility for action lies, particularly in respect of "Winning Ways", which was published by the CMO before Christmas.
The right hon. Member for Hitchin and Harpenden made several points. I shall pick up on some of them. He said that testing of doctors, who are, potentially, carriers of MRSA, was not now the norm. That was mentioned in the 2000 report of the National Audit Office. However, such tests do not only apply to doctors. Nursing staff are no longer subject to such surveillance. It would help if the Minister were to say why it was appropriate to cease to operate such a regime and whether it is being actively considered for the future. We will never eradicate infections in health care settings, but we can certainly do much more to minimise the chances of people picking them up.
I wish to discus several points from the CMO's report, which provides a helpful platform for moving things forward. Hon. Members have already referred to some figures, but I shall refer to a few more. In the last 10 years of the non-mandatory reporting system, there was a fiftyfold increase in reports of MRSA infections in hospitals. Once the mandatory system clicked in, it was unsurprising, perhaps, to learn just how much MRSA infection in the NHS had not been reported because people did not have to do so under the voluntary arrangements that had pertained.
The NAO reported that each year 100,000 people pick up infections in hospital. According to the former Public Health Laboratory Service, patients with health care-acquired infections stay in hospital on average 2.9 times
A couple of years ago, after the NAO report, I undertook a survey of the teams that are responsible for dealing with infection control in our hospitals to find out just what was happening on the ground. I found that 61 per cent. of respondents felt that they did not have adequate resources to do the job. Indeed, two thirds of them said that one real problem that was stopping them doing their job was that they did not have sufficient staff. Many highlighted the fact that they had little or no administrative support to underpin their work. The hon. Member for Stevenage mentioned the need for clear guidance from the Department on staffing ratios for infection control. It is worth bearing in mind that the NAO, when it did its work a few years ago, found one infection control nurse for every 535 beds and concluded that that was inadequate. My survey found similarly low rates.
More recently, the Infection Control Nurses Association said that it continued to be concerned about there being no guidance on staffing ratios. As a consequence, hospitals make things up for themselves. For example, the United Bristol Healthcare NHS Trust has 13,000 beds, but it has only three infection control nurses. Neighbouring Weston Area Health NHS Trust has 300 beds andapparently1.6 infection control nurses. There appears to be no rhyme or reasonno logicbehind how this is done. It appears to be determined by the priority that is assigned locally, rather than by guidance from the Department. It would be useful to know what plans the Government have in that regard.
I also tried to find out about whether the infection control teams were being properly integrated into the management of hospitalsthat issue has been referred to by hon. Members. One in four teams said that they were not consulted about the letting of cleaning or catering contracts. They are key contracts, which can have a bearing not only on the general health and well-being of patients but on the spread of infections. Indeed, 30 per cent. of the infection control teams that responded to my survey said that they were not being involved in the crucial induction training of cleaning and catering staff.
I turn briefly to the patient environment action team initiativethe so-called clean hospitals programme. Ministers regularly cite it as part of their fight against infection in the national health service, but it is nothing of the sort. It should be prosecuted under trade descriptions legislation because the reality is that only one of the 19 categories that PEAT inspects is to do with cleanliness, and there is nothing that specifically addresses questions of infection and its management and control. We should examine the MRSA league tablewhich, apparently, might eventually be
I will conclude by asking a few questions. The issue of guidance and whether it is mandatory is exercising the Infection Control Nurses Association. In his report on infection control, published in December, the CMO stated:
When will that guidance be published, and will it be mandatory? Can the Minister tell us today what its status will be? Will there be further guidance as to the management role in respect of hospital-acquired infections? That is relevant to the point that the hon. Member for New Forest, East made.
Will further guidance be issued to primary care trusts to deal with issues of staffing and fighting infection within the community at the primary care level, not least given the fact that post-discharge surveys of the acute sector to find out how many people get infections after they have left hospital are very rare? There is inadequate data on that. There could be a significant problem that results in emergency readmissions to the NHS.
