|Back to Table of Contents
|Lords Hansard Home Page
First, the Government have made commendable advances in tackling these problemsin particular, their introduction of mandatory reporting, the setting of standards for hospital trusts, the introduction of guidelines and the return of matrons. These are all welcome steps, among others, to which my noble friend will no doubt refer.
But are they enough? I doubt it very much indeed. If we look at some of the plethora of figures and, in particular, the trend, we find them disturbing. The first recorded cases of MRSA in the UK were in 1992there were 104 cases. In 2001, there were nearly 5,000 cases4,904 to be exact. Last year, the figure was 7,000 cases in England and Wales, which compares badly with the early years. Therefore, it is a growing menace, and not just numerically because new strains have been reported in the United States. One strain in particular has hit thousands of fit, young Americans with no links to hospitals. If, as is possible, those bacteria come here, it complicates our problems even more.
We know that the most vulnerable are feeble, older people whose immune systems have been weakened and who may have been prescribed too many antibiotics. We know also that dirty hospitals contribute to the bacteria. At least, we thought we knew that. Now Ministers are saying that there is no strict relationship between hospital cleanliness and MRSA, although it is an important consideration.
Where do we stand? To complicate matters further, Paul Burstow, MP, who has a fine record on this subject, found in a recent study that two-thirds of hospitals with the worst records for controlling MRSA infection had won the highest "green light" rating for cleanliness. That is a puzzle.
No one is going to advocate dirty hospitals, but if clean hospitals have a poor record on MRSA, just what can they do? To what extent are their infection control systems effective? If they are not effective, what is wrong with them? Is it technique, training, lack of money or failure of will? We need urgent answers to these questions if we are to make any real progress. We need to know whether hygiene is related to MRSA. It would seem to be a straightforward question with an obvious answer, but in view of ministerial statements that there is no strict relationship between hospital cleanliness and MRSA, we need to know from the Government whether it is factor, and if so, to what extent. If it is, then it is right to devote more resources and effort to improving hygiene, but if there is no relationship, then hospital hygiene, although important for other reasons, can be discounted in relation to MRSA and other issues demanding greater attention. What is the Government's judgment on this?
Infection control lies at the very heart of any attempt to cope with MRSA. I know that the Government have allocated cash for this, but to what extent is it being systematically monitored? The general shortage of hospital beds creates great difficulties, but all patients with MRSA should be removed from the wards and isolated. This does not happen at present because of the bed shortage, but a room or bed that has had an MRSA patient should be properly sterilised before the arrival of the next patient. What is the Government's view of the high level of bed occupancy in relation to MRSA? Many hospitals are full to capacity.
Overall, what is the Government's assessment of this major battle between bacteria and antibiotics, the outcome of which will have profound and far-reaching consequences not just for this country, but for mankind? Are the bacteria winning? If we reach the stage where antibiotics cannot cope with new strains of bacteria, we are all back in the pre-antibiotic period. The House of Lords Select Committee on Science and Technology, in its admirable report published in 2001 on resistance to antibiotics, stated that:
Do we have sufficient basic knowledge to understand how bacteria mutate for their survival? Or is it the failure of the pharmaceutical companies to research and develop better antibiotics? What are the Government doing to press the pharmaceutical companies to conduct more effective research? It has been claimed that the companies are not doing sufficient research because it may not be profitable. Whatever the reason, it is vital that the Government take some responsibility for pressing them because new antibiotics are undoubtedly an extremely important factor in dealing with MRSA.
It is difficult to pin things down, but a few weeks ago, in a Starred Question, I asked the Government to press the pharmaceutical companies to do further research on new antibiotics. The response was simply to say that it was important that we should invest in
In so far as this is an international problem, the Government should consider calling a world conference of the countries with a particular interest to see whether we can get better co-ordinated research. How do United States pharmaceutical companies compare with ours for helpful research? The Government should campaign for closer co-ordination of research effort and facilities with countries like the United States and the European nations because this is a genuinely international problem.
The battle with MRSA is undoubtedly one of the most important that the National Health Service has had to face since the heady and exuberant days of its foundation. We are all anxious that these so-called "superbugs" should be defeated, or the consequences will be catastrophic. I look forward to the response on behalf of the Government from my noble friend.
Lord Colwyn: My Lords, I thank the noble Lord, Lord Ashley of Stoke, for tabling this Question. I am grateful to him for the way in which he has explained the current situation. I should also apologise to the House because I decided only this morning to make a contribution to this debate and I called to add my name to the list at a very late stage. I am so used to being placed towards the end of a speaking list that I assumed that I would be in a similar position today. I was wrong, and I should say how much I look forward to the contributions from later speakers.
