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Mr. Graham Stuart: I know that it is not the subject of the debate, but does the hon. Gentleman agree that we should consider making mandatory the reporting back to the hospital of the deaths of thrombosis patients? Hospitals do not receive that information, and might not be following the right procedures.
Norman Lamb: I am at risk of getting into trouble with Madam Deputy Speaker, but that is important. Thrombosis is a hidden problem that does not get the attention it deserves.
Health care-acquired infections are a problem not only in hospitals but in care homes and nursing homes. A recently received parliamentary answer showed a rise in deaths in private care homes, too. We must ensure that attention is given to those services as well as to acute hospitals. Some 3 per cent. of the healthy adult population carry C. difficile in their bodies. It is prevalent in the community and is not a problem merely for our acute hospitals.
The motion rightly draws attention to the Healthcare Commission report on Maidstone and Tunbridge Wells NHS Trust. The Secretary of State’s statement on 15 October focused specifically on the trust’s failings. In many respects, that was right: the failings were substantial and in some instances grotesque. Reports that nurses and others told patients to go in their beds were unimaginable, and we would all condemn that action.
The report also raised issues that are the Government’s responsibility. The Secretary of State is right to say that we should not try to score party political points, but he would accept that it is the Opposition parties’ job to hold the Government to account and to ask pertinent questions. I want to go through some of the issues that the Healthcare Commission raised that are ultimately the Government’s responsibility.
The Secretary of State said that there is no direct link between bed occupancy rates and the incidence of hospital-acquired infections, but he cannot deny the clear evidence that such infections are more prevalent in hospitals with high occupancy rates. Page 6 of the Healthcare Commission report states:
“The trust’s bed occupancy rates were consistently over 90 per cent. in the medical wards at both Maidstone Hospital and Kent and Sussex Hospital. Higher bed occupancy led to less time for thorough cleaning of beds and the areas around them between one patient’s moving and another occupying the same bed.”
That is pretty clear, and the Government need to take careful note of what the Healthcare Commission says. Later, the report states:
“The report of the National Audit Office in 2004 found that preventing infections continued to be adversely affected by other NHS trust-wide policies and priorities. The increased throughput of patients to meet performance targets resulted in considerable pressure towards higher bed occupancy, which was not always consistent with good infection control and bed management practices. Higher bed occupancy meant that there was less time for thorough cleaning of beds and bed spaces between admissions of individual patients and a higher probability of transmission of infection between patients. Seventy-one per cent. of trusts were still operating in bed occupancy levels higher than the 82 per cent. that the Department of Health reported it hoped to achieve by 2003-04.”
That is how the Healthcare Commission reported these concerns, so what has happened? The recent Liberal Democrat analysis of official Government figures found that almost half of NHS trusts have occupancy rates
above the recommended level, that a quarter have occupancy rates above 90 per cent, and that 22 hospitals have occupancy rates above 95 per cent. Hospitals are frequently completely full, and the Secretary of State must recognise that the risk is that corners will be cut, as the commission suggested.
Mr. Graham Stuart: I am extremely grateful to the hon. Gentleman for giving way. The chief executive of Hull royal infirmary, my local hospital, has spoken to me about the difficulty of combining high bed occupancy rates with a suitable and proper cleaning regime. Does he agree that, to find out the truth, the Secretary of State need only go to his local hospital?
Norman Lamb: The evidence is overwhelming. I am worried that, rather than moving in the right direction towards the level that the Department believes to be appropriate, the figures are going in the wrong direction. In 1996-97, overall bed occupancy was at 80.7 per cent, whereas it had reached 85.3 per cent. by 2006-07. That is the average, and the House must bear it in mind that many hospitals will be way above that level, as I have already said.
The hon. Member for South Cambridgeshire (Mr. Lansley) referred to the leaked report from the Department of Health. It said that hospitals with occupancy rates above 90 per cent. have MRSA rates 42 per cent. higher than average. Professor Barry Cookson of the Health Protection Agency said in 2004:
“We have got to get down to 85 per cent.”
Moreover, Alison Holmes, a specialist in infectious disease at Imperial college, said:
“The issue about bed capacity and throughput really does undermine best infection control practice.”
How has the Secretary of State responded to the Healthcare Commission report? He rightly condemns what happened in that trust, but there are questions for the Government as well. Does he accept the Healthcare Commission’s position on occupancy rates, and will he review the extent to which overcrowding is associated with an increased risk—and by that I do not mean that every full hospital has a high rate—of hospital-acquired infections?
Alan Johnson: Bed occupancy rates and the management of beds are important, but we do not need top-down targets for them. Does the hon. Gentleman accept that the Healthcare Commission did not make that one of its national recommendations? The report devotes a whole section to such recommendations, but it does not say that the Government should have a national target for bed occupancy. The report makes five national recommendations, and the Government have implemented them all.
