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What did the memorandum highlight? It said that the target would not be reached—indeed, that it may never be reached. That was the view of the director of health protection at the Department of Health. It was not the case that merely a few trusts were performing badly; there was underperformance across the NHS—116 trusts were underperforming. I fully acknowledge that MRSA rates are coming down, which has not been achieved from the mid-1990s onwards, when rates were rising considerably.
The whole NHS is off course by a massive 27 per cent., compared to the absolute target set by the previous Secretary of State. Perhaps most disturbingly, according to the director of health protection, Clostridium difficile is endemic throughout the health service. The Secretary of State said that the situation was variable, which I accept, but almost all trusts are reporting cases. There are far more cases of C. difficile than MRSA, and far more people are dying from it. In 2004 there were 360 deaths from MRSA but 1,300 from C. difficile, and in 2005-06 there were 51,000 cases of C. difficile.
Rather disturbingly, the memorandum reported that measures to combat MRSA do not seem to have an effect on cutting rates of C. difficile. Among the over-65s, incidence of C. difficile increased by 17 per cent. between 2004 and 2005. According to the director of health protection, there is evidence that many trusts do not take the problem seriously enough—an issue to which I shall return. As the Conservative spokesman pointed out, the memo provides compelling evidence of the extent to which the Government’s obsession with targets can be counter-productive and unhelpful in achieving a focus on the highest priorities.
How did we end up with the MRSA target? Why focus only on that infection? Back in 2004 there were rapid rises in MRSA infection, which, as the Secretary of State will remember well, caused a political storm. The response, of course, was to set a tough target, but it was a target only for MRSA, because that was the media story. The memo is revealing about what civil servants think of the value of that target. Three of the six options for how to manage the bad news involved changing the target. It could be extended by adding something on C. difficile, which would show equal concern for that, or changed to cover hospital-associated infections generally without mentioning any specific ones. Switching to locally set targets was another option that would allow C. difficile to be included in local targets. Another option was scrapping the targets altogether or extending the time scale.
It seems to me that that hardly demonstrates a massive commitment to a target that the Secretary of State put such store by. The director of health protection appears to have a different view from that of the Secretary of State about the significance and value of this specific target. One is left with a clear sense that the original target was entirely arbitrary, as the hon. Member for South Cambridgeshire said, and that the director of health protection took the view that it would be sensible to acknowledge that it neglected other infections, and that changing it might well get trusts to take the problem of C. difficile more seriously.
The conclusion, though, was to plough on with the existing target—however narrow, however much it ignored the bigger problems of C. difficile, and however unattainable it was. As we have heard, the focus for C. difficile is to
go for local rather than national targets, but the truth is that the target for MRSA, set on the basis of political calculation, distorts clinical priorities. I shall return later to the issue of how other targets may be compromising efforts to combat these infections.
There is nothing in the Conservative motion with which to disagree. It is right to highlight the challenge that we face and the seriousness of the issue when so many people are dying as a result of infections picked up in hospital. However, it falls short in one crucial respect. Remarkably, it says nothing about the role of antibiotics in health care-acquired infections. If the motion were a prescription for how to tackle the problem, it would be seriously deficient for that reason.
On antibiotics, I would like to highlight the work of Professor Liebowitz, a world authority on hospital-wide infection, at the Queen Elizabeth hospital in King’s Lynn. That hospital has achieved the Government’s MRSA target and also cut the incidence of C. difficile very significantly—by more than 20 per cent. in the last two years. What Professor Liebowitz stresses is the importance of stopping the prescription of the so-called broad-spectrum antibiotics and looking at alternatives. Just last week, she told the Norfolk health and scrutiny committee:
“It’s really frustrating if you have got really good infection control, everybody is washing their hands, but still doctors continue to treat with the same antibiotics”—
thus undermining everyone else’s efforts in seeking to control these awful infections.
Those concerns were echoed in a national survey of NHS acute trusts in England, carried out by the Health Protection Agency and the Healthcare Commission, which specifically looked into C. difficile. Crucially, what the survey found was that the most effective measure in preventing and managing infection is the appropriate administration of antibiotics in hospitals. Given that that is the advice of the Health Protection Agency, it seems incredible that hardly any reference has been made to it in our debate so far.
Mr. Keetch: In common with other hon. Members, my hon. Friend has referred to the washing of hands, which is so important. However, would he accept that it is not so much the washing as the disinfecting of the hands that is so important—and also ensuring that the hands are not re-infected through bracelets or rings? The skin must be properly disinfected before injections or tubes are put into the skin. It is not just washing but disinfecting the skin that is crucial here.
Norman Lamb: I absolutely accept my hon. Friend’s point and I will come on to some broader comments about infection control in a few moments, but let me just finish on the question of antibiotics.
The advice was that trusts should have policies in place to reduce the inappropriate administration of broad-spectrum antibiotics and the regular monitoring of the use of antibiotics through audit and feedback to prescribers. Those findings are also reflected in the results of the European Commission-funded research project, which reported in September 2005. Antibiotic use has a significant impact on MRSA in European hospitals: the hospitals with the highest MRSA prevalence also had the greatest antibiotic use. So not only is the Government’s approach flawed for the
reasons that I have explained, but the motion leaves out probably the most significant factor in tackling the problem.