I hope that I will be forgiven for suggesting some lateral thinking on the serious problem of MRSA infection at such an early stage in the debate. The title of the 14th annual Euro meeting in Basel this time last year was, "The patient is waiting". I interpreted that to mean that at the start of the 21st century, only a relatively small proportion of all diseases can be adequately treated or even cured, and only a small proportion of all patients have access to medicinal products at affordable prices.
Although that may seem a harsh judgment, it is true that for some diseases we do not yet have a rational drug treatment; that diseases are often poorly treated, and that too many patients in poor countries do not receive any benefit.
When I arrived at my surgery this morning, I noticed for the first time the actual wording of the Question tabled by the noble Lord, Lord Ashley, that might differentiate it from the recent series of Questions we have had on MRSA. He has asked whether there are any "new proposals". I suspect that there are no new proposals, so I thought that I would help the Government with a brief intervention in order to draw their attention to a therapeutic treatment that may well be able to control infection by methicillin resistant
I refer to ozone therapy. The gas mixture 02/03 is administered by various routes: topical application on skin and mucosa, or parenteral injection and exposure to blood. In any event, ozone will come into contact with a film of water present on the skin surface, or in the interstitial fluids, or in plasma.
Basic clinical research on ozone therapy has been too little and too slow. I pay tribute to the noble Lord, Lord McNairhe was removed with most of the hereditary Peerswho tried to interest successive governments in this. But it takes time. The therapeutic progress in cancer therapy has not been as fast and positive as had been predicted. Three decades have already passed since President Nixon declared war on cancer. Although knowledge about tumorigenesis has shown an incredible expansion, the mortality rate has barely decreased.
It is intuitive that ozone can have an important therapeutic role in various types of infections because it generates reactive oxygen species also produced by granulocytes and macrophages during an infection process.
When faced by problems with diffuse antibiotic-resistant bacteria, rich countries continue to use often useless, expensive antibiotics, while poor countries, through sheer necessity, use ozone. It is used either as a gas, as ozonised bidistilled water or as ozonised saline or oils. These ozonised solutions have a cleansing effect and act as a powerful disinfectant that kills antibiotic- resistant and anaerobic bacteria.
In these countries, physicians have had to devise all kinds of ways to employ the gas or, even more easily, the ozonised water, to avoid environmental contamination. In the West, we still need to create the mental attitude profitably to use ozone. Once medical personnel realise the advantages it will be put into general use to the benefit of patients. Moreover, with the current increase in medical costs, ozone therapy deserves attention because it reduces hospital assistance and is extremely cheap. The good news is that the work has been done and the equipment and knowledge are available.
I apologise for introducing an aspect on which the Minister will not have received a brief. There is no doubt that ozone therapy will play an increasingly important role in healthcare in the future. Now is not the time to explain how controlled exposure to minute amounts of ozone can immediately halt the process of dental decay and eliminate the use of the dental drill. The prospects for primary dental care are enormous.
Baroness Masham of Ilton: My Lords, two months ago I sustained two fractures of my left leg when I got it stuck in a fire door in your Lordships' House. I went to St Thomas's Hospital for an X-ray and, as my bones are soft and the fractures were unstable, I needed an operation. A doctor at St Thomas's told me that in my case the risk of MRSA was very great and that it might be wise to go elsewhere.
In 1997 I had the honour to be a Member of the Select Committee on Science and Technology relating to resistance to antibiotics and other antimicrobial agents. The committee reported on 17th March 1998. The report stated:
I am grateful to the noble Lord, Lord Ashley of Stoke, for giving the House the opportunity to discuss this life and death matter today. Because of infections, many people have become most concerned about being admitted to hospital. In recent weeks I have heard of several people personally who have been infected with MRSA.
On Tuesday, 25th March, I attended a service of thanksgiving for the life of Major General Sir James Eyre at the Guards' Chapel. He had been admitted to an Oxford hospital with complications. While there, he was infected with MRSA which his widow, a surgeon's daughter, says contributed to his death. She said to me, "Nothing about MRSA has been written on his death certificate". "Why not?", I asked.
Last week, on Easter Monday, an old school friend came over with her husband. They told me that he had been admitted to St Mary's Paddington as an emergency in excruciating pain. He had an epidural but, before long, he developed a large sore with MRSA at the site of the injection. His wife was horrified at the lack of hygiene in the hospital and is writing to the chairlady, a Member of your Lordships' House.
Recently, at a conference, I was talking to a supplier of paper towels. He told me that King's College Hospital had started using a good quality paper towel, which nurses liked and so they washed their hands. He said that the hospital had reverted back to hard, cheaper towels which made the nurses' hands sore, and so hand washing lapsed. I am sure that all noble Lords know the importance of washing hands between patients to help prevent the spread of hospital infections. Good quality soft towels are one source of encouragement.
