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“Dear Joan Ryan

I am writing to you on behalf of Enfield Carers Centre to ask if you will support us in an urgent call that we are issuing to the Chancellor George Osborne in advance of the 2015 Spending Review.

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In the Summer Budget, the Chancellor announced that, as of 2016, there will be a new compulsory National Living Wage of £7.20 per hour. We welcome support for care workers who deserve decent pay. However since we are dependent on local authorities paying us enough to pass this on to our valued care workers this increase therefore has to be reflected in the hourly rate paid by local authorities for care and support.

A report by the UK Homecare Association (UKHCA) has found that councils are going to need an additional £753 million to ensure their local care providers can meet these new pay requirements. Without that funding, care services risk closing down entirely…Care services have been badly affected over recent years by cuts and this is a financial stretch which we cannot meet. Quite simply the home care market, is at risk of collapse.”

I do not think that the Enfield Carers Centre got the answer it was looking for from the Chancellor, and I hope that it will hear some better news today from the Minister. I agree with the National Care Association when it states:

“UK Care Services are an irreplaceable part of the fabric of the NHS. There should be no doubt that what is under threat is a UK support service which is essential to local government and NHS care provision.”

I would like to know how the Minister will address those concerns and what steps the Government intend to put in place to provide a transparent and sustainable funding settlement for social care. The older and disabled people who rely on the service, their families and the all too often unsung heroes who work in it deserve no less.

3.2 pm

Simon Danczuk (Rochdale) (Ind): It is a pleasure, as always, to serve under your chairmanship, Mrs Main. I thank my hon. Friend the Member for Hove (Peter Kyle) for securing this important debate. Proper funding for care homes and social care can go a long way to reducing the pressures faced by our NHS. We must continue to do all we can to integrate social care and the NHS. I am worried that under this Government, it is becoming increasingly difficult to do so, and care homes are becoming increasingly underfunded and overstretched.

Last November, figures were published showing that 5,247 patients were stuck in hospital beds. They were well enough to be discharged, but doctors and nurses felt they could not discharge them because of the lack of care available to the patient. The majority of such people are elderly. They cannot leave hospital because there is no space in their local care homes, and there are not the facilities or staff to look after them in their own homes. Our adult care facilities are not adequate for many people up and down the country, and the problem will only get worse, in many places, under the Government’s proposals.

I have some concerns about the new proposal to give councils the ability to raise council tax by 2%, which they will be able to spend only on social care. It looks like a good initiative at first glance, but council leaders and healthcare professionals can see that it is simply smoke and mirrors. The social care precept, as it has been labelled, will disproportionately affect poorer councils. Councils such as Rochdale will be worse off, while richer areas will be better off. The leadership of Rochdale Borough Council have rightly raised concerns about the policy. Because much of Rochdale’s housing is in council tax bands A and B, the proposal will raise only an extra £1.3 million. That is why poorer councils will be worse off. Rochdale council has already faced cuts to its budget of up to £200 million since 2010. We are struggling to cope, and services are being stripped to the bare bones.

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The precept is welcome, but it will barely scrape the surface of the problem. The funding gap in social care and care home provision is getting worse. The Local Government Association estimates that it is growing by £700 million a year, and the King’s Fund estimates that it will be £3.5 billion by the end of this Parliament. The 2% increase will raise the least money in the areas of greatest need, so it will only increase health inequality, and it will vastly increase funds for councils that are already wealthy.

The most vulnerable have already seen their social care provision cut. The Joseph Roundtree Foundation points out that during the last Parliament, spending on social care fell by £65 per person in the most deprived communities, compared with a rise of £28 per person in the least deprived communities. The Government must do more to help the most vulnerable.

In the autumn statement, the Government announced that from 2017, funding expected to be worth £1.5 billion in 2019-20 will be available to local government. That funding will be included in the better care fund, as my hon. Friend the Member for Hove pointed out. It will go some way to addressing the funding gap and the disparities that will be caused by the 2% rise, but it will not be enough. The director of adult care for Rochdale, Sheila Downey, has made it clear to me that she does not know how much of that money will arrive in Rochdale, or how the funding gap will be filled until 2017.

The increase in the minimum wage will also have an effect on social care services and care homes, as has been pointed out. I welcome the raising of the minimum wage, but it must be accompanied by increased funding to allow for it. Care workers are some of the most underpaid, and they deserve their pay rise, so let us fund it properly. Rochdale’s director of adult care has raised that with me, because she is concerned about how she will find that money in her budget. She is working with local providers on the fees that will be required, but she is adamant that the pressure of the wage increase on social care budgets will not be fully met by the 2% increase. The widely cited ResPublica report from November, which my hon. Friend the Member for Hove mentioned, suggests that 37,000 care home beds could be lost if we do not fund the increase properly, because care providers will simply not be able to remain open. Alarm bells should be ringing. The loss of beds will need to be made up, and it will simply be made up in the NHS.

I finish by saying that I share the vision of an integrated health and social care system. We must achieve that if we are to have a health system that is fit for the 21st century. To achieve that, however, we cannot simply plug the gap; we need to invest in our social care and care homes now. Investment in care provision and homes can take the stress off the NHS. We saw all too recently in the case of the floods what a lack of investment can do. Let us not make the same mistake when it comes to social care.

3.7 pm

Rachael Maskell (York Central) (Lab/Co-op): It is a pleasure to serve under your chairmanship, Mrs Main. I thank my hon. Friend the Member for Hove (Peter Kyle) for securing today’s timely and important debate.

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As a country, we need to give deep thought to the importance we place on social care. We have heard in this debate that constrained finances are skewing the opportunity to do that. I have always said that we can judge a country by the way it treats its older people, and I wonder how we really think we are doing against that test. Those who have served our country in so many different ways deserve the very best care, and I am not sure that our system is built on that model. In fact, the model is now built more on minimal provision as opposed to optimal provision. I wrestle with that approach, and I believe that we really need to think about the direction in which we are going.

The current black hole in state funding for care has been made more challenging as the years have gone on by local authority cuts. We have heard clearly about the impact of a 10.7% budget cut over five years, and the fact that care providers have to pay more has added further challenge. I really welcome an uplift in the pay of care staff, because they are paid a ridiculously low amount of money. They are also faced with pension uplifts, and they have had to wrestle with the rise in national insurance and steep rises in the cost of energy, food and other services. That has all happened at the same time as they face the increasing demands of a challenging and changing demographic, including people with multiple needs, and tighter budgets. What we are seeing is unrealistic: the demand is greater, but the money is less.

Joan Ryan: Will my hon. Friend add to that list the fact that the CQC rates more than 50% of nursing homes as inadequate and needing improvement? The people living in those homes are therefore living in inadequate situations. How will that change, given the circumstances she outlines?

Rachael Maskell: My right hon. Friend makes a really pertinent point. There has to be a debate about safety and about providing good, secure homes for individuals. If people are living in substandard conditions, that is simply unacceptable. If there are not the resources to put that right, we obviously fear for the future.

Another thing we know is that the pressure being put on so many care organisations will make older people far more vulnerable. As we have heard, tens of thousands of beds could be lost. If people do not have security in later life, it can have a real impact on their wellbeing.

As others right across the Chamber have said in the debate, the autumn statement has left many question marks, and one of the issues we are going to see as a result is inequality. Some of the communities with the most demand for investment in social care will get the least money from the precept the Chancellor set out. Taken with the further cuts that local authorities will experience, that will have a cumulative negative impact on the provision of social care. That is happening at the same time as the NHS is really struggling with discharges, because the provision is not there in the community. In my constituency of York Central, some of the transitional beds will be lost because of a care home closure programme, which I will return to.

Cuts to support services for the elderly, such as day care placements, are happening because of the cuts to local authorities, and they are having a detrimental impact. The little things that local authorities could provide that kept people safe in their homes and connected

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in their communities are now very much part of history, as opposed to part of the solution. We keep hearing that finances are tight, but we must remember that it was not the people in our care homes who caused the financial crash—but, my, how they are paying for it.

A care provider in my constituency has highlighted the challenges of the new minimum wage rate and asked how on earth they are going to pay it. They already have staff who are engaged on zero-hours contracts. They tell me they cannot pay for staff to travel between visits. I obviously question that, and I support paying staff proper wages, but I really worry about how providers will deal with these issues in the future and how they will survive. I have written to the Government to raise those concerns.

The issues I have outlined are particularly challenging in a city such as York, which has a high cost of living and high housing costs. When those are combined with low wages, it is virtually impossible to recruit care staff, and that adds to the sector’s challenges. As a result, the care model we have does not really address people’s needs. That has had a real impact on discharges from the NHS and on being able to give individuals timely care in the community. We are now seeing the cumulative impact of these things, as the care home closure programme across York means that fewer beds are available.

The problem we have is that care is seen as a zero-hours, minimum wage, low-esteem industry, when it should be regarded as a high-skilled, professional service and the funding should match that. Those who have the means can afford to pay for what they get—only just, but they can. However, for the rest, care packages are being driven to the absolute minimum. It would therefore be appropriate for us all to agree that current provision is totally unacceptable. We need to draw a line under that and to have a real debate about what needs to be done. After all, who are we talking about? Who are we providing care for? It is our mums and dads. It is the most vulnerable in our society—those with multiple disabilities, those with learning challenges, those with mental health challenges and those whose bodies are not quite working as they once did. One day, it will be us.

Who do we expect to care for those individuals? It is highly trained professionals—the very best—who are rewarded appropriately, motivated and driven to learn more and deliver more. Like everybody else, I have met care workers right across the sector—in fact, I spent time doing care work myself—and I know the passion they have for providing the optimum care for individuals, but if they are not given the time to care, how can they deliver that service?

The Kingsmill review “Taking Care”, which Labour brought forward before the last general election, set out a clear programme for improving care standards and providing training and remuneration. It also dealt with the important issue of registration. It is really important that care workers are state-registered to ensure public safety. The steps the review set out show how we can secure high standards in care and safeguard service users.

We then need to think about how and where care needs to be provided. Of course people have different needs, including physical needs. In my own clinical practice as a state-registered physiotherapist, I would often get people’s confidence up and get them back on their feet, only for them to go home and lose the support and stimulation they had had, because support was not

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available continually in the community. Falls prevention work, which really puts in investment upstream and provides care, means that individuals avoid things such as a fractured neck of femur, which is so expensive to treat, putting more pressure on the health service. Little steps can make such a difference in the community and in care homes, keeping people well and addressing their physical needs.

Likewise, we know that so many people have mental health challenges in later life—two thirds of the occupants of care homes experience some form of mental health challenge. It is really important that the setting individuals are placed in appropriately addresses those needs. We need to start thinking big on these issues. The Dutch—I hope I say this right—Hogeweyk dementia care village is a fantastic scheme. It is about state provision. We need that kind of investment and that imaginative, big thinking around how we provide care in our country.

The issues I have mentioned are exacerbated by some of the most prevalent diseases in our country—loneliness and isolation, and the social and emotional health of the most vulnerable in our society. The tightening of budgets is having a major impact on the wellbeing of old people. Investment in the issue can mitigate the worst aspects. I am totally passionate about that. It is heart-breaking that older people are just given 15-minute appointments, often with a stranger, as opposed to a full support network and a real life. Our goal should be helping people to live, not preparing them to die.

On the challenges we face, we need to take a step back and think about what we want from care provision in future. These are political choices and are possible if somebody believes they can deliver them. I talk to carers who share the vision I have outlined and who want the very best for the people they serve. I also talk to people in residential care, who want hope in their future. Those people would give momentum to a Government who would dare to grasp the nettle to make sure that we provide appropriate care in future.

I want quickly to set out the situation we have in York. I have had many conversations with the residents of care homes, their families and the staff. We are going through a transition. That has already resulted in two care homes closing, and a further two—Oakhaven and Grove House—are set to close early this year. Residents and their families are distraught about the fragmentation that that is causing. Residents are being moved to placements across the city and away from their families. Some placements are on the other side of the city from where their families live, so family members can no longer just pop in to see mum as they do at the moment. Residents are being moved away from their friends in the care home—for some, these are the only friends they have in the world. Staff are also being moved away from their homes. Residents feel that they have not been listened to and that they have been ignored, which is unacceptable.

The council has put its plans ahead of the support that it purports to want to deliver. It is remodelling social care. I very much support the last Labour Administration’s vision for that. However, the sequencing of the changes is detrimental. It is about putting money before people’s needs. We need to hold back on the transition that is taking place, to make sure that there is

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investment upstream, as opposed to making people fit the system and sacrifice some of the only bonds that they have.