The questions that I would put to the Secretary of State are these: what specific steps are the Government taking to shift the prescribing of antibiotics away from broad-spectrum antibiotics? How successful are those steps? What are the trends in prescribing? I do not know whether she wants me to give way to her, but I would be very interested in what she has to say on those specific points. I see that she does not want me to give way, but I very much hope that the Minister will deal with them in his response to the debate—that would be encouraging news.
The motion rightly deals with a range of infection control measures, which the evidence suggests are also important in dealing with the incidence of health care-acquired infections. What is remarkable is the extent to which the Dutch have been successful in keeping rates of infection much lower by adopting a zero-tolerance approach—the “search and destroy” strategy referred to in the motion. The Netherlands uniformly screens for MRSA and isolates those infected. Staff are sent home and wards are often closed down. However, the key to enabling that approach to work is to have enough beds for isolation, as well as good staff-patient ratios.
Ms Hewitt: Will the hon. Gentleman give way?
Norman Lamb: I will. Perhaps the Secretary of State is ready to answer my questions now.
Ms Hewitt: No, I am not intervening on the antibiotics issue, although that is an extremely important point and one that we have endorsed in the guidelines. Is the hon. Gentleman aware that in the Netherlands the rate of hospital-acquired infections is about 7 per cent., and that in England it is about 8 per cent.? Although there are undoubtedly lessons that we can learn, and are learning, from our colleagues in the Netherlands, I deplore the fact that the hon. Gentleman is talking down the achievements of the NHS in that way.
Norman Lamb: I am not talking down the achievements of the NHS in any sense whatsoever; I am saying that we should be prepared to learn the lessons if measures have been seen to be effective in other countries. Indeed, the Conservative spokesman referred to the fact that the Government had previously accepted that there were lessons to be learned from abroad. It appears that that is no longer the case, and I am saddened that there seems to be a move away from objectivity and rationality to rather cheap point scoring.
I return to the key point that sufficient beds are needed to make the approach work—especially to ensure that isolation is possible and achievable. Bed occupancy in the Netherlands is about 60 per cent. In the UK it is nearly 85 per cent., and in many acute hospitals it is much higher. In 2004-05, 88 trusts—one fifth of the total—had occupancy rates of over 90 per cent. According to the evidence, there is a direct correlation between occupancy rates and infection. Frequently acute trusts are full, on black alert. I have just discovered that the Norfolk and Norwich hospital
was on black alert—in other words, absolutely full—on 27 days in the year to the end of October 2006. That is not uncommon; it is frequently the case in many very busy acute hospitals.
In 2000 the National Audit Office highlighted concerns over bed occupancy, as well as the pressure on hospitals to keep down waiting lists. Not a political party, but the independent NAO recommended a modest reduction in occupancy rates to 82 per cent., but that has not been achieved. Why has it not been achieved? One of the main reasons is an aggressive cut in the number of beds: 6,000 were lost in 2005-06.
Norman Lamb: The Secretary of State shakes her head, but it is true: beds have been lost. Increases in day procedures have not kept pace with the cuts in the number of beds, which has resulted in occupancy rates remaining dangerously high. Disturbingly, the NAO also found that 12 per cent. of infection control teams reported that their chief executive had refused or discouraged a recommendation from them to control an outbreak by closing a ward or hospital to new admissions. That reflects pressure to keep beds open. I do not know whether that is still happening.
That finding highlights another impact of inflexible and conflicting targets. The overwhelming political capital invested in cutting waiting times, at the same time as many hospital trusts are struggling with large historic deficits, has resulted in dangerously high occupancy rates, as beds have been cut too fast. That view was specifically supported by the Public Accounts Committee in 2005. It found evidence that bed management policies and the need to meet waiting time targets can compromise infection prevention and control. We also heard of the report from Stoke Mandeville hospital, which found exactly the same evidence of the link between bed numbers and pressure to fill beds because of waiting time targets, and levels of infection.
Daniel Kawczynski: I concur with the hon. Gentleman about the fact that bed occupancy can play a major role in the spread of MRSA. Between now and February 16 beds will be cut in the maternity service at the Royal Shrewsbury hospital, and I fear that that will have a significant impact and will increase MRSA in the maternity service.
Norman Lamb: I am grateful to the hon. Gentleman for that intervention. A large number of beds are being cut across the country. That is directly related to deficits. It may well be appropriate, in certain circumstances, to reduce bed numbers. They can be reduced over time, as there is a shift towards day procedures. However, if numbers are reduced too fast, to meet the demands of deficits, we get problems. That is what the Public Accounts Committee found in 2005.
