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We established the Healthcare Commission in 2003 to ensure continuous improvement in health services and to undertake specific investigations into trusts when allegations of serious failings are raised. Because Maidstone and Tunbridge Wells NHS Trust had consistently been among the 25 per cent. of trusts with the highest rates of C. difficile since mandatory
surveillance began in January 2004, the strategic health authority proactively asked the commission to undertake that investigation in July 2006. The commission interviewed more than 200 past or present staff, and it also reviewed in detail the case notes for 50 people who contracted C. difficile on admission to the trust and then died.
The Healthcare Commission report reveals significant failings in efforts to stop the spread of C. difficile. If the 50 cases reviewed were representative of the 345 people who died, and if one extrapolated from the reviewer’s assessments, C. difficile was probably or definitely the main cause of death in approximately 90 of the 345 cases, and definitely the cause in 21 cases. The Healthcare Commission found that the trust board was unaware of the high infection rates, and did not spend enough time considering issues relating to infection control. The commission’s report made it clear that the individual appointed director of infection prevention and control did not have any real understanding of their role from the outset. Management of the infection control team was considered inadequate, and there was confusion about who actually managed the team. Overall, the governance system that was intended to bring clinical risk to the board’s attention did not function effectively, and the board appeared to be insulated from the realities and problems occurring on the wards.
The Healthcare Commission makes recommendations for action by the trust, including reviewing its board leadership; the priority of infection control at board level; risk management; clinical guidelines; and staffing levels and training. Those actions will be performance-managed by the strategic health authority. Following the recommendation of the Healthcare Commission report, the South East Coast strategic health authority has commissioned an independent review of the leadership of the trust during the period of the outbreaks. An interim report will be made available to the strategic health authority by November.
Although employment is a matter for the local NHS trust board, I have instructed the trust in this exceptional case to withhold any severance payment from the former chief executive of Maidstone and Tunbridge Wells NHS Trust pending legal advice. I can tell the House that James Lee, the chair of the trust, has today offered the Department his resignation, which I have accepted. I have asked the chief executive of the NHS to ensure that a suitable replacement is found so that the trust can move quickly to act on the recommendations of the report and restore public and patient confidence in NHS services locally.
In addition to the independent review of leadership at the trust, I have asked the Department of Health to carry out a separate review of the role of the chair of the trust and the decision-making process that led to the terms and conditions of the chief executive’s departure. That will conclude urgently, and it will be shared with the Appointments Commission.
I am particularly concerned by the Healthcare Commission’s assessment that
“The Trust delayed announcing the outbreak and then produced figures that almost certainly underestimated the number of deaths.”
I have asked that our independent report on the trust’s leadership at the time of the outbreak examine this specific point.
The report identified five national recommendations. It may be helpful to the House if I set these out, together with the actions being taken in response. First, the diagnosis of clostridium difficile needs to be regarded as a diagnosis in its own right, with proper continuity of management. National guidance has been available since 1994, and a revised version taking into account this recommendation will be published shortly. Secondly, the Healthcare Commission said that further consideration needs to be given to the education and supervision of trainee doctors, with a view to improving the recording of clostridium difficile on death certificates. The need for good reporting of health care-associated infections on death certificates has just been reinforced by a chief medical officer professional letter published on 4 October. Further measures will be considered in response to the report.
The third recommendation that has national ramifications was that antibiotics should be targeted, at the narrowest spectrum possible, and used for the shortest possible time. We recently published “A summary of best practice” on this issue, making that very point.
The Healthcare Commission recommended that the national health service and the Health Protection Agency should agree clear and consistent arrangements for the monitoring of rates of C. difficile infection. In April 2007, we improved the mandatory reporting of C. difficile by introducing a web-based reporting system and requiring data on two-year-olds and above to be reported. The final recommendation was that the board of every NHS trust must understand the roles and responsibilities of the director of infection prevention and control, and regularly receive information about incidents and trends. The report acknowledged that duty 2 of the hygiene code addresses this issue.
The situation uncovered by the Healthcare Commission at the three hospitals is truly scandalous. We must all shoulder our share of the blame, but I hope that the House will recognise that the awful failures in Maidstone and Tunbridge Wells are entirely unrepresentative of the standards of care that patients and the public rightly expect, and which are delivered in hospitals across the country day after day.
Mr. Lansley: I am grateful to the Secretary of State for responding to my urgent question. I am sorry that he did not consider it right to volunteer a statement, given the scandalous events to which he refers, and I am surprised that, in the course of responding, he made no mention at all of the report from the Healthcare Commission in July 2006 relating to the outbreaks of clostridium difficile at Stoke Mandeville, and the clear relationship between the findings at Stoke Mandeville then and the findings at Maidstone and Tunbridge Wells.
At the end of the executive summary in the report on the Maidstone and Tunbridge Wells Trust, there was a long discussion about how both trusts had let down patients in exactly the same way. The report went on to say:
“Governance arrangements were weak or overridden by other imperatives”
“including targets relating to finance and access.”