Finally, to pick up on a point made by the hon. Member for Stevenage, education and training are key factors in dealing with this issue. A few posters dotted around the hospital saying, "Now wash your hands" will never be enough. Is it being considered whether we should make training around infection control mandatory, as health and safety regulations and fire regulations are? Will the Minister consider including training on infection control in pre-registration programmes for all health care staff, not just doctors and nurses? That message must be drummed home time and again if we are to change behaviour, reinforce hygiene habits that protect the public by reducing MRSA rates, and save NHS resources and people's lives.
Mr. Andrew Lansley (South Cambridgeshire) (Con): It is kind of you, Mr. McWilliam, to give me the opportunity to contribute to this debate. I shall endeavour to give the Minister proper time in which to reply. It has been an excellent debate and I pay tribute to the hon. Member for Norwich, North (Dr. Gibson) for instigating it and for the way in which he introduced it. I also pay tribute to my right hon. Friend the Member for Hitchin and Harpenden (Mr. Lilley) and my hon. Friend the Member for New Forest, East (Dr. Lewis), who illustrated some of the best ways in which Members of Parliament can become involved.
My right hon. Friend has pursued the matter doggedly. He referred to the involvement of the President of the Republic of France in this regard in an incident in France which, if it occurred at the right time, might have been his motive for raising it with the Prime Minister on one occasion, although I am not aware that the Prime Minister has acted in the same way as the President of the French Republic.
My hon. Friend the Member for New Forest, East reflected the experience of right hon. and hon. Members throughout the House: namely that, notwithstanding the excellent care that our constituents receive in hospitals locally, which is certainly true of Addenbrooke's and Papworth hospitals in my constituency, it is unfortunately too often the case that we receive evidence from members of the public with professional experienceoften people who were, for example, formerly nursing or medical staff in hospitalswho see some of the staff practices when they or their relatives are patients and who regret the failure to adopt some of the basic requirements.
I pay tribute to the many staff who do very well. Addenbrooke's is a good example and it is an intensely busy hospital. It is sometimes suggested that the problem arises because of very high bed occupancy in the NHS, but I do not detect that the busiest hospitals with bed occupancies of 95 per cent. or more necessarily have high levels of cross-infection. Clearly, the risk exists, the requirement on them to react is high and it would be better if bed occupancy were lower, but pressure in the system does not necessarily lead to failing performance.
As I implied to the hon. Member for Norwich, North, we know increasingly what needs to happen in theory, but we must now ensure that it happens in practice. Someone reading this debate might conclude that we have only just discovered the problem in the NHS, but we have been living with it for some time. In March 1995, the hospital infection working group produced guidance, the Nosocomial infection national surveillance scheme was established in 1996, work began on evidence-based guidelines in 1998 for production in 2000, and the fact that hygiene and infection control is a core management responsibility was emphasised and reiterated in 1998, which answers the point about where responsibility lies. Indeed, it is clear that it is a management responsibility in NHS trusts and has been for a very long time. Also, the National Audit Office reported in 2000, the House of Lords did excellent work in 200203its Select Committee on Science and Technology has been referred toand the chief medical officer's was published in the middle of last year. The action that flowed from that was, apparently, not new policy but implementation of the report in December.
What we have seen recently, which in part instigated this debate, is by no means a new response, but reiteration of and emphasis on what has been known for a long time. None the less, although we have known about the problem in theory, it is not decreasing in practice and that is most disturbing. We know from answers that the Department gave to my questions only yesterday that, even with all the action, the incidence is rising. The latest figures under the mandatory scheme show a 1.8 per cent. increase in MRSA reports in 200203 compared with the previous year and a 2.8 per cent. increase overall in reports of Staphylococcus aureus infection.
Some of the figures are worrying. The hon. Member for Norwich, North and I share a strategic health authority, which witnessed an increase of about 6.5 per cent. in the year in question over the previous year. Some SHAs had 20 per cent. increases. The infections are increasingly of MRSA. Ten years ago, the rate of MRSA in Staphylococcus aureus infections was 3 per cent. It is now nearly 40 per cent.