The public are getting frustrated at the dirty conditions of some of our hospitals, which have no discipline and supervision about cleanliness at the patient level. The Government have tried to do their best. More money has been given to the NHS, but it does not seem to have stemmed the spread of MRSA infection. Many people want to see the prevention of the spread by screening hospital admissions, detecting and isolating infected patients and, surely, screening hospital staff who may infect patients and become carriers. More special funding will be required for laboratories and infection control to implement these measures fully. The design of hospitals is important; they should have more basins and disinfection points, such as alcohol wipes and gels by every bed.
We cannot go on increasing the risk to patients. Is it not time for a national research project on MRSA and other antibiotic-resistant organisms? I can think of no better place than Imperial College, in the heart of London, where MRSA has the highest rate of infection in this country. The worldwide problem of SARS has made people sit up and think of infection control.
I would be grateful if the Minister could tell the House about reporting of staphylococcus aureus bacteraemias. Why is there a mandatory and a voluntary scheme? All regions reported higher numbers under the mandatory scheme. When looking at age distribution, this information is obtained only from the voluntary reporting scheme. It is worrying that babies under one have the highest rate of infection, followed by people over 65. Would it not be more efficient and less complicated to have one mandatory scheme?
At a conference on the safety of surgical instruments some months ago, I asked a question on MRSA to a surgeon who was speaking. He said it was something which sometimes infected frail, elderly people. I detected some complacency. I said, what about the young man of 23 who went into hospital to have an ingrowing toenail removed and died of septicaemia, caused by MRSA, a short time afterwards?
We have among us, in your Lordships' House, a living witness who is in the prime of life but nearly lost it from MRSA. The noble Lord, Lord Phillips of Sudbury, has given me permission to relate his experience in this important debate.
The noble Lord returned from a visit to Africa and had to be treated in hospital for a tropical disease. When in Addenbrooke's Hospital in Cambridge, the noble Lord developed MRSA. Antibiotics were given through a cannula and drip, which is thought to be the cause of MRSA entering the bloodstream. The noble Lord was then found to be resistant to vancomycin. He had eight antibiotics and septicaemia in both sides of his body. The tropical disease was cured but the noble Lord was fighting for his life due to a hospital-acquired infection. I am pleasedI am very pleasedthat the noble Lord won his case on that occasion, but it was touch and go.
Baroness Pitkeathley: My Lords, I am most grateful to my noble friend Lord Ashley for giving us the opportunity to focus on this important issue tonight. It is rather ironic, as the noble Baroness, Lady Masham, has said, that so many people are getting so nervous about the relatively minor problem of SARSdo not mistake me, I am not in any way taking the deaths of people from that infection lightlywhile ignoring the enemy within, as it were. As my noble friend has reminded us, MRSA is a killer, and a major one.
In this debate, and especially in view of the number of experts who will speak to us, I want to share my experience as a patient. When I said I was grateful to be here tonight, I meant that most sincerely, since I, like the noble Lord, Lord Phillips, am a sufferer and, as you see, a recoverer from MRSA.
In the seven months I spent in the Middlesex Hospital in 2001, I had MRSA for most of the time. I want to tell your Lordships about that experience and offer some ideas about the lessons I and others can learn from it.
I am pretty sure that I can pinpoint the moment when I became infected. That is a moment for which I feel gratitude, not blame. I was suffering a complete body sepsis after surgery for cancer and a bad reaction to chemotherapy drugs. Admitted to the hospital as an emergency on Christmas Eve, the doctors despaired of my life and told my family to prepare for the worst. Then a wonderful and courageous surgeon told my family that he was prepared to operate. I say courageous, because many surgeons would be too aware of their mortality rate batting average to suggest such a course of action in an apparently hopeless case, even if it had not been Christmas Day. Although he could offer a less than 1 per cent chance of survival, without the surgery the outcome was certain death. So my family, knowing that I would always take the high-risk option, agreed.
Another problem then presented itself, since I was so ill that even moving me to the operating theatre would surely kill me. They decided to operate in the room that I was occupying in intensive care. There was no time to ensure the sterility of the room, of coursethey did the best they could in the short time availablebut I think that I can be fairly sure that there was the source of my infection.
That operation was not the end of the story, of course; much more surgery and many months of devoted care were to follow. However, your Lordships will not be entirely surprised to know that had I myself been conscious enough to make the decision, the risk of getting MRSA would have been one which I too would have been prepared to take in those circumstances.