We have gone badly wrong in many areas of social care, and do not currently place the value on care users and staff that we should. As I have said, this is about political choices and political priorities. I ask the Minister whether there could be any greater priority than getting this right. I urge Parliament from today to take the debate forward. I want all those who have participated in today’s debate to make sure that we prioritise social care so that it is seen as an urgent need to be addressed by the Government in this term, so that we do not have to face challenges and struggles we face at the moment of questioning the finances and the value we put on social care. The question is whether the Government are willing.

3.21 pm

Anna Turley (Redcar) (Lab/Co-op): It is a pleasure to serve again under your chairmanship, Mrs Main. I thank my hon. Friend the Member for Hove (Peter Kyle) for obtaining this important debate with his customary determination to tackle the big challenges of the day and his concern for the most vulnerable in society. As everyone on both sides of the House has agreed during the debate, older people deserve the right to live with dignity and decency; but, as has also been discussed, too often that is not the case, and I am afraid the situation seems set only to get worse.

Eighty-six per cent. of care home places are run by the private sector for profit. Local authorities are the largest single purchasers of those places across the country. Because of intense budgetary pressures, which my right hon. Friend the Member for Enfield North (Joan Ryan) and my hon. Friend the Member for York Central (Rachael Maskell) clearly explained, local authorities reduced their fees by an average of 5% between 2010-11 and 2015-16. According to the sector analysts LaingBuisson, the care home sector is closing more beds than it is opening for the first time since 2005, with a net loss of 3,000 across the UK last year. In the north-east we expect to have a substantial crisis in social care as a result of the Government’s failure to grip the issue.

As my hon. Friend the Member for Hove said, the homes most at risk are those dependent on residents paid for by local councils at rates far below those paid by self-funding residents: proprietors say rates are actually below break-even point. In the north-east, only 18% of people requiring care are self-paying, compared with 54% in the south-east. In Surrey, by contrast, only 1% of people in residential homes are paid for by the state.

The Financial Times has noticed that the care home market is highly polarised between lucrative self-pay homes, mostly in south-east England, and those with local authority residents, such as Redcar and Cleveland, which are struggling. Given that disparity between areas such as Surrey and areas such as mine, and since there is a crisis in the funding not of residential care but of state residential care, it is probable that the market will not collapse nationally, but will fall over in areas such as mine where the state is the main payer. If a major provider struggles it is likely to mean that it will close its homes in the north but not the south.

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There is no capacity in local government to take over those homes. Any private sector supplier that did so would be taking an unsustainable risk, because they are currently loss-making businesses. At the moment there appears to be no plan B for the Government. I want to ask the Minister whether he accepts the scale of the impending crisis. Crisis point will be reached shortly in our region as demand continues to increase while spending is drastically cut back. The Government’s care legislation will further increase the burdens on councils in England. The only way in which providers can make any money is by cutting services and by squeezing workers’ pay and conditions.

The comprehensive spending review in December 2015 gave councils the option of adding a social care precept of up to 2% to annual council tax bills to raise extra money to pay for adult social care. However, as well as being regressive, as we have already discussed, the precept will at best raise £2 billion by 2020, against a predicted funding gap of closer to £8 billion. Indeed, the King’s Fund estimates that at best the precept will raise £800 million.

I want to use this opportunity to raise some contributory factors to the crisis, which the Government need to address, and I will begin by talking about the care workforce and national minimum wage compliance. The Resolution Foundation has estimated that care workers—both those in care homes and those providing home care—are already collectively cheated of £130 million a year because of sub national minimum wage pay. That is driven by chronic underfunding of the care sector, poor employment practices, poor commissioning practices and the ineffective enforcement of the national minimum wage by Her Majesty’s Revenue and Customs.

One employer, which will remain nameless at this stage, has put to its workforce a set of proposed changes to terms and conditions, to prepare for the introduction of the national living wage. Those include withdrawing all bank holiday and overtime enhancements, removing contractual sick pay, scrapping the meal allowance for workers when they are eating with clients, asking workers to pay for their own registration with the Disclosure and Barring Service, enforcing eight hours per annum of unpaid training time, introducing new duties and making changes to existing duties. In care homes non-payment of the national minimum wage is driven by a failure to pay for actual hours worked, such as when staff are not properly recompensed for overnight sleep-ins or time spent training; failure to pay for uniforms; and deduction of money for accommodation that does not form part of an employment contract.

The Financial Times has said that,

“businesses that run care homes for the elderly are at risk of going bankrupt, especially those reliant on revenues from local authority funded places, from a double blow of the imminent increases in the minimum wage and tighter immigration rules, making it harder to recruit from overseas”.

That is the issue I want to discuss next. The care sector is particularly dependent on migrant labour. The latest estimates suggest that nearly a fifth of the workforce are non-British. Unison has highlighted a particular problem in the care home sector with regard to the treatment of migrant workers. In a recent round-table event, a group of Filipino workers reported that they were paying £300 a month each to share a flat with only one toilet and no lounge at the residential care home where they

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worked. The rate paid for the work they did was £7.02 per hour, but there were then monthly deductions. The deductions were for their uniform—they got one per year but had to pay every month—and for training; that is a breach of national minimum wage law. The cost would normally be more than £200 a month, and it transpired that the workers were not necessarily getting the uplifts in the minimum wage that they were entitled to.

The round table also heard that a working week for the staff could sometimes be as long as 60 hours, depending on staffing levels, despite the fact that they were contracted for 36 hours. They could also find themselves working a 10-hour night shift for a paltry £35, way below the national minimum wage, and with no sleeping permitted. The employer extorted £500 each from that group of workers as their initial five-year period in the job came to an end, on the basis that payments were needed to retain a licence to hire foreign workers and to protect their immigration papers. The staff were also subject to body searches before meeting the employers. To compound matters, they were then obliged to pay fees of £2,000 each for a solicitor to renew their work permits—in cash. The work permits are for work with that one employer, so if the workers lost them they would lose their visa and have to leave the country. Not only is the exploitation of immigrant workers immoral, but it drives down terms and conditions across the sector for all workers and reduces the number of job opportunities for local people.

I want to discuss some wider problems in the care home sector. The social care workforce are predominantly female, with the latest estimates suggesting that 82% of care workers are women and that the percentage is broadly similar across all types of care. Social care is a highly gender-segregated sector, with low pay and poor conditions reflecting, as my hon. Friend the Member for York Central has mentioned, the historic undervaluing of what is deemed to be women’s work. Compared with other sectors, the workforce are also particularly concentrated in the 45 to 60 age bracket. Government-backed attempts to move away from that disproportionately middle-aged demographic have foundered, largely on the basis that the quality of work, pay and conditions are simply not attractive enough to bring in younger staff.

Residential care tends to be based on shift work and there are often problems with short-staffing, with care workers being called on at short notice to cover shifts. That can be particularly problematic for night shifts, where the compensation is often insufficient. There may also be pressure from care providers to work beyond a 48-hour working week. Vacancy rates and staff turnover are high across the sector. Councils are struggling to retain social workers in the face of high caseloads, a blame culture and competition over pay. High turnover has damaging implications for the continuity and quality of care.

There is no English language requirement for care workers whose first language is not English. The overall level of training and qualifications across the care sector is low. There are expectations of induction training for staff but the nature and quality varies considerably. There is less training available in outsourced services, and there are particular concerns about agency staff not receiving training. There are increasing expectations for care workers to carry out medical treatments that have previously been the preserve of nurses or other

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NHS professionals, but there is no concomitant expansion in training. There are no longer any universal standards for providers to meet benchmarks for percentages of trained staff in their workforces. Without obligations it makes no business sense for providers to do that training voluntarily, because of the high turnover of staff. There is also no central quality assurance mechanism for training, which leads to a lack of faith in qualifications, and no incentive—

Mrs Anne Main (in the Chair): Order. I ask the hon. Lady to bring her remarks to a close in the next few seconds.

Anna Turley: I will. In summary, the Government’s crisis in funding for care homes has pushed the sector to the brink. Terms and conditions for the workforce are being squeezed, and the current funding structure for local authorities is simply unsustainable. The Government must get a grip.

3.30 pm

Patricia Gibson (North Ayrshire and Arran) (SNP): I thank the hon. Member for Hove (Peter Kyle) for securing this important debate. As Members might imagine, I have listened with great interest to the debate, albeit from a Scottish perspective. However, it is in all our interests and, indeed, in the interests of a decent society that those who require care can access the care they need, and are treated with dignity and respect wherever they live in the United Kingdom. There are challenges, many of which have been debated this afternoon, as our ageing population grows in number and as needs become more complex, requiring additionally trained and supported staff, and bringing all the pressures outlined by the hon. Member for Hove.

I declare an interest in the issue as my mother-in-law, Iris Gibson, is fortunate to receive wonderful care at the marvellous Haylie House, which is located in the lovely Ayrshire coastal town of Largs in my constituency of North Ayrshire and Arran. Hon. Members might be interested in the approach taken in Scotland under the Scottish National party Government, who have been working hard to ensure that as many people as possible who need care in Scotland receive care in their own homes. Indeed, the number of older people receiving personal care services in their own homes in Scotland has increased from 36,000 in 2004-05 to 47,810 in 2013-14.

Since July 2002, local authorities in Scotland can no longer charge for those personal care services. In addition, payments for free personal and nursing care have been increased in line with inflation annually by the SNP Government since April 2008, improving the lives of about 7,000 to 8,000 vulnerable older people in Scotland, but, of course, funding continues to be a challenge in Scotland and across the UK.

As for carers, Scotland’s First Minister, Nicola Sturgeon, has pledged to increase carer’s allowance to the same rate as jobseeker’s allowance, which is a clear recognition of the very important job that carers do. I want to pick up on something that has been highlighted by several Members, which is what I would call the so-called national living wage because it is, in fact, nothing of the sort. It is a minimum wage, unlike the Scottish living wage that actually relates to the cost of living. The Scottish Government are a living wage employer and continue to encourage Scots-based businesses to become living wage accredited employers.

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The hon. Member for Hove is correct that the caring sector has become associated with low pay. That is a scourge on that important sector, and must be acknowledged and tackled in any discussion about the future of the whole care sector. I agree very much with the hon. Member for Rochdale (Simon Danczuk) that the provisions of the social care precept are not enough. What is needed is more investment in the care of older people from central Government. Many private care homes argue that they will struggle to pay the national living wage, as outlined by the Chancellor, of £7.20 an hour from April—never mind the living wage that the Scottish Government are encouraging employers to pay, which currently stands at £8.25 an hour.

We have heard from the hon. Member for Redcar (Anna Turley) about some shocking employment practices. The SNP is committed to improving the quality of care in Scotland and will consider carefully the impact of the living wage on the care sector. Make no mistake: any discussion about how to improve the quality of care must include a discussion about the scourge of low pay. Indeed, the Scottish Government are taking forward the recommendation of the residential care taskforce to undertake financial modelling of the costs of paying the living wage.

Mrs Anne Main (in the Chair): Order. I ask that the hon. Lady sticks as closely as possible to the subject of the debate, which is care homes in England. I have given her some latitude but she is somewhat straying off the point.

Patricia Gibson: I was simply going to ask the Minister to ensure that the scourge of low pay is tackled as far as possible under the Chancellor’s arrangements to ensure that the wage levels are at least enforced. As we have heard from the hon. Member for Redcar, that is not even currently the case.

It is clear that there are urgent concerns about care homes, which must be addressed. I look forward to the Minister’s taking the opportunity to do so. The urgency of the concerns are apparent as care home margins are squeezed by a lack of investment and a failure to deal with the funding of long-term care to an acceptable and sustainable level with local authorities facing even tighter budgets. We should recognise that care services are a vital component of the fabric of the NHS.

What happens in the care sector in England has a direct consequence for the care sector across the UK. Caring for our older population and caring for our carers is an issue of social justice. Of course there is a price tag and a cost for supporting older people, but politics is about choices and the challenges of our ageing population will only increase. We must make the choice to treat them with dignity, and to support carers and our older population as much as we can. We cannot afford not to.

3.35 pm

Barbara Keeley (Worsley and Eccles South) (Lab): It is a pleasure to speak in a debate with you as the Chair, Mrs Main. I think it is the first time for me, although others have a different experience. I congratulate my hon. Friend the Member for Hove (Peter Kyle) on securing this important debate. As well as his speech,

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there have been speeches and interventions from my right hon. Friend the Member for Enfield North (Joan Ryan), my hon. Friends the Members for Dewsbury (Paula Sherriff), for Rochdale (Simon Danczuk), for York Central (Rachael Maskell) and for Redcar (Anna Turley), the hon. Members for Newton Abbot (Anne Marie Morris) and for Bexhill and Battle (Huw Merriman), and the SNP spokesman, the hon. Member for North Ayrshire and Arran (Patricia Gibson).