Action must be effective. As my right hon. Friend the Member for Hitchin and Harpenden made perfectly clear, it is not merely that we want to make hospital treatment safe for patients, although that is at the heart of our objectives. For the health service, there could be a win-win situationnot only would treatment be safer for patients, but pressure on the health service would be relieved and the service would have additional capacity.
Based on the figures that have been mentioned, such as a 9 per cent. incidence in this country, it is not inconceivable that we could halve the rate of hospital-acquired infections. The accurate current figure may even be higher. International comparisons suggest that half that is the best that is available in other health care systems. The Public Health Laboratory Service study conducted in 2000 on the socio-economic burden of such infections suggests that halving the incidence of hospital-acquired infections could release the equivalent of 5,000 bed years. The hon. Member for Sutton and Cheam (Mr. Burstow) mentioned that almost 3 million bed days are in total attributable to hospital-acquired infection. Halving that would mean that 250,000 finished consultant episodes were available for alternative health treatment. To put it another way, it could reduce the overall average bed occupancy from 90 to 86 or 87 per cent. That would relieve the pressure on the NHS dramatically. There is a big gain there for the NHS if we can achieve it.
I am not going to repeat the points made in an excellent debate that has detailed many of the things that could be considered. The hon. Member for Norwich, North talked about the importance of hand washing and all that goes with it, and listed the options in that respect, including reference to the Netherlands, which is interesting because it has about three times our number of infection-control nurses.
It seems that there is a symptomatic element to the way in which, over recent years, the Government have responded to the problem in relation to its response to the NHS as a whole. We have had guidelines, and we have had reorganisationswe are having the reorganisation of the PHLS and the establishment of the Health Protection Agencyand there are now directors of infection control. At the same time, one wonders why, although the balanced scorecard reflects MRSA incidents, the planning and performance management system criteria for the NHS do not include infection control anywhere. Unfortunately, managers are not free to respond in the way that they feel is best for patients and right for their trust. They have to respond to what the NHS centrally tells them they should concentrate on.
However, we need managers to be able to respond. The NHS and its professionals must have the freedom and the responsibility to respond. It was common ground in many of the speeches today that front-line freedom and responsibility need to be given, along with
As the hon. Member for Norwich, North said, it is vital that surveillance leads to action. It is vital that there is research, although I wonder how complete the research instigated in 1998 was and why many of the treatments and ideas in relation to equipment and best practice that are offered by professionals in the NHS to all of us when we talk about the subject are not already reflected in the research and guidance available. Research needs to lead to action.
The final question was made perfectly clear by the hon. Member for Sutton and Cheam: who is responsible? It would be tempting to say that it is all the Minister's responsibility, but I do not believe that the NHS can be run that way. The responsibility rests with front-line staff, but we cannot give them that responsibility, and expect them to deliver on it, unless we also give them the necessary freedom and authority. It would certainly be the intention of the next Conservative Government to enable that to happen.
The Parliamentary Under-Secretary of State for Health (Dr. Stephen Ladyman) : It is not my habit to say, "What a good debate it has been," because, frankly, my contribution usually follows an hour and a half of turgid rubbish and I do not like to mislead the House. On this occasion, however, it has been a good debate, and I congratulate my hon. Friend the Member for Norwich, North (Dr. Gibson) on selecting an important subject and winning the opportunity to get these matters on the record.
I will not congratulate the Opposition, however. I wrote several paragraphs accusing them of scoring party political points and taking a negative approach to the subject, and they have gone and let me down by doing neither of those things. Large tracts of my speech have had to be thrown out. I congratulate all hon. Members on taking a positive view of all issues.
