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Health Care-Associated Infections
Mr. Deputy Speaker (Sir Alan Haselhurst): We now come to the second debate on the Opposition motions. I must inform the House that Mr. Speaker has selected the amendment in the name of the Prime Minister.
4.16 pm
Mr. Andrew Lansley (South Cambridgeshire) (Con): I beg to move,
That this House supports NHS staff in their efforts to minimise healthcare associated infections; notes with distress the failings disclosed in the report by the Healthcare Commission into the outbreaks of clostridium difficile at Maidstone and Tunbridge Wells NHS Trust; deplores the failure by the Department of Health to secure new leadership at the Maidstone and Tunbridge Wells NHS Trust at an earlier stage; regrets the repeated failure of the Government to ensure compliance with proven methods of containing infections, including screening prior to admission, adequate isolation facilities and optimum bed occupancy rates; and calls on the Government to support NHS bodies in implementing zero tolerance strategies for healthcare-associated infections.
Time and again, we have brought Ministers to the Chamber to try to get action to combat infections in hospitals. Time and again, they stand at the Dispatch Box and say that that is a priority. Time and again, the independent evidence shows their subsequent failure to do what is proven to be needed. The Healthcare Commission’s report on the outbreaks at Maidstone and Tunbridge Wells NHS Trust is only the latest, although possibly the worst, example of such reports.
When we brought the Secretary of State to the House to comment on the report, he said that that was an exception, but in 2005, the latest year for which we have figures, 3,807 deaths were reported to be associated with clostridium difficile, and 1,629 with MRSA. In 2006 some 20 NHS Trusts had C. diff rates higher than those reported at the Maidstone and Tunbridge Wells NHS Trust, although I hope that very few of those trusts are responsible for the kind of failings that were disclosed at Maidstone.
The purpose of the debate is once again to demand that the Government implement the comprehensive strategies against hospital-acquired infections that they have been advised to pursue for years. In particular, we hold the Secretary of State to account for his failure to act in relation to the failings at Maidstone and Tunbridge Wells. In our motion I have focused on three main topics—screening, isolation facilities and bed occupancy rates. I acknowledge that there is much else that will form part of a comprehensive strategy, including an antibiotic regime, high cleaning standards, improved hand hygiene, surveillance and new technologies for antimicrobial techniques and surfaces. I set out much of that in our previous debate in January, but I draw attention to the three matters that I mentioned, over which the Government could exercise influence through investment and policy.
In the chief medical officer’s report “Winning Ways”, published in December 2003, he stated:
“Some countries have been particularly successful in controlling MRSA.. Notable is the experience of the Netherlands. The Dutch strategy has been based on a policy of ‘search and destroy’. This involves screening patients for MRSA and isolating those found to be positive. . .The Dutch have been able to set aside sufficient
numbers of single rooms in modern hospitals and maintain a high healthcare worker to patient ratio. As a result, this approach has been remarkably successful.”
So for nearly four years—I am sure hon. Members sometimes get tired of hearing us go on about it—based on that evidence, we have been calling for a search and destroy strategy.
If the Government had listened to the chief medical officer in the first place, and latterly to us, we would be halfway through the process of removing endemic infections, particularly MRSA, in our hospitals, and we would be halfway to achieving some of the MRSA rates experienced in the Netherlands and Denmark, and, as the European antimicrobial resistance surveillance survey published Europe-wide this week suggests, we would have made greater progress in the same direction as France has done. Thus far, however, we have not matched its performance.
Dr. Julian Lewis (New Forest, East) (Con): Does my hon. Friend recall the case that I raised at Health questions a few days ago? A decorated RAF war hero in my constituency nearly died after contracting C. difficile in Southampton general hospital following a routine operation. Does my hon. Friend think that the reason for the inaction is that the people who suffer so much—and in many cases lose their lives—are of a certain age? If such things happened to people of middle age or younger, perhaps the Government would feel it necessary to take firmer action and act more decisively. Is not a form of ageism at work in respect of the problem?
Mr. Lansley: I recall my hon. Friend’s question, and I fear that he may be right, although I wish he were not. It is clear from the report on Maidstone and Tunbridge Wells NHS Trust that some of the same infection control issues were manifested in the lack of response to issues of privacy and dignity. That, of course, impacts disproportionately on the very elderly. Although C. difficile is not confined to the very elderly, they are particularly at risk. I share my hon. Friend’s concern.
A search-and-destroy strategy would clearly take several years to achieve its aims, just as would a zero-tolerance approach in respect of C. difficile; we face increasing risks from new strains and from community-acquired infections. I do not discount the simple fact that even with such a strategy, there is a continual fight against the reintroduction of infection. However, an aggressive strategy of that kind is even more necessary now, as those more virulent strains become evident.
Angela Browning (Tiverton and Honiton) (Con): I want to pick up the point about elderly people who contract MRSA and other infections. Some of the most common sites for such infections are leg ulcers, which are very frequent among older people, whether they are admitted to hospital, in residential care or seen by practice nurses in the community. Does my hon. Friend agree that, as leg ulcers are so open and likely to acquire such infections, we should not only tend to their healing, but concentrate more on the issue of leg ulcers among the elderly, so that we can see whether they have acquired those diseases?