The care home sector in England is in crisis. A toxic combination of a chronic lack of funding plus rising demand and increased costs means that care providers are facing an extremely difficult time. I will go on to say more but we heard a great deal about that during the debate. The social care settlement announced in the autumn statement does little to provide the additional resources that the care home sector needs. As I said in Health questions last week, the Government’s funding proposals for social care are risky, uncertain and late. They are risky because the better care funding is back-loaded. It does not reach £1.5 billion until 2019. Indeed, it offers nothing this year and only £100 million next year.

Funding from the social care precept is uncertain. It can only raise £1.6 billion if every single council decides to raise council tax by the maximum amount and that is by no means certain. Only about half of councils chose to increase council tax this year. Despite social care pressures, it is unlikely that all councils will want to implement an unpopular tax increase at this time. Both sources combined are late, because they do not help this year and they only reach £3.5 billion in 2019-20. Council leaders—including, I think, a council leader in Essex—wrote to the Prime Minister asking him to move some of the funding forward.

In a joint review of the spending review undertaken by the King’s Fund, the Health Foundation and the Nuffield Trust, the total funding gap for social care is found to be between £2.8 billion and £3.5 billion by the end of this Parliament. We need to make it a goal to close that gap. The three organisations conclude:

“Public spending on social care as a proportion of GDP will fall back to around 0.9 per cent by 2019/20, despite the ageing population and rising demand for services. This will leave thousands more older and disabled people without access to services.”

I suspect that it is probably hundreds of thousands, not just thousands.

The plans for the social care precept are seen as unfair due to the wide variations in the revenue that local councils can raise from their council tax base. Deprived areas can have the highest need for publicly-funded social care, yet councils in those areas are less able to raise significant additional revenue from council tax.

Let me give the example of my local authority in Salford. The adult social care budget is now £61 million. It has had to be cut by £15 million since 2010 due to cuts in the central Government grant, and 2% of our council tax—the maximum we could raise if everyone paid and, of course, they do not—is £1.6 million a year so that does not close the gap. Ministers have failed to explain how the social care precept can be implemented in a fair way that addresses the differences in need across the country. That is important.

The care sector responded to the spending review by saying:

“We believe the package put forward for social care will not enable us to fill the current gap in funding, cover additional costs

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associated with the introduction of the National Living Wage, nor fully meet…growth in demand due to our ageing population… the settlement is not sufficient, not targeted at the right geographies and will not come soon enough to resolve the care funding crisis.”

That is absolutely clear, and it is the sector itself saying that.

The social care funding crisis is most apparent in the care homes sector. In his opening speech, my hon. Friend the Member for Hove gave a useful analysis of the differences between large and small providers, but I will focus on what could happen with the biggest care home operator. Four Seasons owns some 470 homes and cares for 20,000 residents, mainly older people. It has been reported that, in the third quarter of 2015, Four Seasons lost more than £25 million before tax, and the rating agency Standard & Poor’s has warned that Four Seasons could run out of money in as little as six months. Squeezed local authority fees and the cost of temporary nursing staff are cited by the company as the reason for its financial difficulty, and we know from this debate that those pressures are only going to rise.

The so-called national living wage will be introduced in April 2016, and we have just heard the views of the hon. Member for North Ayrshire and Arran, the Scottish National party spokesperson, on that. Perhaps the key thing, whatever we think of the level of the national living wage, and it probably is not enough, is that the Government have so far provided no assistance to help care home providers or local authorities to address the increasing costs caused by their own policy, welcome though it is, because increasing the pay of staff working in the care sector is vital—I think we all agree on that.

Before the spending review, a sector-wide group of charities, organisations and providers wrote to the Chancellor expressing concerns about the funding gap in social care. They said that a £2.9 billion social care funding gap would have these results:

“Up to 50% of the care home market will become financially unviable and care homes will start to close their doors. 74% of homecare providers who work with local councils, have said that they will have to reduce the amount of publicly-funded care they provide.”

Care homes are already finding it difficult to provide quality care, as we have heard. The CQC’s 2015 report recognised that, of course, adult social care providers face challenging times, but it raised concerns, as my hon. Friend the Member for Hove did, that nursing homes provide a poorer quality of care than other adult social care services. Indeed, just under half of nursing homes rated up to 31 May 2015 were rated good or outstanding, and one in 10 were rated inadequate. That trend is likely to continue unless the funding gap is addressed.

We have heard about the ResPublica report released in November, which projected a funding gap of more than £1 billion for older people’s residential care alone by 2020-21. My hon. Friend referred to that, and it could result in a loss of some 37,000 beds, which would be greater in scale than the collapse of Southern Cross. A loss of beds on that scale would have significant costs for individuals, families and the NHS. If all the residents of lost beds in care homes included in the report were to flow through to hospitals, the annual cost to the NHS is put by the report at £3 billion.

There has been excellent coverage in this debate of the postcode lottery that exists in certain regions of the UK. Of course, care homes in certain regions are much

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more likely to be subject to significant financial pressures. A market insight report by LaingBuisson found that the proportion of self-funders varies dramatically between regions, and we have already heard some examples. In 2014, in the north-west, only 18% of residents were self-funders, compared with 54% of residents in the south-east. That contrast has already been drawn out by my hon. Friends. Those differences have significant implications for the financial viability of care homes in regions with higher levels of local authority-funded residents.

It is no surprise that the Government’s policies have failed to attract investment in state-funded social care, and it has not happened on its own; but many providers have been forced to attract private funders to maintain their profitability, and LaingBuisson concluded:

“Prospective new care home developments for state-funded clientele…struggle to meet investment criteria because of inadequate fee levels on offer from local authorities in most areas of the country”.

That is a serious point.

The hon. Member for Bexhill and Battle raised the issue of migrants working in nursing in the care sector, but there is a further issue with recruitment to which my hon. Friend the Member for York Central referred. Independent Age and the International Longevity Centre produced a report called “Moved to Care,” which raised that issue:

“Migrants and particularly non-EU migrants play a big role in the care workforce. Nearly 1 in…5 care workers was born outside of the UK”.

The report states that one in seven care workers—more than 191,000 people—is a non-EU migrant. The care sector has a vacancy rate of nearly 5%. That is the recruitment problem that my hon. Friend the Member for Hove talked about. Given those statistics, the serious thing is that care workers do not appear on the shortage occupation list, so a fall in net migration could have a serious impact on the care sector. As the hon. Member for Bexhill and Battle asked—this is in addition to what I was going to ask today—would it be viable for skilled care workers, including senior care workers, to be included on the tier 2 shortage occupation list, as are nurses?

Good quality, affordable care in old age is a basic right, but the current pressures that care providers and local authorities face mean that there is a risk that good care will become the preserve of the wealthy. Julia Unwin, the chief executive of the Joseph Rowntree Foundation, has said that the effects of reduced home care capacity would be “devastating.” She said that,

“care homes are already under financial pressure.”

We have heard ample examples of that. She continued,

“if proper funding is not provided…with these additional costs, the Government risks creating a two-tier care home system where good care is only available to those who can pay for it.”

Ministers must do more to ensure that the most vulnerable people in our society start to receive the good-quality care that they need.

A sustainable financial settlement is needed, but the Government’s policies are ineffective and are failing to take account of differing needs across the country. We had an opportunity for a settlement with the Dilnot reforms, but chronic underfunding has led to long delays in implementation. Will the Minister reiterate his support for the implementation of the Dilnot reforms? After all,

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page 65 of the Conservative manifesto—that was not very long ago—stated that that is what the party would do.

Whatever we do about the cap on care costs, we must first address the deepening funding crisis. A first step would be for the Government to admit that the plans announced in the spending review do not address the funding crisis that has been so amply referred to in this debate. What steps will be taken to protect services from collapse? That is the priority. Without a radical change in policy, care homes will be unable to offer the services needed to ensure what almost everybody in this room would want—that every older person has the care they need and the dignity and respect that they deserve.

3.47 pm

The Minister for Community and Social Care (Alistair Burt): It is a pleasure to serve under your chairmanship, Mrs Main. I congratulate the hon. Member for Hove (Peter Kyle) on securing the debate and thank him for introducing it courteously and knowledgeably. He is a valuable addition to the House, as indeed are a number of the new Members who have spoken. This is another example of a debate where the House’s knowledge and passion is conveyed in an entirely reasonable but challenging manner. I do not think this is the only debate we will have on this subject, so we will return to a number of issues.

I thank colleagues for their contributions. My hon. Friend the Member for Bexhill and Battle (Huw Merriman) spoke about the quality care provided in our care homes, and it is important not to lose sight of that. The right hon. Member for Enfield North (Joan Ryan) spoke about costs—we will come back to that—and workforce issues. The hon. Member for Rochdale (Simon Danczuk) spoke about the need to ensure that local authorities in poorer areas are covered, and I will speak about that. The hon. Member for York Central (Rachael Maskell) spoke about choices, and I will come back to her on that in a moment.

The hon. Member for Redcar (Anna Turley) spoke knowledgeably about workforce issues. The hon. Member for North Ayrshire and Arran (Patricia Gibson)—we wish her mother-in-law well in the home where she is situated—gave more examples of what is happening in Scotland. I am always keen to see whether we can find anything that can be extrapolated from what is done up there. The hon. Member for Worsley and Eccles South (Barbara Keeley) spoke with her usual eloquence and from her strong background in the subject. Again, we will be covering a number of these issues over quite some time, and it cannot be completed today. I thank colleagues from all parties who made interventions.

I will not be able to respond to every point in 10 minutes. I will talk about quality and care issues, the spending issue and contingency—what to do if there is a problem. I think those are the three biggest things. That does not mean that I am uninterested in integration and winter pressures, which we believe we are working through and tackling. I will not talk much about the workforce, but I entirely agree that we should value the workforce at all levels and provide a decent career path. I agree entirely with the view that everyone has to be valued in a way that has not really been the case in social care up to now.

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There are a number of other issues that I will just not be able to touch on. If there were specific questions directed at me and I do not cover them, I will go through them and write to the appropriate Member.

In general, we all start from a common position on the importance of this issue and the context in which it is set: an ageing population; people living longer with multiple long-term conditions; and many of our care workers working with dedication, both in homes small and large and in domiciliary care. I praise Chris Ryan of Bedford, who does much the same job as the gentleman the hon. Member for Hove mentioned in looking after a smaller home. It is a family business with a great sense of care and compassion, and I see those things in many homes.

May I start with a few words about quality? I am conscious of time, and I will try to keep my remarks on the three main issues that I want to cover quite short. In a way, we cannot win with the inspection regime. If inspection is done thoroughly and reveals things that need to be changed and improved, I can be lambasted for things that are inadequate. On the other hand, if we do not have a regime that turns up the things that need to be changed, then we are missing things.

The tougher inspection regime and the work that the Care Quality Commission is doing are good for us all. The bulk of homes—60% of the homes inspected, and a third of all homes have been inspected—have been rated “good” or “outstanding”. The CQC started with some local knowledge and wanted to go to the most difficult homes first. When it goes back to them it sees improvement, because the job of inspecting is not just about closing people down; it is also about seeing what improvement needs to be made.

In many cases, care is not about resource per se. I will never stand here as Minister and say that money and resource do not matter, but I will always say that making sure there is good-quality care is about many other things as well. There is tremendous variability of provision. There are people who handle the same resource in very different ways, and some are poorer at it than others. Quality of management, quality of leadership and in particular the use of registered managers in homes are all important issues, and there is much that can be learned through the inspection regime.

It is important for us to set out the five key questions, so that we remember what the regime is intended do. These questions are asked of each service that is inspected: is it safe, is it caring, is it effective, is it responsive, and is it well led? All inspections deliver a rating for the answers to each of those five key questions, on a scale that ranges from “inadequate” to “requires improvement” to “good” and “outstanding”. It is right that we do that, and I am not afraid of the answers that have been produced.

However, I want to go slightly beyond that process. I am never content to rest on what the inspection regime is bringing forward; I listen to other voices as well. Although I do not respond to all the tweets I receive, I read them all, and I am in contact with some of those who represent families and with those who have uncovered things and who do not feel that the inspection regime is doing its job. I say to them that we can do more, and I am listening carefully. I want to use the experiences of those who have been through poor circumstances to see whether we can make any changes that will make such

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circumstances less likely. There will never be nil bad circumstances, although there should be, but we must do all we can, and I am listening carefully to some less heard voices to try to ensure that that is the case.