The subject is serious. Hospital-acquired infections are significant economically and, more importantly, significant to the welfare of patients. It is right and proper that we take the matter seriously. The infections are caused by a wide range of organisms. They are a problem not only for the national health service and this country, but for services everywhere. That point was forcibly made by my hon. Friend. Such infections are difficult and expensive to treat. They affect patients by causing illness, pain, anxiety, longer stays in hospital and sometimes death. We must face the challenges that they present.
Several right hon. and hon. Members presented anecdotal evidence and evidence from their own experience. I will not comment on the specific examples that they have given, except to encourage the hon. Members for Weston-super-Mare (Brian Cotter) and for New Forest, East (Dr. Lewis) and the right hon. Member for Hitchin and Harpenden (Mr. Lilley) to ensure that the chief executive of the trusts concerned
I will not engage in the debate on nurse training that was raised by the hon. Member for New Forest, East because it is a subject for another day. It is important to recognise that we have a different health care system now; it is far more advanced compared with the old days. It is appropriate that a largely graduate work force provide nursing. It is not easy to make direct comparisons between the training that nurses currently receive and the training they received 20 or 30 years ago, or to say that one is worse than the other.
The infections that have been discussed are a worldwide problem. In the United States, Australasia and most European countries, including this country, the percentage of patients who experience a hospital-acquired infection ranges from between 4 and 10 per cent., and there is a remarkable degree of consistency between nations. Although the UK is at the high end of that range, at about 9 per cent., the figures offer no comfort to anyone who wants to use them to suggest that the national health service or the UK is doing a broadly worse job than elsewhere.
One hospital-acquired infection is methicillin-resistant Staphylococcus aureus. It is only one, but it is very importantthe right hon. Member for Hitchin and Harpenden referred to it as a superbug. It shows a different geographical distribution to the other hospital-acquired infections. The particular aspect of the bacteria that causes us so many problems is its antibiotic resistance. The hon. Member for Sutton and Cheam (Mr. Burstow) asked whether any new classes of antibiotics are in the pipeline. I am not aware of any, but the problem is of great concern to the Government and to the pharmaceutical industry. As someone who used to work in the pharmaceutical industry and whose pension is in part in its hands, I can assure him that I, more than anyone, would like to see new classes emerging. However, as far as I am aware, they do not exist and that is an issue for us to address.
The European antimicrobial resistance surveillance system shows that some countries, such as the Netherlands, Finland, Sweden and Denmark, have maintained low levels of MRSA bloodstream infections. We have a much higher level of infections and that is why the distribution of MRSA is different from that of some other infections. Having said that, we are not alone in experiencing increasing levels of MRSA. The same problem has been occurring in Austria, Belgium, Germany and Ireland since 1999. Demographics, long-term investment and the infrastructure of health services vary widely across Europe, as do historical approaches to infections such as MRSA. That is probably why there are differences in different countries.
Since the 1980s, the Netherlands has maintained a more rigorous search-and-destroy policy with regard to MRSA than we have. It involves screening patients and isolating those found to be positive. The Dutch have been better able to do that by setting aside sufficient numbers of single rooms in modern hospitals, which have high health care worker to patient ratios. Although
Since 1997, our guidance for major hospital redevelopment has aimed for a minimum of 50 per cent. of bedrooms to be single. We have implemented major recruitment drives for qualified health care personnel and increased the number of training places for doctors and nurses. As our plans progress, we will increasingly be better placed to achieve the same low infection levels as the best examples abroad.
Unfortunately, not all hospital-acquired infections are preventable and many factors contribute to the problem. For example, more susceptible patientssuch as those with severe or chronic diseasesare being treated than ever before. At the same time, advances in treatment that improve patient survival can leave them more vulnerable to infections. The hon. Member for Sutton and Cheam compared survival rates of people who have hospital infections and the time spent in hospital of people who get such infections with what, I believe, was the average time spent in hospital. In order to be accurate, we must compare people with hospital-acquired infections with people of a similar level of weakness, because they are the ones who are most likely to have got the hospital-acquired infections in the first place.