“While it should be noted that improvements have subsequently been made at Stoke Mandeville, it seems unlikely that these similarities are coincidental. We are concerned that, if organisations are struggling, they should not compromise patient safety by making decisions and taking actions that put some patients at risk.”
So when the Secretary of State says that the events at Maidstone and Tunbridge Wells are wholly exceptional, I hope that indeed they are, but they are not an isolated case. We have had other cases, and the common link between them is that managers in the national health service have been more focused on the Government’s targets and the Government’s imperatives than on patients’ safety. I find it utterly astonishing that we should be here time and again, including in debates in Opposition time, most recently in January, pressing the Government to take the necessary action to deal with the incidence of infection.
The Secretary of State referred to the virulence of C. difficile, but he did not give us the figures. In 2001, 1,214 death certificates included a mention of clostridium difficile. By 2005, the figure was 3,807—comparable to that for deaths from road traffic accidents in this country. Between 2005 and 2006, there was a further 7 per cent. increase in the number of cases of C. difficile reported in national health service hospitals.
What was happening last year? Yesterday, we discovered from The Sunday Telegraph that last October the Government received internally from the head of the infection unit at the Department of Health a report saying that they should put in place a programme costing £270 million, including £200 million specifically for isolation facilities. What did the Government do last October in response to that report?
When we pressed Ministers about the impact of targets, as we have done repeatedly, did the Secretary of State and his predecessors not understand that, back in the middle of 2004, NHS staff in the clean your hands campaign were continuously being told to use alcohol rubs to reduce the incidence of MRSA? Staff should do that; however, as the Maidstone report makes clear, too many staff did not understand that at the same time they had to continue to use soap and water and a proper routine for hand washing to combat clostridium difficile. As we have seen MRSA figures peak and come down, we have also seen clostridium difficile figures rising dramatically, so that deaths from that are at least double those associated with MRSA.
Where are the other measures that could and should have been taken to tackle clostridium difficile? We know that there are cleaning technologies that will be increasingly effective, including dry hydrogen peroxide vapour cleaning systems. We know, for example, that nurses across the NHS have been looking for support in accessing Flexiseal, a faecal management system—but they are not getting it. We know why, as they report back to us, the Royal College of Nursing and others—it is due to cost concerns on the part of management.
Ministers constantly tell us that the health service is receiving unprecedented increases in resources; surely now is when resources should be devoted to infection control, isolation facilities and the relevant technologies. In his response to my question, the Secretary of State
has said nothing about the target announced last Wednesday—I say “announced” advisedly; it was issued by the Under-Secretary of State for Health, the hon. Member for Brentford and Isleworth (Ann Keen), to the BBC, but not to anybody else, in a press release. The chief executive’s report to the NHS last week did not mention it at all. What is the target? Suddenly, the Government now say that the response to the problems is to have a new target to reduce clostridium difficile by 30 per cent. by 2011 on a 2008 baseline. We do not even know what the baseline is.
Frankly, we cannot carry on as we are. There is no tolerable level of clostridium difficile at 70 per cent. of the current level. If a hospital thought that, it would think entirely the wrong thing, and it is wrong for the Government to point hospitals in that direction. I have been in hospitals—good hospitals—whose attitude is one of zero tolerance. That is the attitude for which we have been arguing for four years, and what the chief medical officer mentioned in the “Winning Ways” report of December 2003. However, the Government are not promoting it.
Last Thursday, all those who were deeply shocked by what was reported at Maidstone and Tunbridge Wells NHS trust will have heard the Secretary of State blame the trust board and management and no one else. However, when did he receive the draft report? Why did he not act on it then? Why is he acting on it only now, when the public are shocked and outraged at what has happened and he has to recover his position? When he blamed the trust board, why did he not acknowledge that faults have continued at Stoke Mandeville hospital, at Maidstone and Tunbridge Wells NHS Trust and at other trusts? All that means that the Government’s policy is also implicated. Those who were shocked by what happened at Maidstone and Tunbridge Wells will want to know that it will never happen again. The Secretary of State will be able to reassure them only if he changes the Government’s policy and ensures that patient safety, instead of the Government’s misplaced targets, becomes the imperative.
Alan Johnson: Let me point out that I laid a written statement this morning, although I accept that the hon. Gentleman wanted a verbal statement made in Parliament, and I am very happy to come here and do that. The report was published last Thursday and there has of course been publicity about it.
The essential point to tackle is the allegation that targets are somehow responsible for what happened at Maidstone and Tunbridge Wells. Having read the report and the recommendations to us as a Government, I think that it is completely irresponsible to suggest that hospitals cannot meet what are very important targets. We can have a debate about targets. I said during my very first appearance at this Dispatch Box that the era of top-down targets was over and we needed to move to a new level. However, I do not accept the idea that there is a choice whereby one can either have a target to reduce time waiting in accident and emergency to four hours or have people forced to wait in accident and emergency for 10 to 12 hours, as they did in the past, as the price to pay for safer hospitals.