I will speak about spending, which I know is at the heart of this debate, before I cover contingency. The hon. Member for York Central spoke about choices. I will not labour this point, but it needs to be said, because it is at the heart of all we do—yes, there are choices to be made. In a different context, I hear much talk about “mandate” from Opposition Members. The Government also have a mandate, and it is a difficult one. It is to try to ensure that our spending on public services matches the needs of the population and also looks after the future, ensuring that we are not running a continuous debt and running into more debt. It is a difficult choice, and we put it to the people and they gave their answer. We are working with that mandate.

The hon. Lady also said that how a society treats its old people is a measure of the quality of that society. That is quite true, as it is of our treatment of our children, those with mental health issues and our prisoners. It is also true of how we treat the future and what we leave for the future. That is why this Government, like every previous Government who have had to make difficult choices, including Labour Governments, have never been able to spend as much money as some would have wished. That is at the heart of this debate as well. We will do what we can with what we have got, and I will explain how we will do it, but that is the difficult choice that we have to make, and the hon. Lady does not have to do so yet. All I will say is that I will explain what we are trying to do in making that choice.

Peter Kyle: I am grateful to the Minister for giving way, and for letting us know that he reads all the tweets he receives, because that has opened up another avenue for communicating with him; he may well regret that, even by the end of today.

Part of the Minister’s mandate is to reduce spending—we understand that—and part of his mandate is to spend money better, which is an issue that has come up time and time again in this debate. There was cross-party support for an independent evaluation of the better care fund and how it applies to the care home industry. May I specifically ask him whether he will support the call for that evaluation, which came from Government Members as well as from Labour Members?

Alistair Burt: We are constantly evaluating the better care fund. We work on it with local authorities on a regular basis, and with the Association of Directors of Adult Social Services, so it is constantly being evaluated. I do not know whether something else would add to that process.

Barbara Keeley: I have made the point about choices to the Chancellor in the past. Perhaps the Minister has not got the Chancellor on side yet; I hope that he will do so. However, the inheritance tax giveaway that this Government have enacted will cost £1 billion by 2020. How far would that £1 billion go in social care? A long way.

Alistair Burt: We could all pick items of Government spending that we do not particularly fancy and say, “Oh, if only it was applied to this, it would be great”.

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Every single Government and every single Chancellor have faced the same argument. We are where we are. We have made choices about a whole variety of things, and we have a range of obligations to deliver to the public. In this particular instance, however, I want to talk about what we are spending and what is new. I will do so briefly, but I must cover that.

The Government are giving local authorities access to up to £3.5 billion of new support for social care in 2019-20. We believe that the precept could raise up to £2 billion a year, and with that money and the £1.5 billion that was included in the spending review, we believe that by 2019-20 there will be the opportunity for a real-terms increase in spending on social care.

Barbara Keeley: Will the Minister give way?

Alistair Burt: No. I have only three minutes. If I give way, I will not be able to cover everything now.

Barbara Keeley: I just want the Minister to say how councils such as the Essex council that wrote to the Prime Minister will manage until 2019.

Alistair Burt: I will give two responses to that and talk about the equalisation of funding. First, we are working closely with local authorities and with ADASS. I do not pretend in any way that the situation will not be tough for the next couple of years; it will be. However, we believe the resource is there. Secondly, the social care precept will come in this year, and that money will be made available more quickly. It will be difficult and it will be tight, but a lot of changes are being made and a lot of work is being done to ensure that services are more efficient. Those things are going on all the time.

I want to address the problem that was raised about the precept and explain how it will be used to ensure that local authorities do not miss out. The Department for Communities and Local Government published for consultation a provisional local government finance settlement in December. Recognising that local authorities have varying capacity to raise council tax, it is proposed that the additional funding for the better care fund that will be available from 2017 should be allocated using a methodology that provides greater funding to authorities that benefit less than others from additional council tax flexibility for social care. That will include consideration of the main resources available to local authorities, including council tax and business rates.

Peter Kyle: Will the Minister give way?

Alistair Burt: No, if the hon. Gentleman will forgive me; I have 90 seconds left.

That is how there will be some degree of equalisation, to respond to the point made by the hon. Member for Rochdale. More money is being spent, and there is an equalisation process.

I will speak about contingency plans briefly. Local authorities now have a responsibility, through the Care Act 2014, to monitor the care providers in their area for any early warning of difficulties. In total, 44 care providers are included. Local councils are also under a duty to provide contingency plans for what would happen if there was a failure of provision, and 95% of local authority areas are currently covered by such contingency

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plans. Of course, I am looking for answers from the other 5% to ensure that coverage is there. If there is a failure of provision, local authorities have a responsibility to step in, and we are addressing the situation to ensure that contingency provision is in place.

We believe that we have put in money that will assist the system and provide the care that is needed. With local authorities, we are constantly looking at what can be done to make things more efficient. We want to ensure that money is spent properly. That is why the social care precept is there; it can only be spent on social care. I have mentioned the position of councils that might be in particular difficulties over that issue, and over time, we will see whether that provision is sufficient. The Government and I will keep this issue under constant review, and we will talk about it again—

Motion lapsed (Standing Order No. 10(6)).

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Dartford Crossing: Congestion

[Sir Alan Meale in the Chair]

4 pm

Gareth Johnson (Dartford) (Con): I beg to move,

That this House has considered congestion at the Dartford Crossing.

It is, as always, a pleasure to serve under your chairmanship, Sir Alan. I am pleased to secure this debate on an issue that has dominated road transport in the south-east and beyond: the congestion so often found at the Dartford crossing. Local people have in their thousands signed a petition relating to the issue, and that has prompted a response from the Government. I do not believe, however, that it is right to wait for the number of signatories to reach the 100,000 trigger point for a debate in the House, so I am pleased to have secured a debate today.

The tunnels have caused problems in the area for pretty much all my life. It is fair to say that there was a period of respite when the bridge was built, but that was back in 1991, and the problems have grown ever since. In Dartford, we believed that there would be further respite when the tollbooths were finally removed but, alas, that has not been the case. Today we have congestion like I have never known before.

Quite simply, the approach to the Dartford crossing is Britain’s worst stretch of road. I challenge the Roads Minister to name one stretch of road in the UK that is worse than the Dartford crossing approach. It will be interesting to see whether he can come up with a single road in the whole United Kingdom that can compare. The congestion has a huge impact on local residents. Children cannot be picked up from school and people cannot get to work or home from work. People say to me that often it is like being a prisoner in their own home. Businesses are also affected, particularly those on Crossways Boulevard. If the congestion continues, it will ultimately cost Dartford hundreds of jobs.

We have a growing economy. London and the south-east are envied around the world for their wealth creation. The south-east provides not just thousands but millions of new jobs. It is very much the financial engine of the country, but the whole area is held back by Britain’s worst stretch of road. It is pointless to have a financial engine if the tyres are punctured. As the Prime Minister said in response to my hon. Friend the Member for Sittingbourne and Sheppey (Gordon Henderson), we cannot secure inward investment for Kent unless we have a modern road system. That applies as much to the A249, which my hon. Friend asked about in Prime Minister’s questions, as it does to the Dartford crossing.

The congestion is not only a transport issue; it also leads to pollution. The pollution created at the Dartford crossing is nothing short of a national disgrace. It is both noise pollution and air pollution. According to Public Health England, a staggering 6.7% of the deaths in Dartford are at least partly attributable to long-term exposure to human-caused particle air pollution. In other words, more people die from air pollution in Dartford than anywhere else in Kent or Essex. The figure is the second highest in the whole south-east, behind only Slough, which is of course home to Heathrow

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airport. The worst area in the east of the country is Thurrock, and we know where the Dartford crossing links up to. Why should the people of Dartford be subjected to such high levels of pollution? Why should the health of people in Dartford be put at risk by the road scheme?

The congestion at the Dartford crossing will be properly dealt with only when we have another crossing in the lower Thames area. In my opinion, that crossing should be located away from Dartford and east of Gravesend if it is to provide a proper alternative for the motorist. I shudder to think of the problems that will be caused if another crossing was to be built at Dartford.

Stephen Metcalfe (South Basildon and East Thurrock) (Con): I congratulate my hon. Friend on securing this important debate and echo some of his comments, particularly on air pollution in Thurrock. I am privileged to represent parts of that area. He talks about an additional crossing east of the existing crossing. Does he agree that both options A and C answer a question that was posed 10 years ago? We should broaden the debate and potentially look further east, and west into London, to resolve the issues.

Gareth Johnson: My hon. Friend makes an important point, and I pay tribute to his campaigning on behalf of his constituents on transport links in Basildon and Thurrock. As I understand it, the Mayor of London continues to assess the alternatives to the Blackwall tunnel, and that work is ongoing.

With the Dartford crossing, I argue that options D, E and F have been assessed previously and have been properly looked at. We are left with options A and C. My hon. Friend the Member for Gravesham (Mr Holloway) is a vociferous opponent of any crossing east of Gravesend. I disagree with that stance; I believe that there needs to be that alternative for the motorist, but we need a decision. We need something to be built as soon as possible, because the current situation is completely untenable.

Gordon Henderson (Sittingbourne and Sheppey) (Con): Would my hon. Friend accept that any crossing east of the Dartford crossing would have to take account of the existing problems on the M2 and the A2?

Gareth Johnson: My hon. Friend makes an important point, and I would add the M20. It has been years—I cannot remember it happening in my lifetime—since we have seen any major improvements on the M20, A20, M2 or A2. It is high time that we had some road improvements in the county of Kent. We have increasing levels of traffic coming from the port at Dover through to the east of England and round to ports such as Harwich. Kent is being used as a thoroughfare. There are too many pinch points and too many roads that simply cannot cope with the amount of traffic that we have. A garden city is being built in my constituency. We have population growth throughout the county, which in many ways is welcome, but we must have the infrastructure to match that, and a crucial part of that infrastructure is investment in our road network, because the local roads simply cannot cope with the demands of the levels of traffic.

On whether there should be a crossing at Gravesham or Dartford, my argument is that another crossing at Dartford would give us years of roadworks. As a

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consequence, we would have more traffic squeezed into what is already a pinch point. It would be nothing short of a disaster for the town.

Mr Adam Holloway (Gravesham) (Con): I thank my hon. Friend for securing the debate. It strikes me that we need to fix the appalling problem at Dartford—I was not aware of the awful statistics he mentioned on respiratory illnesses—but is not the answer, therefore, to fix the problem at Dartford, rather than unnecessarily create a whole range of problems for 20,000 people to the east of Gravesend?

Gareth Johnson: My hon. Friend the Member for Gravesham and I disagree on this. Understandably, he wants a crossing, but not in his constituency, and I fully understand the reasons why. My argument is that if we had another crossing east of Gravesend, we would see far less of the stationary traffic that creates the most pollution. It is estimated that 30% of the traffic currently using the Dartford crossing would move east of Gravesham, where there would be another crossing, giving not only relief to Dartford but an alternative for the motorist. If we insist on having just one crossing point at Dartford, no matter how wide we make it, it puts so much pressure on the roads in the area that they will not be able to cope. One single problem on the M25 at Dartford can cause mayhem in the area. We need an alternative. Unless we have that alternative, there will always be problems at Dartford.

Mr Holloway: Does my hon. Friend not agree that the reason for the northbound back-up is that we have a tunnel bore? According to Highways Agency staff, the problem is caused by dangerous goods vehicles backing up. It takes seven minutes to reverse one. Should he not concentrate on fixing the problems at Dartford, rather than creating problems for people living elsewhere?

Gareth Johnson: HGVs that are too high and need to turn round do cause problems with delays in that area—

Mr Holloway: It is the problem.

Gareth Johnson: It is not the only problem.

Mr Holloway: It is the main one.

Gareth Johnson: The existing tunnels were designed for roughly 140,000 vehicles a day, and anything up to 170,000 vehicles currently use them. Inevitably, according to the laws of physics, there will be congestion at certain times going through the existing Dartford tunnel. So we have two options. We either build a crossing further away from Dartford to give motorists an alternative, or we put another crossing next to the existing one, putting an increasing amount of pressure on local roads that cannot cope at the moment. If we put more traffic there, even after the roadworks are finished we will have even more problems.

Mr Holloway: That is the point. If my hon. Friend wants to protect his constituents from respiratory problems, he has to have a way of stopping those great build-ups at Dartford. Of course the multi-billion-pound answer is to build another crossing, but another bridge at Dartford going northbound will help his constituents much more quickly.

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Gareth Johnson: Even if we had 100 crossings at Dartford, we would still rely on a small geographical area that would inevitably be a pinch point. The only solution is to have another crossing east of Gravesham. I struggle to think of organisations outside of Gravesham that believe Dartford is the best location for another crossing. The organisations I have spoken to—outside of Gravesham—agree that there should be a crossing elsewhere and an alternative for the motorist. That is the way forward and it is the only way in which we will see real relief from the problems we have today.