The hon. Member for Weston-super-Mare pointed out that representatives of nursing homes occasionally suggest that the problem does not affect them. I also often hear stories from nursing home proprietors that they worry when their residents go into hospital. In fact, we have a lot of evidence to suggest that nursing homes can be reservoirs of infection. The previous Government recognised that by publishing guidance for infection control in nursing homes. It is too simplistic to suggest that acute hospitals are causing the problem and that nursing homes have to deal with it.
There is no one simple solution to the complex and multifaceted problem, as others have described it. It is generally accepted that up to 30 per cent. of cases could be avoided with the better application of existing knowledge and good practice. In other words, it should be possible to reduce the estimate of UK hospital-acquired infections from 9 to 6 per cent. However, we cannot eradicate all infections by changes in working practice and hygiene, as some erroneously suggest.
Unfortunately, use of antibiotics exerts an inevitable Darwinian selection pressure on bacteria to develop resistance. Bacteria are genetically promiscuous, and, once selected, resistant bacteria can spread or transfer their resistance genes to other bacteria, which makes infections more difficult to treat. The increasing prevalence of antimicrobial-resistant micro-organisms, especially those with multiple resistances, is a global
In recent years, we have actively provided the NHS with advice on combating the infections and with additional support and resources. As health care associated infections are caused by a variety of micro-organisms, reporting systems, in general, do not identify cases acquired in hospitals. That is why we are developing a new national mandatory surveillance system that will track the national situation and help trusts to monitor their performance and to act to improve patient care. The system started with MRSA blood stream infections in 2001 and is being developed to include other organisms.
Cleanliness was raised by many hon. Members. Although common sense suggests that there is an association between cleanliness and infections such as MRSA, we do not have evidence to show that. However, we are working to improve both infection control and cleanliness. 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, there is still room for improvement.
I agree, however, with the hon. Member for Sutton and Cheam, who said that we should not draw too close a parallel between the efforts that we are making to ensure cleanliness in hospitals, and infections. He was right to suggest that. The right hon. Member for Hitchin and Harpenden suggested that staff screening might be an issue. We do not carry out such screening because MRSA is a transitory organism and staff screening would not tell us anything of much use. Hygiene and the use of protective clothing at appropriate junctures is a better way forward.
Hand hygiene is likely to be particularly important and is receiving more attention. The amount of alcohol hand-rub purchased through the NHS Logistics Authority has increased by 35 per cent. in the last year. The National Patient Safety Agency toolkit to improve compliance with hand hygiene is being piloted in six NHS trusts. In June, we announced that £12 million would be allocated over the next three years for hospital
In recognition of the need to do better on this subject, the chief medical officer set out a comprehensive range of actions in the report "Winning Ways", to which hon. Members referred. Many measures reinforce good clinical practice, but there are a number of new measures. Before I talk about those, I shall deal with catheters, which several hon. Members mentioned. "Winning Ways" and the guidelines that we are issuing include the use of catheters. My hon. Friend the Member for Stevenage asked about single-use catheters, which are now routinely used for intravascular and urinary cases. We are also trying to build up an evidence-base for other medical devices that it might be more appropriate to introduce. Where evidence suggests that there will be benefits from introducing different types of single-use medical devices, they will be introduced. I assure hon. Members that we are aware of the issues relating to catheters and are doing our best to address them.
As part of "Winning Ways", there will be an investigation of new systematic approaches to identification, evaluation and control of safety hazards. There will also be further work to improve auditing, and a research programme. We announced that £3 million would be available over three years. That is in addition to the Department's antimicrobial-resistance research programme of more than £2 million, and any work that the Medical Research Council might want to initiate in areas such as bacteriophage, if proposals are put to it.
Mr. John McWilliam (in the Chair): I should explain that at 4 o'clock there is a likely to be at least one Division. In that case, the sitting will be suspended for 15 minutes. If there are two Divisions, I will suspend for a further 15 minutes.