Mr. Lansley:
I am grateful to my hon. Friend. She and other Members may recall the work being pioneered by Ellie Lindsay, a former nurse of the year, in East
Anglia. She has set up leg ulcer clubs and sought hard to persuade primary care trusts to operate precisely the focus that my hon. Friend mentioned. Unfortunately, Ellie Lindsay has had less success than she would have wished for. However, she is fighting to achieve what my hon. Friend mentioned.
Dr. Brian Iddon (Bolton, South-East) (Lab): The measures that the hon. Gentleman is outlining are fairly obvious, and they are critical. However, is not the real problem antibiotic resistance? Unless we tackle that at root by promoting more research, we will be stuck with the problem for a long time. Can the hon. Gentleman tell us what research was instituted by the Conservative Government to persuade the pharmaceutical industry and Government laboratories to crack that major pharmaceutical problem?
Mr. Lansley: The hon. Gentleman may say that the measures are obvious, and they may be obvious to him, but they were not as obvious as they should have been in the Maidstone and Tunbridge Wells NHS Trust. From memory, I think that only about 7 per cent. of the appropriate C. difficile patients received access to Vancomycin. We have to make sure that the available antibiotics regimes are being used. In the majority of cases that it reviewed, the Healthcare Commission found that broader-spectrum antibiotics were being used when narrower-spectrum ones were available. Of course there is a need for research and the constant addition of techniques to deal with the problems.
Mrs. Madeleine Moon (Bridgend) (Lab): Does the hon. Gentleman agree that, especially when we talk about ulcers, there is more to consider than broad-range antibiotics? There are other, effective ways of dealing with leg ulcers in particular. I am thinking of the surgical maggots available from ZooBiotic. They not only clean the wound, but combat the MRSA. The overuse of broad-spectrum antibiotics in dealing with infection in leg ulcers sometimes exacerbates the problem.
Mr. Lansley: I am grateful to the hon. Lady. I recall her Adjournment debate on that subject earlier this year, which clearly caught the interest of the House. Where C. difficile is concerned, staff in the NHS need to be extraordinarily well aware of the risks that they run with broad-spectrum antibiotics, particularly when they are combined with proton pump inhibitors, because the combination of those two things can leave patients very vulnerable to the consequences of C. difficile infection and its proliferation. The hon. Lady refers to one way of combating that, but another would be the use of probiotics, which has been pioneered in Nottingham.
The hon. Member for Bolton, South-East (Dr. Iddon) talked about things being obvious. Some of the things on which we should focus have been obvious for a long time—the point is that those things have not been done. Let us take the screening of patients for admission. Ministers have repeatedly told the House that they are in favour of screening at-risk patients, but it was not until September this year that they came to the House to say that they supported the universal screening of
admissions. I welcome the fact that they have now done that, albeit that it is nearly three and a half years since we called for it to happen.
This is not the first time that the Department of Health has advised that. Last November a best practice code was published, which said:
“The logical conclusion of risk factor assessments and the results of modelling studies is that the most appropriate approach to the reduction in MRSA carriage in the population, and resultant MRSA infection, is the universal screening of all admissions to hospital”.
Now, a year later, Ministers tell us that they are going to put in place the resources to support screening; we said during the general election that that should be done and that the necessary technology should be supported.
The hon. Member for Bolton, South-East mentioned research; we said that there should be research and support for new technologies to deliver rapid screening, so that when one is in a ward and asks staff about the process of managing patients, one does not find that it will be two days before they are in a position to be able to access results and know whether patients are infected.
In the past few weeks, I have had responses to freedom of information requests that I made of hospital trusts, and the results are deeply disappointing. Only 2 per cent. of trusts said that they screen all patients for MRSA, only 32 per cent. of trusts can provide any data on the number of patients screened, and not one trust collects data on whether patients are isolated following a positive MRSA screening result. None offered data on whether, if a patient was screened and found to be positive, they would as a matter of course be put in a single room or isolated. I am afraid that that rather accords with the findings of the Health Protection Agency, which were published by the Department just a couple of weeks ago, although not with a press release. The HPA said that nearly one third of trusts did not screen all patients, only 60 per cent. screened all previously MRSA-positive patients, and only 55 per cent. screened all patients from nursing homes, despite that being a high-risk factor. It is all very well to say that there should be screening of admissions, including emergency admissions, but that has been said before and it has not been done. We want to see results.
On the isolation of patients, Pat Troop, chief executive of the Health Protection Agency, said:
“The most effective way of controlling the spread of both Staph. Aureas and MRSA is through early detection and appropriate isolation and treatment.”
In 2004, the National Audit Office noted that many trusts had undertaken a risk assessment but only a quarter had obtained the required isolation facilities. The study published by the Department last month said:
“Three quarters of Trusts indicated that they had problems implementing isolation policies due to inadequacies in the number and fitness for purpose of isolation rooms.”