Stephen Metcalfe: I am grateful to my hon. Friend for giving way and being so generous with his time. Does he accept that the danger with his approach of championing a crossing east of the current crossing is that we will still experience air pollution at the existing crossing and create a new area of air pollution to the east potentially coming into my constituency? Because both options A and C land in Thurrock, we will end up with pollution both in the west and the east of the borough. Would it not be better to move some of this to a wider extent and not concentrate it in south Essex?

Gareth Johnson: My argument is that if all the traffic uses one area, it inevitably leads to traffic hold-ups and increased pollution. The best way of dealing with pollution in an area is to relieve the congestion. The only way to properly relieve congestion in north Kent is to have another crossing away from Dartford—east of Gravesend —that gives motorists an alternative and ensures there is less chance than we have now of the horrific jams that we so regularly see in that area.

Kelly Tolhurst (Rochester and Strood) (Con): I thank my hon. Friend for securing the debate today. My constituents complain continuously about the tunnel and congestion. They also think the charges are a tax on local businesses in the south-east. Does my hon. Friend agree that, whatever option is put forward, we need a real strategic view and a project that suits north Kent’s development over the next 20 years and meets our needs? We are an important part of the UK and any project must be suitable for the future—not just for now—and not simply solve a problem in the short term.

Gareth Johnson: The hon. Lady is absolutely right. That is why option C ensures that the vehicles using the M20 are able to access the Thames. We must take into account the growth in population in the area. I pay tribute to the work that the hon. Lady has put in for her constituency. I know that the problems with the Dartford crossing affect her constituents, a number of whom have contacted me. I pay tribute to the work that she has put in on their behalf to help alleviate some of the problems that they have had, particularly using the Dart Charge system.

I need to make progress; I am aware that the Minister will have limited time to respond. I will focus on the small part of Dartford where a lot of the problems are caused—the roundabouts at junction 1A and the Bluestar roundabout at junction 1B. These need a major overhaul and greater enforcement of the vehicles that block traffic on the roundabouts. Highways England correctly points out that that is an issue for Kent County Council. We therefore look to those organisations together to tackle the issues.

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I recently held a round-table summit for all authorities with responsibility for the crossing. Both Kent County Council and Highways England know that the current situation is untenable, and that they need to find a solution. Congestion is also caused at the slip road from Bob Dunn Way, which causes huge problems for the people who live on an estate called The Bridge, which is adjacent to that road. If Kent County Council is unresponsive to requests made by Highways England, it should make that publicly known. Kent County Council must work with Highways England to find a solution to the problems that we currently face.

The new road layout was put in place to facilitate the free-flow system that saw the back of the tollbooths. I still maintain that it was right to remove the tollbooths, but the road layout simply has not worked. The Dart Charge system is riddled with administrative errors and incompetency. Hardly a day goes by—I am sure this is the case for my colleagues in Kent and in Essex—when I am not approached by a motorist who has been wrongly or unfairly given a penalty notice. I do not want any tolls on the crossings in the area, but where they exist motorists have a right to have confidence in the tolling system. The London congestion charge rarely makes a mistake, but the same cannot be said about Sanef, the company that runs the Dart Charge system. Will the Minister look again at withholding payments to Sanef until it can rectify the mistakes it frequently makes?

I anticipate that the Minister will claim, on behalf of Highways England, that journey times have improved since the new road system was put in place. I do not dispute that traffic flow has improved from Essex into Kent. However, it is hard to find anyone in Kent who thinks that journey times the other way round have improved. Highways England claims that journey times northbound have improved by five minutes. However, that calculation is obtained purely by measuring traffic flows for just 1.5 miles before the tunnel entrance, compared with 6.5 miles approaching Kent from Essex. Why the difference between the two? It seems that the figures have been taken to obtain the most favourable outcomes. I hope that this is not simply a case of cherry-picking. Why not measure from the same distance northbound and southbound? Parliamentary answers today show that such figures are not available.

In conclusion, Highways England has accepted that it needs to do more, and I agree. The approach to the Dartford crossing is a hellish, unpredictable nightmare for motorists. The crossing strangles the town of Dartford and causes misery and anger. It damages both the economy and the health of the local area and must be improved as a priority. The road layout needs a major overhaul. Britain’s worst stretch of road needs to be given priority by both Highways England and the Department for Transport. It is essential that everybody who has been stuck in jams at the crossing hears that action will be taken to improve the situation in advance of a new crossing being built.

Sir Alan Meale (in the Chair): Before you start, Minister, I apologise for the short time you have to respond. I thought it was important that the local Members had a chance to participate in the debate and get their message across.

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4.20 pm

The Parliamentary Under-Secretary of State for Transport (Andrew Jones): Thank you very much, Sir Alan. We need to ensure that local Members’ voices are heard—I have absolutely no problem with that and will rattle through what I have to say. The need to champion the constituencies in the area, recognise the problems and seek answers has come across very strongly.

I congratulate my hon. Friend the Member for Dartford (Gareth Johnson) on securing this debate on an issue that is incredibly important to him. We have discussed it on previous occasions, and he is a vigorous local champion and continues to highlight the issue. It will be no surprise for him to hear that we agree on many of the issues he has raised. He has played an important role in bringing people together locally, and I hope that, as that work continues, I will be able to offer support, and that we will be able to work together and count on each other’s mutual support as we make progress and develop solutions.

The crossing consists of two bored tunnels for northbound traffic and a bridge for southbound traffic. It was initially built as a tunnel 50 years ago to provide a link between Kent and Essex, and provides the only road-based river crossing east of London. It is a link in the M25, which is used by many to orbit or bypass the capital, as well as a connection to several strategic radial routes. As my hon. Friend said, since it was originally built, the area has seen enormous growth. The M25 has been constructed, as have the Lakeside and Bluewater shopping centres. Traffic levels have increased, including freight, and the crossing provides connections to a host of international gateways in the south-east, including the port of London, the Medway ports, the port of Dover and the channel tunnel.

The incremental upgrades that have been made as growth has occurred have led to a layout ill-suited to the needs of today’s traffic. The crossing is now one of the busiest stretches of road in the country. I cannot say that it is the worst road in the country, because I am afraid to say I have heard that accusation from many colleagues in this place, but I can certainly agree that it is a real problem, so we have to work together to find a solution. The Dartford crossing is hugely busy, with more than 50 million vehicle crossings each year, and it has been operating well above its design capacity for years.

When incidents occur, the consequences for the road network are severe. Delays can take a long time to clear, meaning that road users have to endure unreliable journeys. There are typically more than 300 unplanned lane closures every year. When the crossing closes, users have no choice but to wait it out, use the Blackwall tunnel, or take the long way around the M25, all of which are unacceptable options. Such resilience issues will worsen until we build on the actions we have taken recently and get the planning right for future capacity.

The free-flow system has been mentioned a number of times in the debate. Until recently, the road layout on the south shore of the crossing broadened out to multiple lanes to accommodate toll booths and then merged back into four lanes in each direction. The new arrangements, known as free-flow charging, require remote payment of the Dart Charge. Drivers no longer need to stop to pay at a barrier, and there is no need for multiple lanes

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to merge back in. The new arrangements have reduced journey times, although I recognise the concerns that my hon. Friend has about the accuracy of the data. I will pass them on to Highways England and ask it to write back. I will then forward the reply to him. The latest data from Highways England show that journeys are now on average a third faster than before the new system was introduced. Those traveling from the north to the south are saving almost 7 minutes, which is a reduction in journey times of around 36%. Less positively, for those traveling from south of the river the journey time saving is around 3 minutes per trip, which is much smaller.

Mr Holloway: Does my hon. Friend agree that we need to be a lot more creative if we are to rescue the people of Dartford and prevent the blight on 15,000 homes? We have to think about things such as using the tunnel for local traffic and anticipating the huge future effects of driverless cars. We also need to do pretty straightforward things such as running freight trains—rather than unloading them all at Dover, we should let them run north.

Andrew Jones: I entirely agree that creative approaches are required. We will need to take a number of approaches, because there is no single, silver-bullet answer to this question. If I have time, I will discuss some of these issues shortly.

After several months of close working, in December, Highways England made proposals to both Kent County Council and Dartford Borough Council to make better use of technology, such as signalling and signs. The proposals have been with Kent County Council for a short period, and a response is due in the next few days. In addition to that partnership, I hope data sharing will help both authorities to agree strategies to help traffic moving between the local network, which is controlled by Kent County Council, and the strategic network, which is run by Highways England. I expect decisions to be made and improvements in place by February. My hon. Friend the Member for Dartford has supported the initiative through his work to bring all parties to the table, and I hope he will be pleased with the results as it develops.

Highways England is working hard to improve the traffic safety system, which meters traffic if congestion is backed up on the other side of the tunnel to prevent the dangerous build-up of traffic inside the tunnel. Nevertheless, I agree with my hon. Friend that there are still unacceptable levels of congestion at the crossing, caused by the limits to its capacity and driven by the extreme growth in traffic. More needs to be done. That “more” is the development of a lower Thames crossing. From the debate today and the conversations I have had with colleagues, I recognise that a new crossing is not going to be an easy option. There will perhaps be some difficulty in getting everyone aligned behind it, but I have no doubt that we need to get it in place.

The Dartford crossing’s capacity has been exceeded. In July and August 2015, the bridges and tunnels carried 20,000 more crossings a day than they were designed for. Dart Charge is at best a medium-term solution to the capacity challenges. The 2011 national infrastructure plan named a new lower Thames crossing as a top-40 project. Successive Governments have investigated the need for

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additional crossing capacity in the lower Thames area and where to locate it. The Government are committed to delivering the investment required for a new lower Thames crossing in the next road investment period. Highways England is currently concluding its examination of routes at the two remaining location options: a further crossing near the existing Dartford-Thurrock crossing, or a new link further east to connect the A2/M2 with the A13. There would be many benefits to a new lower Thames crossing, some of which have already been articulated during the course of the debate, but the decision is very important and will affect thousands of people, so it is vital that we get it right.

On the administration of the Dart Charge scheme, Sanef’s performance is of concern to colleagues. I have called Sanef in to meet me at the Department to highlight our concerns. Complaint levels are at their lowest to date, but I will continue to monitor the situation and ensure that the feedback from colleagues present is delivered back to Highways England, Sanef and Kent County Council. Local service providers are working together, and I guarantee my support for finding solutions to make the situation better. I will do all I can to support them and local Members. The situation is very challenging. It is driven by growth and capacity constraints. We can take some short and medium-term measures to improve the situation, but a long-term measure in the form of increased capacity via a new crossing is the only answer that will make a significant difference.

Question put and agreed to.

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Hand Hygiene: NHS

4.30 pm

Nigel Mills (Amber Valley) (Con): I beg to move,

That this House has considered hand hygiene in the NHS.

I am grateful for the chance to raise these concerns. It is a pleasure to serve under your chairmanship, Sir Alan. I secured this debate to highlight some important issues. The germs that cause infections are spread to patients primarily on the hands of healthcare workers, so cleaning hands is the No. 1 way of reducing the spread of infection. Guidelines and rules are already in place, but they are not followed closely enough and the inspection regimes do not do their job and do not produce meaningful data about hand hygiene compliance levels. This serious issue has a dramatic effect on the health of many thousands of patients a year. For many of them, it could be avoided. There is a way of dramatically improving this issue for patients.

The data on this issue are scary. The 2011 prevalence survey showed that 6.4% of hospital patients—one in every 16—contracted an infection while in hospital. Imagine going to a restaurant where one in 16 customers was made ill by the food. No one would go back again; we would not allow it to stay open. But that is what the data showed for our hospitals five years ago. We should not be willing to accept that.

Infections contracted in hospitals affect 300,000 patients every year and cause 5,000 deaths. They have a dramatic impact on those individuals and a significant impact on the NHS, because patients who contract such infections remain in hospital on average two and a half times longer than patients who do not. They spend an average of 11, and a maximum of 25, extra days in hospital at an estimated cost of about £1 billion a year. It is estimated that 30% of such infections can be avoided simply by better applying the existing rules and practices.

The NHS must improve its performance on this fundamental issue. We should not be willing to accept that level of unnecessary infection. I am not saying that such infections are caused by people deliberately not washing their hands enough. They probably do not realise what they are doing, and their behaviour is not corrected. I suspect that most people in the NHS do not realise how many times they should wash their hands when they see a patient and do not know that they are not doing all they can. I am sure most people are extremely keen to do everything they can to fix this problem and prevent such infections. We must look at what more we can do to put systems in place and enforce them. We should give people support, training, peer pressure and peer reviews to ensure it is happening, rather than blame individuals. This issue will become increasingly important as the problem of antimicrobial resistance grows. We cannot rely on antibiotics to fix such infections and tackle the problem, so it is important that we stop the infections in the first place and prevent the situation from getting worse.