The hon. Gentleman is quite right about Stoke Mandeville, where the local trust and management said that their problem was in dealing with targets. That is little more than a weak excuse. Hospitals all over the
country are tackling targets day in, day out. They want to get waiting times down; they want an eight-minute target for a blue light to turn up; they do not want people to wait more than four hours in accident and emergency; and they want to ensure that the level of hospital-acquired infections is reduced. It should not be suggested that this was the problem at Maidstone and Tunbridge Wells, given the selected findings in the report highlighting the two biggest reasons for C. difficile growing. The first is hand washing. The report says:
“Compliance with hand washing was ... variable among staff, particularly consultants.”
The second biggest cause of C. difficile, as opposed to MRSA, is a certain complacency about antibiotics. The report says that in a sample of 50 patients reviewed by the Healthcare Commission, 42 per cent. had been given inappropriate antibiotics and in a significant minority of cases aspects of antibiotic treatment were poor. It goes on to list a whole series of the most appalling errors that took place at the hospital but do not happen at other hospitals around the country. That should not be put to one side as if there is an excuse for this hospital because it was also dealing with national targets. I do not accept the hon. Gentleman’s point, although it is of course typical of the Opposition at the moment. [ Interruption. ] I am sorry, but it is. A report such as this, which points out appalling failures, is being turned into an argument about national targets.
I fully accept the specific points that the Healthcare Commission’s recommendations directed to Government— they were all mentioned in my statement and they will all be acted on.
The hon. Gentleman rightly mentioned the hospitals that he has attended, as have I, where there is zero tolerance of hospital-acquired infections. It is an absolute priority everywhere; there is nobody in the NHS who does not understand that zero tolerance is the policy that should be adopted throughout the NHS.
The hon. Gentleman asked when I received the draft report. I received it on 9 October. He asked why I did not act on it then. I did. The position as regards the board, which I mentioned in my statement, is part of those actions. A residual power rests with the Secretary of State about the position of the trust board, but in exercising that I want to be absolutely sure, in relation to all its members—not just the chief executive or the chair—that the action that we take will not result in any action against the NHS, and we are absolutely sure of our ground. It is absolutely right to do that, given the seriousness of the situation.
Mrs. Gwyneth Dunwoody (Crewe and Nantwich) (Lab): The Secretary of State was right to take urgent action against the members who had responsibility for the trust, but will he explain where the clinical voices were that were not raised during the period in which the infection was allowed to take hold? Why is it that the general public have not heard an outcry concerning those who were directly responsible for infection control? Is he now prepared to instigate a ruthless programme to limit some of the actions of the general public inside hospitals to ensure that we return to a state where hospitals accept that they must restrict public access, or anything that will complicate the opportunities of patients to recover?
Alan Johnson: My hon. Friend is absolutely right to talk about the clinicians, such as the medical director and the nursing director. They are all part of the review that is going on about the leadership, and they are all subject to the action, which we are reviewing at the moment, that we take about that. It is not just a matter for the chief executive and the chair.
My hon. Friend was also absolutely right to ask where the patients’ voice was in all of this. I understand that 26 members of the public—relatives of patients—complained early on. Why were those complaints suppressed? The very comprehensive Healthcare Commission report—a commission set up for this purpose—identifies a whole series of issues. Therefore, the publication of the report is the start of the process, not the end, and we have to get deeper into the matter to ensure that lessons are learned and that the same thing does not happen at any other hospital.
Norman Lamb (North Norfolk) (LD): I add my deepest sympathy to the families affected by this awful business. It is a traumatic and distressing infection to suffer from, and for anyone involved it is a horrifying process to go through. There are far too many people dying of this condition throughout the country.
It is right to stress the sense in which the individual hospital trust is primarily responsible for an outbreak of this sort, and the negligence that appears to have taken place. However, the report refers to occupancy rates in particular, and across the country hospitals are full to capacity, in breach of the national guideline of 85 per cent. Will the Secretary of State initiate a study that determines to what extent hospitals are over-full and considers the relationship between that situation and the outbreak of this infection?
With regard to the accountability of the chief executive and other senior staff, does the Secretary of State agree that failing to maintain the highest possible standards of infection control should amount to gross misconduct, and that it is entirely inappropriate for people to leave on substantial financial packages in the aftermath of such an event? He told the House, when he saw the report, that he could have intervened before the package was announced in order to discharge the whole of that board. Why did he not do so? Will he tell the House when he got to know of the financial package that had been put together? When exactly did that information come through to the Department?
Will there be compensation for the families who have suffered the tragic loss of a loved one as a result of apparent recklessness? The Secretary of State says that the chief executive is writing to all hospital trusts to give this matter priority, but will that override the myriad other priorities that are imposed centrally by the Government? Finally, it has taken more than a year for the Healthcare Commission to reach its conclusions, but the evidence that must have emerged during its study should surely have told it that urgent action needed to be taken. More than a year is far too long a wait for any decisive action to be taken by the trust, when the evidence must have appeared much earlier.
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