Norman Lamb: I accept that. None the less, we must take the report very seriously, and I have quoted directly from it. Although the Secretary of State talks, rightly, about avoiding top-down targets, but they have often led to over-full hospitals. The report mentions the pressure of targets. The Secretary of State shakes his head, but page 8 of it says:
“The trust struggled with a number of objectives which they regarded as imperative. These occupied senior managers’ time and compromised control of infection, and hence the safety of patients.”
“We are concerned that where trusts are struggling with a number of problems that consume senior managers’ time, and are under severe pressure to meet targets relating to finance and access, concern for infection control may be undermined.”
There is specific reference to A and E targets:
“One senior manager said that because of other pressures and ‘over-heating’ in the trust, the A&E target was delivered at the price of chaos elsewhere in the system.”
The Secretary of State has to understand that Maidstone is not alone; those concerns apply across the NHS. Trusts often feel that they are bamboozled by targets. He has accepted in other contexts that an over-reliance on top-down targets sometimes has perverse effects. I am in a sense challenging him to concede that that is a factor in the problem, as the Healthcare Commission recognises. Does he accept what the commission says? If so, is he prepared to ensure that hospitals are given guidance stating that, although there are other priorities, this must be the top priority?
The third issue that the Healthcare Commission deals with is the pressure of finances, which is a Government responsibility and leads, among other things, to cuts in nursing staff. The report says:
“Both trusts had undergone difficult mergers, were preoccupied with finances, and had a demanding agenda of reconfiguration and private finance initiative... Additionally, the impact of financial pressures was to reduce further already low numbers of nurses and to put a cap on the use of nurses from agencies and nursing banks.”
Does the Secretary of State accept that in the past two years intense financial pressures on trusts to balance their books have sometimes had perverse consequences? That appears to have been the case at the trusts in question.
The next issue the report raises is the MRSA target. What concerns me is that, by targeting only reductions in MRSA, the former Secretary of State imposed what I regard as a political target of halving the MRSA rate by 2008, without paying any attention to C. difficile, which was increasing very rapidly. Again, the Healthcare Commission raises concern about that issue. Page 7 of its report says:
“Before the outbreak it only monitored the MRSA rate, as there was a national performance target in relation to MRSA, though not as regards C. difficile.”
So the trust’s attention was focused on MRSA, not on the bigger problem of C. difficile.
The strategic health authority has a role as well, as the report says that, before August 2006,
“the SHA was not aware of the relevant performance of trusts with regard to rates of C. difficile infection.”
That body is supposed to monitor the performance of trusts in its area.
Commenting on the role of the Health Protection Agency, the report says that meetings with directors of infection prevention and control in Kent “focused on MRSA” and that there
“was no local monitoring of C. difficile”.
Again, the focus was on what the Government chose to target—I think for political reasons—rather than on the growing problem of C. difficile. Again, targets distorted clinical priorities. Does the Secretary of State accept that setting arbitrary targets for MRSA, at a time when other hospital-acquired infections were increasing, had perverse consequences and was dangerous and damaging?
The next issue is antibiotic prescribing. All the professionals I have talked to say that that is the central and most important issue when dealing with C. difficile. I was surprised that the motion makes no reference to antibiotic prescribing. [ Interruption. ] I know that the Conservative spokesman talked about it. The Government amendment also misses it out. The Healthcare Commission report says:
“Antibiotics need to be seen, like all medication, as potentially dangerous drugs”.
In 2005, a study of 300 European hospitals showed that the highest levels of MRSA were associated with hospitals using a high level of antibiotics, particularly the broad-spectrum antibiotics that we have debated previously. The Health Protection Agency and Healthcare Commission report in 2006 said that 38 per cent. of trusts did not have restrictions in place to prevent inappropriate antibiotic use.
The Government have issued new guidance on antibiotic use, but is it being monitored? Have trusts implemented the new guidance, and is it being applied effectively? It is clearly important that the prescriptive rules are applied. When I visited Hereford county hospital last week, I was told that a new policy on antibiotics had been introduced earlier this year and had had a dramatic effect.
Beyond Maidstone, the Conservative spokesman referred to the importance of screening and he was right to question why it has taken so long to introduce it. The Government say that they will introduce it for non-emergency cases by next year and for emergency cases within the next three years. In Hereford, I was told that screening of emergency cases had been implemented earlier this year. If that hospital and a small percentage of others—the Conservative spokesman referred to a survey he had undertaken—can do it, why cannot all hospitals? Does it really need to take three years to implement screening for emergency cases across the country?
I will conclude by setting out what we see as the priorities. First, I urge the Government to undertake a thorough, robust review of the impact of overcrowding in our hospitals. Overcrowding does not necessarily mean that a certain scenario will happen, but all the evidence indicates that there is a link, which needs to be addressed. The trends are in the wrong direction.