I want to talk about the existing hand-washing rules, the systems for monitoring them and why they do not work. I will look at some things that can be done to improve the situation. I hope the Minister will accept that I do not intend these ideas to be controversial or costly; they are ways of enforcing the rules that are already in place and of using the existing systems.

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There is a generally accepted international standard for the number of hand-washing moments when nurses and doctors treat patients. It is not controversial; all nurses and doctors are taught it as part of their training. It is an accepted standard in the NHS and most hospitals around the world. I am not asking for a super gold standard for the UK. I do not want to create anything new, different or complicated. That set of moments when hand-washing is needed is accepted by everybody; it is just a question of how many of them are acted upon.

The National Institute for Health and Care Excellence put in place rules for hospitals to assess compliance with that number of hand-washing moments, so we do not need a new framework or a new duty on hospitals. Hospitals already have a duty to assess how well their staff comply with the rules for the five hand-washing moments when they deal with patients. When the Care Quality Commission audits hospitals, it checks how well those rules are enforced, so the systems are there but they are not working and we are not getting the outcomes we ought to have.

One of the problems is that hospitals check the compliance of their staff mainly through observations carried out by a member of staff on the ward or a member of the team. Normally, a nurse who happens to have half an hour spare one day is asked to review how well her colleagues are performing the five hand-washing moments. If I am doing a job and someone tells me, “Right, today you’re being observed on these criteria,” my performance goes up a bit because I know I am being observed and I do everything I can to comply—far in excess of my normal behaviour.

Another issue is that the staff members conducting the review are not trained in how to do it. They may not be entirely familiar with how many hand-washing moments there are or how many arise in the care of patients, so there is a combination of effects. If the people reviewing their colleagues, perhaps their friends, have not been trained to do so—they are not specialists—and are not fully familiar with the rules, it is not surprising that we do not end up with the most reliable data.

The vast majority of the observations show that the nurses and doctors observed are somewhere in the high 90s for compliance, which means they clean their hands more than 96% of the time, as they are meant to. The problem is that independent assessments carried out by people in a more reliable way suggest that compliance is significantly lower. Those data suggest that the actual compliance levels are somewhere between 18% and 40%. There is a set of rules and a system for checking compliance, but it is producing a dramatic false positive. It suggests that we are in the very high 90s for compliance, when we are nearer 20% compliant. It overstates the results by a factor of nearly five, with the terrible effect that there are more infections than there need to be and patients are suffering.

The NHS and other international health bodies accept that the levels of compliance with the hand-washing rules in the high 90s cannot possibly be right. Everybody knows they are false positives, but they give excessive reassurance to the boards of trusts that their staff are compliant, so further action is not taken. Everybody accepts that there has been progress in recent years in tackling infections, which have been reduced from even higher levels. The measures that were adopted to tackle

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infections had an effect on clostridium difficile and MRSA, but the problem is that we do not track instances of other infections, so it is hard to get data on how many are being tackled.

There have been various studies to try to assess levels of hand hygiene compliance to see what can be done to improve it. I am grateful to the Deb Group, one of the large employers in my constituency, which has an interest in this issue because it makes hand hygiene gel. It has some innovative ideas about how we can monitor hand hygiene compliance. I am grateful for the information it gave me for this debate. I should be clear that I am not advocating any one solution or product; we need a greater recognition in the NHS that this is an issue, and that there are better ways of assessing compliance. We need to encourage greater compliance.

As for recognition of the issue, Sir Mike Richards, the chief inspector of hospitals at the CQC, has highlighted the inaccuracy of local hand hygiene audits, so one would think that action is required. If we recognise that hand hygiene is important and if we recognise that we are nowhere near as compliant as we ought to be, one would think that many hospital trusts would be taking action to try to improve the situation. Sadly, that is not the case. Trusts have a lot on their plates and there are many issues, financial and others, to deal with, so they may decide that an area with compliance levels in the high 90s is not a stone that they want to turn over. They may fear that some proper audits might lead to the discovery that they are only 25% compliant and thus incur some unnecessary wrath.

However, the experience is that hospitals that take the matter seriously do get positive feedback. The CQC report on Burton Hospitals NHS Foundation Trust, which was in special measures until last year and is not too far from my constituency, highlights its use of a method to count the number of hand hygiene moments and the number of times ward staff were complying with the rules. It received some positive feedback in the letter from the chief inspector of hospitals in the report, which states that the hospital was using

“innovative practice to increase hand hygiene, using the latest technology monitoring the use of alcohol in sanitising gel.”

They were not marked down for having discovered an issue; they were complimented. The report states:

“We saw innovation in practice on ward 11 (male surgical ward) where the infection control nurses had worked with staff to reduce infection control risks and increase hand hygiene. The team implemented technology which counted the use of alcohol sanitising gel and compared it against the target of how often it should be used. This was in response to hand hygiene audits which needed improvement.”

On action that the trust must take to improve, the report states:

“The trust must ensure that ward assurance targets, such as hand hygiene practice and recording of patient observations, is achieved at a consistent level in the emergency department.”

We can see from that that if hospitals take the matter seriously, recognise that they are not as compliant as they ought to be and take action, that helps them in these audits.

The big ask here is what more we can do to ensure that CQC reviews identify that hospitals are perhaps fooling themselves into thinking that they are compliant when they are not. Perhaps asking, “Are you really doing accurate and competent monitoring of whether your

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staff are complying with the hand hygiene rules? Do you have any independent assurance that that data is accurate or are you just relying on surveys done in an idle half an hour by a member of staff who is not really trained, which can produce false positives?” should be a regular feature of all inspections. Work done over a long period to improve levels of hand hygiene compliance in hospitals has produced data showing that when hospitals improve performance and increase the number of hand hygiene moments, infections decrease at a pretty similar rate to the increase in hand hygiene moments. Data exists in the public domain that shows that that is not just a coincidence. If a hospital can increase compliance, infection rates can come down, improving outcomes for patients and reducing costs to the NHS.

My suggestion is not particularly complicated or expensive. It would not lead to the creation of new rules or new burdens that people have not been trained for. I am simply asking that hospital trusts around the country comply with the rules that are already there and monitor whether their staff are complying with the standards that they have been trained in. The NICE guidelines could be tightened up so that hospitals must not only monitor whether staff are compliant, but do so in a competent, independent and impartial manner and not rely on the occasional untrained observation by members of the same team.

When the CQC goes around hospitals assessing cleanliness and patient safety, we should expect it to check whether competent work has been done. If it has not, it should encourage and instruct hospitals to take the matter seriously. When hospitals show higher than average instances of infections, it should check that they took this issue seriously and that the relatively simple and low-cost measures that can be taken to reduce infection were applied. When hospitals are not doing that, it should be regarded as a serious issue.

There are many things in health that we cannot control or fix or that are incredibly expensive, but what we have here is a set of rules that already exist. It is a simple thing that most people are trained in. By doing everything that we can to comply with it, we could save a lot of money and a lot of patient suffering. There is the potential for real improvement. I hope the Minister will accept that this is a serious situation, and that there is more that NICE and the CQC can do and more that hospital trusts can be expected to do, so that the prevalence of infections in the next report is at the lowest possible level.

Sir Alan Meale (in the Chair): As the debate is only an hour long and we have three quarters of an hour remaining, I want to inform Members that I intend to call Back Benchers first, then the Front-Bench Spokespeople and then the Minister. I will call the Back Benchers who stand.

4.45 pm

Mrs Madeleine Moon (Bridgend) (Lab): It is a pleasure to serve under your chairmanship, Sir Alan. I commend the hon. Member for Amber Valley (Nigel Mills) for calling the debate. It is such a simple issue. We are taught from early childhood to wash our hands, and yet somehow it seems to get lost. It seems to have disappeared

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out of our daily practices. We are failing on one of the easiest ways of addressing so many conditions that are costing this country a huge amount and causing the NHS a terrible problem.

We are told every day whether we should take vitamins or whether we should drink red wine, which is either good for us or destroying our lives, and we are told what superfoods to eat, but a simple, life-changing thing that can be added to the daily routine is washing one’s hands on a regular basis. It is one of those bizarre things that came up during a quiz. The question was, “What is the fastest thing that a human being can do?” and the answer was sneezing. Apparently, a sneeze comes out at 100 mph and can spread across a huge area. Most people catch it in their hands and do not then think to wash them. We all know about washing our hands after going to the bathroom, but we somehow cough and sneeze into our hands and pass diseases on, particularly to those who are vulnerable, in the most frightening of ways.

Globally, poor hand-washing leads to 600,000 deaths a year. Another horrible statistic is that 28% of commuters across the UK have faecal bacteria on their hands. I dread to think who found that out and how they did it, but there we are. It takes just 30 seconds of washing to stop an infection being passed on to someone else and it can make huge difference. In Europe alone, 25,000 people a year die from infections resistant to antibiotics. Resistance to antibiotics is on the global agenda and hand hygiene is a way that we can actually reduce our dependence on antibiotics and prevent common illnesses such as food poisoning.

I want to bring to the Minister’s attention today a deeply concerning condition that sadly not many people seem to know about, but hand-washing really can make a difference to it. CMV, or cytomegalovirus, is a common virus that can infect anyone. Most people will not know they carry it, but if a pregnant woman contracts the virus, she can pass it on to her unborn child with catastrophic results. Almost 1,000 children are affected by the condition every year. CMV can cause miscarriage or stillbirth. Five out of 1,000 babies will die in their first year of life, and two to three babies a day are damaged by CMV, which was identified in 1956 by the same research team that discovered polio, mumps and rubella. There is no vaccine to deal with it, but we can prevent passing it on simply by washing our hands.

CMV is responsible for 25% of childhood hearing loss, as well as for vision loss, physical impairment, ADHD—attention deficit hyperactivity disorder—behavioural and learning difficulties, and cerebral palsy. It is passed on by bodily fluids, mainly saliva and urine, often from small children. It is battled simply by washing hands in soap and water and by getting parents to understand that they must not share food, cutlery or drinks with their children. No parents, I hope, would think of changing a child’s nappy without washing their hands, but how many parents wipe a child’s nose without thinking to use a handwashing sanitiser or washing their hands. Parents should ensure that they wash their hands both before and after feeding a child. Those are simple ways to prevent dramatic changes.

Hand-washing can prevent diarrhoea, vomiting, food poisoning, the norovirus and MRSA. It is a simple way to change infection rates. We could save the NHS huge amounts of money. I am pleased that nurses are very

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conscious of it, but we almost need to have every patient watching for other people’s visitors and ensuring that they use the antibacterial washers as they enter the ward. The statistic mentioned by the hon. Member for Amber Valley—one in 16 patients acquires an infection—is horrific. That is not something that on the whole doctors have to combat; it is something that every one of us as patients, visitors and fellow citizens should take responsibility for tackling. I am delighted that we have had the opportunity to raise the profile of the issue today.

4.51 pm

Andrea Jenkyns (Morley and Outwood) (Con): It is a pleasure to serve under your chairmanship, Sir Alan.

I thank my hon. Friend the Member for Amber Valley (Nigel Mills) for securing the debate and for his support of my campaign on hand hygiene. I also thank the hon. Member for Central Ayrshire (Dr Whitford) who, with the hon. Member for Wolverhampton North East (Emma Reynolds), worked with me on a cross-party campaign on hand hygiene. Recently, we got more than 50 MPs to sign up to it. I ask anyone present who has not signed up to join us, please. Hand hygiene is a bit of a personal crusade of mine. We simply cannot ignore the importance of hand hygiene in hospitals and the community. It is the single most effective, yet simple, way to prevent avoidable infections and so reduce the burden on the NHS.

I will talk a bit about my background and why I am such a fierce advocate of hand hygiene. My father, Clifford, was diagnosed with lung cancer in 2011; the prognosis was good, but he got fluid on his lungs and he went into hospital for a routine operation. The simple procedure should have taken about 20 minutes, but a junior doctor practised reinserting the lung drain with medical students for two hours. My father subsequently became infected with MRSA. What we saw in the hospital was shocking. One nurse walked in, put antibacterial cream on her hands, put something up my father’s nose and did not wash her hands. Basic things were not happening. I constantly observed a failure to follow basic hygiene procedures, which I mentioned to nurses at the time, but I was ignored and even rebuked. A few months later, in November 2011, he died from MRSA.