What about bed occupancy? In April 2001, the Government said, in response to the Public Accounts Committee:
“Health Authorities should plan bed numbers in order to achieve a bed occupancy rate of no more than 82 per cent. in 2003-04.”
What happened after that? The bed occupancy rate went up. It is still at 84.5 per cent., and in many parts of hospitals, it is way above that.
Martin Horwood (Cheltenham) (LD): Cheltenham’s private Nuffield hospital might agree with the hon. Gentleman, because it told me that it credited its virtually zero rate of infection to two policies: aiming for a 70 per cent. bed occupancy rate, and not outsourcing its cleaners. Does he now bitterly regret that his party, when it was last in government, pursued the exact opposite policies, which led to more than 90 per cent. bed occupancy rates and the outsourcing of cleaning staff?
Mr. Lansley: The point that I am making is that the Government were aiming for 82 per cent.—I would not aim below that—and they have not got there.
The Secretary of State for Health (Alan Johnson): That was a good intervention.
Mr. Lansley: Does the Secretary of State think that that was good? He might like to tell the hon. Member for Cheltenham (Martin Horwood) that there were serious inadequacies of cleaning at Maidstone and Tunbridge Wells, but that the cleaning contract was not outsourced. In reply to questions, the Secretary of State and Ministers consistently say that there is no evidence to support the proposition that outsourced cleaning is necessarily any better or worse than in-house cleaning.
Mr. Lindsay Hoyle (Chorley) (Lab): Will the hon. Gentleman give way?
Mr. Lansley: No, I am not going to give way; I am moving on.
Let me make it quite clear that bed occupancy rates are too high. In the past year, the Government have reduced the number of acute and general beds in the national health service by the largest proportion since 1982. We saw a reduction of 6,000 acute and general beds, which has taken us down to a figure of 127,000 such beds, when the NHS plan said that there would be a 2,000-bed increase to take us up to a figure of 135,000. There is a very big gap. Last year, The Independent said that the Department had conducted a review suggesting that reducing bed occupancy to a maximum of 85 per cent. would save 1,000 cases of MRSA a year. Apparently, according to speculation in the press, there are further factors that the Government know about, but which they have chosen not to publish. When the Secretary of State replies, perhaps he will tell us about some of those factors that the Department has found in its research.
Let me make something clear about these three factors. They are interrelated, and they require the Government to support investment in isolation facilities, as well as the policy change on screening. Screening requires more isolation facilities. It is no good having screening for admissions if there are insufficient isolation facilities available to back it up. Isolation requires more single rooms, and therefore more beds. It is no good the Government going down the road that they propose, if they are cutting beds at the same time, and if nurses do not have time to clean beds before patients are admitted.
Those three things go together, and the Government do not appear to understand the necessity for a comprehensive strategy.
I shall just take a moment to talk specifically about Maidstone and Tunbridge Wells NHS Trust. I find it astonishing that the Government’s amendment does not mention the outbreak of C. difficile at Maidstone, or the report. It really should. The House will recall the appalling failings in the standard of care provided. They were probably, or definitely, the main cause of death of approximately 90 patients, and they may have contributed to the deaths of approximately 270 patients in the period up to September last year. The failings were many.
Of course, some of the reporting concentrated on the failings of the nursing care, and they were severe, but we must be aware of the nurses’ point of view. Given the intense pressures, very limited access to additional staffing—staffing numbers were going down—and bed occupancy rates of 90 per cent. or more, they find it hard to take the fact that they are held responsible for the poor professional standards when the management were putting them under intolerable pressure. The report discloses serious failings at every level: on antibiotic prescribing, which we were talking about; on lack of training; on the failure to establish an isolation ward for four months; and on simply admitting the scale of the problem. The public in west Kent were simply not told about the nature of what was going on.
Mr. James Gray (North Wiltshire) (Con): Does my hon. Friend agree that it is terribly important that hospitals own up to the size of problems? I am dealing with a case in the Royal United hospital in Bath—I am looking forward to visiting the hospital on Friday to talk further about it—which is denying that there were any cases of MRSA at all during September. However, I know that my constituent, Mr. Don Stevenson of 8 Hatton way, Corsham, went down with MRSA on 8 September. Surely it is wrong that hospitals are denying the facts. They must face up to them, and deal with them.
Mr. Lansley: That is extremely important. The code of practice, which we debated in the House a year ago, and which Ministers said would solve those problems, specifies in terms that there must be openness and information to the public about infection rates. It is quite astonishing that in a press release the management of the Maidstone and Tunbridge Wells NHS Trust tried to claim that infections had been brought in from the community. Only a small proportion of infections were acquired that way, so it was an outrageous claim.
Astonishingly, senior managers—the director of nursing and the chief executive—at one point denied to the Healthcare Commission that it was the trust’s policy not to cohort patients for nursing. Contrary to the guidelines, that was exactly what was being done, but they did not seem to realise that, so management failings were extraordinary.
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