Secondly, there needs to be zero tolerance of failures of infection control. We need to get the mindset right. If senior hospital managers have failed in their duties to control infection, that needs to be treated as gross misconduct—it is that serious—rather than their getting a pay-off and a comfortable early retirement. That principle needs to apply throughout the trust, from the most senior people to those working on the wards. There should be no pay-offs. I acknowledge that the Secretary of State indicated that himself.
The next point is that matrons must be in charge of the staff in the ward, even if those staff happen to be
employed by an independent contractor. The matron needs to have the power to remove an individual from the ward if they are not meeting the required standard.
There has been discussion about the Dutch approach. I recognise that rates in the Netherlands are not much lower, but we ought to acknowledge its good practice and strict process to deal with outbreaks. The Secretary of State is right that that is possible only because of the space in Dutch hospitals, but that brings us back to the occupancy rate. There needs to be space for isolation, and to enable a hospital to have some slack in the system. He is right that historical underfunding in this country resulted in too much pressure on the system, but staff need to be sent home if they are infected.
There need to be changing facilities for staff. Again, the Secretary of State is right: it may not be appropriate to impose such measures from above, but surely the Department of Health needs to say that all hospitals should, as a matter of best practice, have changing facilities for staff, so that they do not have to travel home on a bus in their uniform. We need monitoring of death certificates to ensure that it is common practice to record hospital-acquired infections when they are a contributory factor to death. The Healthcare Commission report found, in the sample from Maidstone that it considered, that in 20 per cent. of cases where C. difficile was not mentioned on the death certificate, it was a contributory factor. In other words, if we simply looked at death certificates, we would understate the scale of the problem. In many cases—I have come across the issue as a constituency MP—people who have died in hospital had C. difficile but there was no reference to it on the death certificate. We need common good practice on the issue, so that we can accurately assess the scale of the problem. The rules on antibiotic prescribing should be rigorously applied, too.
Finally, it is important to give the patient the power and the right to raise concerns in hospital about failures in hygiene standards. There must be a mechanism through which the patient feels able to raise concerns in hospital without feeling that they will suffer in some way. I recognise that the Government have taken steps to address the issue of hospital-acquired infections, but the question is whether they are doing enough, and are doing the right things. Today, I have raised a series of issues that the Healthcare Commission highlighted, and that fall within the Government’s responsibility. If the Government intend to criticise the trust—and it is right that they should—they must also acknowledge their role and what they can do to address the concerns that the commission raises. I think that we all agree that the issue has to be treated as a top priority, so that we can ensure that people are safe when they visit hospitals, care homes and nursing homes.
Madam Deputy Speaker (Sylvia Heal): Order. Mr. Speaker has imposed a 15-minute limit on Back-Bench speeches, but in view of the limited time available for debate perhaps hon. Members will restrict their remarks to approximately 10 minutes, so that more of them can succeed in catching my eye.
5.37 pm
Mr. Jim Devine (Livingston) (Lab):
I prepared two speeches for this afternoon’s debate. In one of them,
I assumed that there had been a constructive contribution from the Opposition, which meant that we could have a serious debate about a problem that affects not just Britain but all of Europe, and a debate about how other countries are dealing with this serious issue. Sadly, the Opposition decided to play politics with people’s lives. It is important to give them a bit of a history lesson on what they did on the issue when they were in power.
I worked in the national health service from the early ’70s to the early ’80s. Those of us of a certain age can remember going into an NHS hospital where there was that smell of cleanliness. When a person who worked in the hospital left the ward and went straight to the pub or social to meet friends, people could tell that they had been in the hospital all day from the clean smell that prevailed. Let me tell hon. Members what happened on my ward. A domestic came on duty at half-past 7 in the morning and went off duty at 2 o’clock. Another domestic came on duty at 4 o’clock and went off duty at 8 o’clock. Those individuals were part of the health care team. They were totally accountable to the ward sister or the charge nurse. In fact, they made a major contribution not just to the cleanliness but to the morale of the ward. For example, when they were going off on Saturday, they would take bookie lines into local bookmakers for patients. They made a significant contribution to patients’ well-being and care.
Sadly, the Conservatives came to power in 1979. In 1982 they introduced compulsory competitive tendering. [Interruption.] Conservative Members are laughing.
Mr. Devine: I will give way to the right hon. Lady if she is not covered by a private medical insurance scheme. Is she covered?
Miss Widdecombe: I am covered.
Mr. Devine: Then I should not give way. This is an important political point. It is the height of hypocrisy for Members to come to this place and complain about their local NHS when they do not use the national health service. I was born in the NHS, I worked in the NHS and I use the NHS.
Miss Widdecombe: I am grateful to the hon. Gentleman for giving way rather unwillingly. He blames contracting out of cleaning services and competitive tender. My local trust has in-house services, and look where that has got it.
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