Afterwards I got in touch with MRSA Action UK, the charity, and became its regional representative. In Parliament, I set up an all-party group for patient safety for the Patients Association—I commend the Minister, the Secretary of State and the shadow Minister, the hon. Member for Ellesmere Port and Neston (Justin Madders), for supporting it. From my conversations with the Secretary of State and other Ministers, I know they are taking hand hygiene seriously and have plans to deal with it.

On areas for improvement, the World Health Organisation has taken a lead in establishing good practice in hand hygiene around the world, although through Dame Sally Davies, our chief medical officer, and the Prime Minister we have put the issue of antimicrobial resistance on to the global agenda. The WHO talks about the five moments for hand hygiene and identifies when medical workers should wash their hands, providing clear guidance that could make a real difference to hand hygiene routines. I commend the work done by everyone at the WHO.

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In England, hand hygiene is most frequently monitored through direct observation—a member of the ward staff will take time to observe colleagues and their adherence to the five moments of hand hygiene. Such studies often produce incredibly high rates of compliance, nudging around 80% or 90%. That is because direct observation is ineffective. Only a minimum of 10 moments have to be observed, which on a busy ward is negligible. Furthermore, staff are aware that they are being monitored and will often change their behaviour—I know that from personal experience.

The APPG had an evidence session at which a lady from the Royal College of Nursing was present. I asked her a simple question—whether she had ever disciplined anyone or taken any of her nursing staff to one side to discipline them on lack of hand hygiene. The answer was no. That was in a 20-year career. We need to ensure a place of consequence if hand-washing is not adhered to.

The hon. Member for Amber Valley and I were presented with some startling statistics at a recent meeting with the Deb Group, which kindly sponsored our cross-party Handz campaign. They included registered rates of hand hygiene compliance as low as 20% to 40% in hospitals in which Deb systems were installed. Such figures are common to other companies offering a similar service in the healthcare sector. We cannot ignore the fact that, although the hospital statistics show a high rate of compliance with the five moments, in reality it is not always the case.

We need to implement a new system for proper observation and monitoring, hand in hand—excuse the pun—with proper awareness of the risks of poor hand hygiene. The hon. Member for Central Ayrshire has told me a lot about the fantastic work being done in NHS Scotland, educating the public with a proactive campaign of posters and information.

Douglas Chapman (Dunfermline and West Fife) (SNP): As the hon. Member for Bridgend (Mrs Moon) has suggested, there are simple ways in which to improve hand hygiene. Recently, when visiting a school, I noticed that children were washing their hands to the two verses of “Happy Birthday to You”, which seemed to be going down well and was doing the trick. Does the hon. Lady accept that that is a good way of introducing children to hand hygiene at an early age? It is cost-effective, simple, memorable and starts the hand hygiene routine at a very early age.

Andrea Jenkyns: I thank the hon. Gentleman for making that point. With MRSA Action, the charity that I am involved with, I have been going into schools and we use that technique of singing “Happy Birthday” twice. The Handz campaign with the hon. Members for Central Ayrshire and for Wolverhampton North East is about education in schools and promoting hand hygiene from a young age. It is a year-long campaign running through to October and we are also going to go into care homes—there was a recent Westminster Hall debate on care homes—to emphasise the importance of good hand hygiene with the vulnerable in care homes.

Going back to what I was saying, hospitals in Scotland are covered in reminders for people to wash their hands and about the risks brought on to the ward if they do not. I am sure that the hon. Member for Central Ayrshire will mention this herself, but, in Scottish hospitals, people observe staff members when the staff members do not know they are being observed, which is a much better system than the one we use.

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To sum up, we need to do a number of different things to improve hand hygiene compliance. First, we need to improve observation and reporting of hand-hygiene breaches so that we can get real and effective reports on compliance. As I said earlier, we need a place of consequence when that does not happen.

Secondly, we need to make it clearer to patients and staff when a ward is not hitting its compliance targets. NHS staff strive for brilliance and we thank them for their hard work, but we need to ensure that they are aware of areas in which they need to improve.

Thirdly, we need to ensure that people are properly aware of the risks of poor hand hygiene compliance in hospitals and elsewhere. Those achievable aims would make a real difference. The hon. Members for Wolverhampton North East, for Central Ayrshire and I are working hard to increase awareness through the Handz campaign and are planning further events.

Hand hygiene goes beyond people catching infections in hospital. More infections means that more antibiotics are needed for treatment, which leads to antimicrobial resistance, which is a huge global threat. Dame Sally Davies, our chief medical officer, has been an advocate on that issue and supported our campaign.

Hand hygiene is incredibly important. I reiterate my thanks to my hon. Friend the Member for Amber Valley for securing the debate, which will make a valuable contribution to discussions on the subject. The UK already leads the fight and it is great to see so many colleagues from the Government and other parties with such great enthusiasm for the subject.

5 pm

Jim Shannon (Strangford) (DUP): It is always a pleasure to serve under your chairmanship, Sir Alan. It was especially nice to hear the hon. Member for Amber Valley (Nigel Mills) introduce the debate, and it is good to participate in it. I would like to give some personal knowledge and put forward some viewpoints.

I congratulate the hon. Gentleman on so succinctly setting the scene for the rest of us to follow. To add a bit of background to the debate, patients in the NHS today have a 6.4% chance of catching an infection in UK hospitals. There are 300,000 healthcare-acquired infections annually, of which 5,000 result in mortality. We cannot ignore the mortality rate—5,000 people dying in our hospitals is 5,000 too many. If the figure was one, that would be one too many. If we can take steps to prevent those deaths, we should do so.

Although our figures are below the European average, many other developed countries perform better, including the United States at 4.5%, Italy at 4.6%, Slovenia at 4.6% and Norway at 5.1%. I know that the Minister will address that in his response, but if the States, Italy, Norway and Slovenia can do it better, I am sure that we can achieve their levels, which would be a two percentage point drop or thereabouts from our current figure.

Not all healthcare-acquired infections are preventable, but it is believed that approximately 30% of them could be avoided by better application of existing knowledge and realistic infection control practices. Hand hygiene is an essential component of that.

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I remember when my brother was in an accident. He liked racing motorbikes, but unfortunately 11 years ago he had a very serious accident that resulted in him being in a coma and in intensive care for some 19 weeks, followed by 2 years of rehabilitation. Whenever we visited him in the Royal Victoria hospital in Belfast, we all had to wash our hands. He was not able to respond to us at that stage, but his family and other people who knew him wanted to go and see him because of the severity of his injury. The nurse was clear: she said, “You have to wash your hands every time you go to that bed, because the risk of infection for someone in that extreme circumstance is very real.” Every time we left the bed and went outside the ward, we had to wash our hands before we went back to the bed—that was clearly outlined.

To me it was clear: we do that because we want to visit the person in the bed, but we may unwittingly have infections on our hands. The hon. Member for Bridgend (Mrs Moon) spoke earlier about sneezing. Unwittingly, we cover our mouth with our hand and then rub our hands. Then we might stick our hands in our pockets and rub them on the pockets. Even when using a hanky, there will still be infection on the hands. That is the point I am trying to make. It is clear that we have to do something.

The infection prevention and control sector claims that basic hand hygiene standards are not being met on many NHS wards. If that is the case, a clear guide needs to be given to those on wards to ensure compliance. The Deb Group claims that although 90% to 100% compliance with hand hygiene standards was reported by UK hospitals—it is easy to say that—the true figures are between 18% and 40%.

As health is a devolved matter, I have asked the Minister responsible for health back home questions on MRSA infections in hospitals, because even though we have few infections, it is clear that something needs to be done. Back home—it is probably the same elsewhere—many would say, “If you’re ill, be careful in hospital, because you have people with open wounds and people whose immune systems are down. If you bring in your colds, flus and coughs, or whatever it may be, that can have an impact.”

Deb also argues that the data collection method is flawed and that direct observation artificially inflates compliance, as nurses observe colleagues meeting the requirements and undertake a tick-box exercise. There needs to be more than that. NICE issues guidance on hand-washing in hospitals and encourages strict hand-washing practices, but it does not include a demand that accurate data be recorded. We want to ensure that that happens. If we record the data, we are making an effort and, if we are doing that, we are washing our hands. There may be some weight to Deb’s concerns, and that should be extremely worrying for all of us.

Good hand hygiene practice in hospitals is the single most effective way to prevent the spread of infection, and we should take action to ensure that more effective records of hand-washing on NHS wards are made in future. That is a simple yet effective way of making our hospitals safer, and with the recent growth in antimicrobial resistance we need to act sooner rather than later to ensure that poor hand hygiene does not further increase the severity of HAIs.

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We have had an extensive hand hygiene strategy in Northern Ireland since 2008, and although some problems persist—in all honesty, we cannot stop all infections—we have seen results from simply adopting a thorough hand hygiene regime in our hospitals, with education on the importance and effectiveness of hand hygiene being an essential part of the Department of Health, Social Services and Public Safety’s regional infection control strategy. Like in Scotland and in some individual trusts, we are taking action to address the issue.

Accurate records are the starting point for addressing the problem. There are many examples across the world, but a recent three-year pilot in a hospital in South Carolina in the United States of America found that once staff were trained in how to use electronic hand monitoring systems, compliance with best practice increased and MRSA rates dropped. That saved the hospital $433,644 from April 2014 to March 2015. There was therefore also a financial advantage, and although that is not the reason to do it, it is an example of what can be done to stop infections and address costs.

As we seek to have a more streamlined and cost-effective NHS, those are the sorts of approaches we need to look into. Indeed, the introduction of such a system at Burton Hospitals NHS Foundation Trust drove up hand hygiene compliance by up to 50% in just three months. That is an example from this country, which shows what we can do if we put in the effort.

With 5,000 people dying each year as a result of HAIs, it is clear that action must be taken. With resistance to antimicrobial treatment increasing, we need to get on top of the issue before it is too late. Hand hygiene is the simplest and most effective way to do that, so let us make sure hospitals are doing that right and doing it well.

Sir Alan Meale (in the Chair): We now move to the Front-Bench Members, and we have only until 5.30 pm. I therefore ask Members to be succinct. Minister, if it is possible, could you give a minute or so at the end to the Member who moved the motion to allow him to wind up the debate?

5.8 pm

Dr Philippa Whitford (Central Ayrshire) (SNP): Thank you for calling me, Sir Alan, in a debate that sounds simple but is important. The education centre in my hospital in Ayrshire is named after Sir Alexander Fleming, because the man who discovered penicillin was an Ayrshire lad. It may be that people have got complacent and think that the age of infections is done with. In earlier generations, children did wash their hands, but then people got too casual.

In Scotland, we began to be much more fixated on hand-washing in 2001, after some of the evidence about the impact of hospital-associated infections came out. In the early 2000s, our uniforms changed: white coats were banned, tops needed short sleeves and eventually we moved to no ties or jackets. We also began to have more audit in the system. We went through a painful experience between 2006 and 2007: a massive clostridium difficile outbreak in the Vale of Leven hospital in which 163 patients were affected and 34 died. Nicola Sturgeon, our First Minister, was the Cabinet Secretary for Health at the time, and she instantly set up a hospital-acquired infection taskforce when the problem became obvious. The whole approach accelerated.

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We have several different organisations that are part of driving hand-washing, but it is about the culture. It is not a question of someone facing the threat of losing their job or being sanctioned; it is about getting people to see hand-washing as part of the rhythm of every contact. There is observation, as has been mentioned, and there are also ward champions. The observation is hidden, so no one knows it is happening. I must say, to my chagrin, that in every single audit of staff, doctors were the worst. That fact was published, to shame doctors by showing that we were the slowest to adopt the right practice. We also observe visitors, and there is alcohol gel as people come into wards. My office was on the ward, and it was easy to see physios, nurses, doctors and visitors interacting with the alcohol gel.

I pay tribute to the hon. Member for Morley and Outwood (Andrea Jenkyns) for setting up the APPG for patient safety, which I am part of, and the Handz campaign. In Scotland, we have the “Happy Birthday” hand-washing campaign, which has been running for some time. We already have that campaign in schools, but it is important to raise the issue.

To verify hand-washing, we have the Healthcare Environment Inspectorate, which turns up without anyone knowing it is coming. Its inspectors are down under the beds and poking around in the mattresses on the trolleys. They are observing staff and, believe me, if there is a dusty corner, they will find it. They also look at surfaces—is there a cracked surface or a rough bit of floor that could be difficult to clean? It is about not only hands but the cleanliness of the entire ward.

My hospital was lucky in that it never outsourced cleaning. We never had companies coming and going. We kept our ward maids. It was their patch, in which they took pride. The supervisor comes along, like your mother-in-law, wearing a white glove, to check exactly what everything looks like. They can be seen under the bed, in among the frame, cleaning every pick of it while chatting to the patient. Those are simple things, but we need to do them, because we are moving into what could be a post-antibiotic era. To think that we could lose something that we started using in 1942 after 80 years is absolutely terrifying, so we need to bring that culture back.