Last year, a Department of Health internal policy review was leaked to The Independent. It showed a direct link between bed occupancy and infection rates. Do the Government accept that link? I would be interested to hear the Minister say whether he accepts
it. Further evidence of an inadequate response in this country, particularly to the growing problem of C. difficile, came from the national survey carried out by the Health Protection Agency. It confirmed that rigorous infection control measures—the rapid isolation of patients, effective hygiene and clean environments—were critical. It found that only 40 per cent. of trusts routinely isolate patients with C. difficile. That is a hopeless record across the country. That is not rubbishing the NHS; it is a statement of fact that ought to cause the Government real concern.
The survey also found that trusts have no agreed definition of an outbreak and are unclear to whom they should report an outbreak once it has been identified. Again, that is not acceptable. If the Government were prepared to accept that these things are not acceptable, we might start to make some progress. On the basis of those findings, it is hardly surprising that the survey also found that two thirds of trusts confirmed that the incidence of C. difficile had increased in the previous three years.
My question to the Secretary of State and to the Minister who will respond to the debate is: how have the Government responded to the findings of that national survey conducted by the Health Protection Agency? Given the highly disturbing evidence revealed in the leaked memorandum that C. difficile is now endemic in the health service and that many trusts are not taking it seriously—that is not us rubbishing the health service; that was said by the director of health protection—what steps are the Government taking to change that mindset? Will the Secretary of State acknowledge that contradictory targets may be making the situation worse?
Given just how many people are dying from those infections, I am sure that no matter which side of the political divide we are on, we all agree that the state of affairs is completely unacceptable, and that urgent action needs to be taken to improve performance across the health service.
On cleaning services, I should like to explore a report in the Health Service Journal, which says that the Minister will recommend that trusts consider bringing cleaning services back in-house. It was reported in the Health Service Journal that a report including that recommendation was due to be sent to the Prime Minister this month. Will the Minister confirm that?
Andy Burnham: You shouldn’t believe everything you read.
Norman Lamb: The Minister may say that, but I would be grateful if he confirmed, in this debate, whether that claim is true. Will he publish the report that he is sending to No. 10, as that would be helpful? Is there any evidence that contracted-out services perform to a lower standard? I do not know, but the union Unison published a research paper two years ago in which it was claimed that contracted-out hospital cleaning had resulted in a lower standard of cleaning. The research paper said that the number of cleaners had halved since contracting out was first introduced by the Conservative Government. Does the Minister accept that evidence? Judgments should surely be made on the basis of evidence, and if the claims are true, we all have something serious to think about.
Dr. John Pugh (Southport) (LD): My hon. Friend will be aware that financial pressures play their part. For example, in my local hospital the turnaround team that is sorting out the hospital’s finances insisted that the hospital reduce its cleaning regime, even though it has a good record on MRSA. Is that not a further anxiety?
Norman Lamb: It is. So many negative measures are driven by the financial crisis affecting much of the health service, particularly during this financial year. Before Christmas, the Select Committee on Health highlighted the fact that so-called soft targets are often affected, even though in the long term, those soft targets are often among the most vital parts of the operation.
Does the Minister agree with the Royal College of Nursing’s proposal to introduce 24-hour cleaning teams, which could be rapidly deployed by nursing staff? It seems an eminently sensible proposal. We must surely ensure, too, that every front-line NHS staff member receives compulsory training. In an earlier intervention, my hon. Friend the Member for Somerton and Frome (Mr. Heath) made the point that basic standards of cleanliness are not what they used to be. That may well come down to inadequate provision of the training necessary to ensure that those high standards are maintained. Will the Government commit to providing that training? There should be a thorough review of isolation facilities, with a timetable for improvement. Will the Minister commit specifically to that, too?
This subject is incredibly important. It is clear from an accumulation of evidence—evidence confirmed by the infamous leaked memorandum—that the current strategy is not succeeding, that far more needs to be done, that efforts to minimise the number of tragic deaths that occur as a result of health care-acquired infection must be prioritised, and that must not be compromised by action taken because of other, politically driven targets.
5.8 pm
Laura Moffatt (Crawley) (Lab): It is a pleasure to follow the hon. Member for North Norfolk (Norman Lamb), who made an interesting contribution. I did not wholeheartedly agree with it, but it took a thoughtful look at the difficulties surrounding health care-acquired infections. I was particularly interested to hear his exchange with the hon. Member for Hereford (Mr. Keetch) on the issue of hand-washing. That exchange exposed one of the complexities of the subject, namely, the fact that it is not only hand-washing technique that is important, but the agent in which hands are washed. All the anti-bacterial solutions in the world will not tackle Clostridium difficile, because it is a spore, and it has to be dealt with in a very different way. I hope that that highlights some of the problems that we face.
If I were still in my former profession and took a swab to Members’ noses in the Chamber and other interesting little places, many of us would be found to be carrying Staphylococcus aureus, which can cause harmful infections. That is the reality and the difficulty of the situation that we face. I do not often turn to the Evening Standard—it is not my chosen publication—
for sensible contributions to debates in the news, but yesterday’s article by Dr. Mark Porter on the cause of health care-acquired infections was excellent. It did not get into silly nonsense about whether the problem was caused by this Government or that Government, but it outlined where the difficulties are. Dr. Porter said: “Indeed, you”—meaning the public—
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