In the NHS, every single trust publishes its infection figures every quarter. The hon. Member for Amber Valley (Nigel Mills) mentioned all infections, and as a surgeon I have to admit that infections happen for all sorts of reasons. The reason why C. diff and MRSA are so important is that their root cause is the poor use—prolonged use—of antibiotics, which causes C. diff, and poor hospital hand hygiene, which causes MRSA.

Trusts’ infection rates are published every month and pinned up on the wards, so that visitors can see them. We also put out the reports of the Healthcare Environment Inspectorate. I have shown a critical report on one of our hospitals to the hon. Member for Morley and Outwood, to show how thorough and challenging the inspection is; there are no holds barred. That is what has to be done. There are also infections out in the community. The hon. Member for Bridgend (Mrs Moon) mentioned cytomegalovirus, which, again, can simply be reduced by hand-washing.

We in this place have to realise our part in all of this. We shake hands with hundreds of people. We go and eat our lunch, and I do not see people forming a queue

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at the ladies or gents to wash their hands. We should all have a bottle of alcohol gel in our bags. I am on the House’s medical panel, and I have put on the agenda that we should have exactly the same dispensers of alcohol gel used in hospitals outside our canteens. We need to set examples, whether that is by visiting local schools or simply by showing all the people we interact with.

The NHS has a responsibility for hand hygiene. We need to change the culture in the NHS, so that if a member of staff is near a patient and touching not only them but their environment, the member of staff washes their hands or uses alcohol gel before their next contact. We in this place also have a role in getting the message out into society.

5.14 pm

Justin Madders (Ellesmere Port and Neston) (Lab): It is a pleasure to serve under your chairmanship, Sir Alan. I congratulate the hon. Member for Amber Valley (Nigel Mills) on securing this important debate. I also pay tribute to the hon. Member for Morley and Outwood (Andrea Jenkyns), who chairs the all-party parliamentary group on patient safety and has been a passionate advocate on the issue. Indeed, infection prevention was the first subject that the APPG decided to focus on. She referred to the startling answer given by an RCN representative at our first meeting that no nurse, in her experience of some 20 years, had been disciplined for failing to wash their hands. I do not know whether that is because this system is, by its nature, self-policing, but it raises questions about whether the issue is treated with the appropriate importance that we would all agree it should be.

There have been excellent contributions today. My hon. Friend the Member for Bridgend (Mrs Moon) and the hon. Member for Strangford (Jim Shannon) rightly said that washing hands after coughing and sneezing is such a simple thing to do, yet so many of us fail to do it. My hon. Friend the Member for Bridgend mentioned the devastating effects that CMV can have, and how easily it can be prevented. There were also excellent comments from the hon. Member for Central Ayrshire (Dr Whitford), who spoke from her personal experience with remarkable candour about which health professionals have the most to do to catch up in this area. She is right: this is all about the culture in which our health professionals work.

During my Christmas break, I spent a Saturday night shadowing an emergency medicine consultant at the Countess of Chester hospital. It was an incredibly busy environment, and the pace was relentless. Despite the extremely challenging circumstances faced by staff, there was a continual focus on hygiene at every stage. Hands, as well as equipment, were constantly cleaned and sanitised before and after every contact with patients. Indeed, I am now something of an expert at cleaning trolleys.

My experience, however, was not an isolated one. The importance of compliance with hand hygiene is something that NHS staff treat with a high level of importance, and it is worth recognising that, despite the difficulties highlighted today, most staff in the NHS do the right thing and do a fantastic job.

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Despite the improvements in recent years, the rates of healthcare-acquired infections in England remain stubbornly high, with what can only be described as inadequate checks on compliance with hand hygiene best practice. As the hon. Member for Amber Valley said in his opening remarks, around 300,000 people per year—or, to put it another way, one in 16 people—get an infection while being cared for in the NHS in England. As he rightly pointed out, if that was our experience at a restaurant, we would not consider it acceptable.

As well as the devastating impact on the patients who are immediately affected, those infections have a significant financial impact on the NHS—the most recent reliable estimate derived from the Plowman report puts the figure at £1 billion per year—and lengthen hospital stays.

The growing threat of antimicrobial resistance adds to the seriousness of the matter and the urgent need for the Government to act. Antimicrobial resistance-associated deaths are projected to increase 2,000-fold by 2050. A report by the World Health Organisation states that resistance is very frequent in bacteria isolated in healthcare facilities and that, at present, antibiotic-resistant bacteria are the cause of over half of all surgical site infections.

Given the clear scientific evidence that good hand hygiene by health workers reduces infections, and in particular MRSA, it is clear that hospital workers are on the frontline against this threat. We therefore need more action to bring about improved hand hygiene to avoid problems in future.

Of course, not all hospital-acquired infections are preventable, but it is believed that around 30% could be avoided by better application of existing knowledge and good practice. It is also widely accepted that good hygiene practice in hospitals is the single most effective method of preventing the spread of infections. That was recognised by NICE in early 2014 when it issued a new quality standard, which included six statements designed to reduce infection rates, with the central aim being that all patients should be looked after by healthcare workers who always clean their hands thoroughly, both before and immediately after contact or care.

While those aspirations are laudable, since the publication of NICE’s guidance, the positive progress made in recent years appears to have stalled, and in some cases possibly reversed. The most recent figures I have seen make worrying reading, with C. diff showing no reduction in the past year, the rate of MSSA increasing and the rate of MRSA increasing by a worrying 14%. For all its aspiration, the NICE guidance is seriously flawed, not least because it relies upon monitoring by direct observation by nurses, which not only takes up valuable nursing time but has been found to overstate compliance rates.

The chief inspector of hospitals for the Care Quality Commission, Mike Richards, has drawn attention to the inaccuracy of local hand hygiene audits. The high compliance rates reported by hospitals simply are not supported when we look at the levels of hospital-acquired infections. We have heard that the compliance rate is more likely to be 18% to 40%, rather than the 90% to 100% reported by hospitals. As the hon. Member for Amber Valley set out with great clarity, there are possibly a great number of reasons for such a discrepancy, and there seems to be an element of self-fulfilment about how assessments are carried out. The trials that have

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been undertaken to ensure that there are more accurate data have also been shown to improve compliance with best practice.

The introduction of electronic monitoring equipment at Burton hospitals NHS foundation trust was found to improve hand hygiene compliance by 50% within three months. I would therefore welcome an expansion in the use of data and electronic monitoring, and I would be grateful if the Minister could set out in his response how he intends to address that. There is clearly a role for the Care Quality Commission. A key element of every inspection needs to be an assurance that proper checks on hand-washing are carried out. The greater use of data would also enable a new era of transparency to be ushered in. Patients should have the right to meaningful information about hand infection control and hygiene.

Another cause of the recent increase in infection rates is the chronic shortage of nurses on many hospital wards and the increased use of agency staff, caused in part by the Government’s decision to slash the number of nurse training places after taking office in 2010, as well as the worrying retention trends. Significantly, when there is a high turnover of staff, it is much more difficult for best practice to be instilled, monitored and ingrained into the culture of a hospital. I hope that when the Minister responds, he will say a little more than he was able to last week at the Dispatch Box about improving the retention rates for nursing staff.

Finally, as well as improving practices within the NHS, we need to improve hand hygiene among the public at large. Studies have shown that, despite awareness about good hand-washing practices being widespread, one in five people do not wash their hands after using the toilet. According to the Royal Society for Public Health, one of the major barriers has been an assumption by people that they do not carry any diseases. However, on average, studies have shown that hands can carry about 3,000 different bacteria, so we also need to explore what more we can do to improve good hand-washing practices among the public. The cross-party Handz campaign, which was launched by the hon. Member for Morley and Outwood, has already done very good work to raise awareness of these issues, and I hope it will provide a catalyst to drive forward improvements both inside and outside the NHS.

5.22 pm

The Parliamentary Under-Secretary of State for Health (Ben Gummer): I thank my hon. Friend the Member for Amber Valley (Nigel Mills) for bringing this important matter to the notice of the House, and I thank hon. Members on both sides of the Chamber for their speeches and contributions.

Hand-washing is an interesting thing, is it not? For the majority of human history, from Pontius Pilate to Lady Macbeth, it was associated with a bad act. Hand-washing was what someone did after they had done something wrong. It was only through the transformation in clinical knowledge in the 19th century that the understanding of hand-washing and its criticality in reducing infection rates became commonplace, but it was a long fight. It is worth remembering that Ignaz Semmelweis, the man who made people understand that washing their hands in obstetric and maternity settings reduced the risk of infection, was so criticised by his colleagues that it drove him to insanity, and eventually

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to death in an asylum. This was a hard-won victory, and I utterly endorse the wise comments made by the hon. Member for Central Ayrshire (Dr Whitford): perhaps it is because it has become such a commonplace part of our modern understanding of hygiene that we have forgotten its central importance in reducing infection.

My hon. Friend the Member for Morley and Outwood (Andrea Jenkyns) came to the Department of Health a few months ago and sat in on one of the Secretary of State’s Monday morning care meetings to discuss her Handz campaign and the fact that she wanted to set up an all-party parliamentary group on hand hygiene. I know that her personal testimony brought acuity to our understanding of why this is important. It is all too easy to see MRSA, E. coli and C. diff rates plotted on a chart and to forget that, actually, the result of those infections can lead to the tragic and completely unnecessary loss of life. However, even if it does not lead to that, it can often mean a very extended stay in hospital, with serious injury sometimes incurred as a result of infection.

The overall story of infection caused by poor hand-washing has been good over the last decade. Rates of MRSA, MSSA, C. diff and E. coli have all come down— very considerably in some circumstances—but, as the shadow Minister, the hon. Member for Ellesmere Port and Neston (Justin Madders), rightly noted, we have plateaued in almost all of those, and worryingly so. In fact, in the case of MRSA, there has been a worrying, albeit slight, increase in rates in hospitals. That has now been consistent enough to constitute a trend.

We have to be clear that, from the Government’s perspective, we are still not entirely sure in each case why the reductions have not continued. To some extent, it is clear that an increasing role is played by community infection and community onset, or expression, of infection. We do not yet have a full understanding of the relationship between community settings and hospitals, and the chief medical officer is working very hard to try and understand it. Therefore, this is a pressing moment, not least because of the problems of antimicrobial resistance, which the hon. Member for Central Ayrshire mentioned, and which is why we have to be particularly vigilant.

Overall, the one thing that will guarantee that we do not make more progress is if I make a central directive from Richmond House and then ensure compliance through a massive, bureaucratic reporting mechanism. The only point on which I differed from anyone in their observations was when the shadow Minister, in his generally very wise comments, talked about the relationship to staff retention. That was because, although general infection control should be part of how teams work, it should be part of the personal, professional responsibility of a clinician, no matter where they work—whether in the community or between hospitals as a bank nurse or clinician—to take infection control very seriously.

How do we improve matters? How do we make sure that, as in so much of the NHS—to copy Bevan’s words, which I do not tire of using—we are “universalising the best” and lifting poor performers, of which there are several, up to the best standards in the country, some of which can be found with our neighbours in Scotland?

Dr Philippa Whitford: I have not worked in a hospital in England, but the poster campaign that the hon. Member for Morley and Outwood (Andrea Jenkyns) referred to involved massive posters that were in the lifts

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and targeted at visitors, porters, nurses and doctors. The five points of contact were above every sink and in every room. If we are trying to change a culture, I wonder whether the first thing is actually just to try to get the campaign out there among staff and visitors.

Ben Gummer: I take the hon. Lady’s point, and I agree that we have to re-educate the public that we have not won the battle and that we have to re-engage. I will take her comments to the chief medical officer and talk to her about what more we can do to re-engage the public in the debate on hospital-acquired infections.

Douglas Chapman: My hon. Friend the Member for Central Ayrshire (Dr Whitford) has outlined some of the initiatives taken by the Scottish Government and the NHS in Scotland. Despite those measures, hospital-acquired infections in Scotland still cost the NHS £183 million a year. If we managed to reduce those infections by 20%, that would give us a saving of £36 million. A 40% reduction would give us £73 million. Does the Minister agree that there is a huge financial incentive to

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reducing the infection figures as much as we can, especially in these times of public spending restraint?

Ben Gummer: The finances follow the far bigger win, which is the benefit to patients and the saving of lives.

One further thing that I will attack quickly is compliance monitoring. It is a very interesting area, and I would encourage local trusts to look at it in detail. The CQC has it as one of its main targets and, in the new inspection round, which will come very soon, it will want to look at the area as a central part of its monitoring.