I cannot fault the precautions that the staff in intensive care took to try to prevent the spread of infection. Such few visitors as were allowed to me were always told about washing their hands, wearing aprons and applying disinfectant gel. Of course, ward rounds do involve doctors and other staff moving from bed to bed, sudden emergencies arise and deliveries of supplies are absolutely essential. When one moves from intensive care to a ward, those precautions are even more problematic. Visitors have free access to most wards at most times of the day. There are not always handy basins for people to wash their hands; patients go endlessly to X-ray, to physio, to ultrasound, which all offer opportunities for infection to spread. But these visits are essential, of course.
Your Lordships may be surprised to hear me say that MRSA was a great friend to me and my devoted family in some ways. It required me to be barrier nursed, which in turn required a side ward. That could be quite cosy, as I could have my radio and TV, my visitors and my endless undignified examinations in some privacy. But there were only two side rooms on the whole of the ward, so what happens if more than two patients need barrier nursing? There were times when I had to be on the open ward and the beds there were pretty close together. But when you are immediately post-operative, the nurses need to keep you under close surveillance, and the side ward with its closed door is not then the safest place, in spite of the risk of infection.
If a crash call comes when a nurse or doctor is attending a patient, and they know that their colleague is alone at the other end of the ward, washing their hands and changing their apron may not be the first thing on their minds. If there is only one night sister or house doctor on call for a large group of wards at three in the morning and a new line or ventilator is urgently needed, it is perhaps understandable that hygiene takes second place.
If a patient is unable to eat for months on end, as I was, the only means of keeping them alive is via a Hickman line putting food into the blood stream. By their very nature, such lines become infected after a few weeks. However, one then has to balance the risks of sending the patient back into the theatre for more surgery, because a new line has to be put in under general anaesthetic, against the risk of the spread of the infection.
New technology systems exist that enable health and social care staff to use their time in the most effective, patient-centred way. As well as in-home systems, we are now able to give on-call GPs access to minimum data on patients to allow them to assess patients seen as an emergency in their own home, instead of admitting them to an A&E department. Therefore, we can provide monitoring at home, thus avoiding the risk of hospitalisation.
Another very important element in the fight against hospital-based infections to which the Government are committed is the development of small diagnostic and treatment centresDTCs. These are already established in some parts of the country, and I have seen them operating effectively in the United States. They specialise in cold surgery and patients are in and out in a day. I am sure that the development of these centres to enable patients to have surgery without the risk of infection will be an important factor in fighting MRSA.
As one district nurse said to me, one thing that we can say about MRSA is that people never get it in the community. She was right. Hospitals are the culprits, as we have heard tonight. So we must proceed on two important fronts. We must improve hygiene in hospitals and continue to fund appropriate research. But we must keep people out of hospital as much as possible by looking at other forms of care which will not only preserve them from infection but also offer them treatment and care that fits their lifestyle, instead of expecting them to fit in with hospitals' routines and culture.
I am extremely grateful to be recovered in health and that I did not die of MRSA or any of the many other things which might have killed me. My devotion to the NHS, which was already strong, is, as your Lordships can imagine, unshakeable now. So I hope that we can all approach the undoubtedly challenging task of tackling MRSA. I hope that we can do so in a way that offers help, not blame, to the NHS and its skilled and devoted staff.
Lord Chan: My Lords, I add my congratulations to the noble Lord, Lord Ashley, on drawing the attention of your Lordships' House and the Government to this troublesome infection which has recently become more common in our hospitals, is more difficult to treat and undoubtedly contributes to an increasing number of deaths. I also thank the noble Baronesses, Lady Pitkeathley and Lady Masham, for sharing their personal experience and adding realism to the debate.
Methicillin resistant staphylococcus aureus is a problematic infection acquired in hospital. According to the Public Health Laboratory Service, which monitors the extent of such infections in Britain's hospitals, and as the noble Lord, Lord Ashley, said, MRSA infections in England and Wales increased by 50 per cent, from about 4,800 cases in 2001, to more than 7,000 last year. Vancomycin is the drug of last resort for treating patients, particularly in hospital, with postoperative infection. As the noble Baroness, Lady Masham, described in relation to the noble Lord, Lord Phillips of Sudbury, some cases of MRSA are showing signs of developing resistance to Vancomycin. Britain's first case of VRSAVancomycin resistant staphylococcus aureuswas reported only last year. That was the first fully Vancomycin resistant strain of bacteria. As a result, doctors are faced with a very difficult-to-treat bacterial infection that can cause death.
Hospital-acquired infections have been greatly underestimated and they are increasing every year. Bacteriologists such as Professor Hugh Pennington estimate that hospital-acquired infections kill around 5,500 patients annually and contribute to the deaths of another 11,000. Some members of the public have proposed that the spread of MRSA may be the result of dirty hospitals with poor levels of cleanliness. The Government have rightly set up their Clean Hospital Programme to tackle the problem. However, a new study found that all 40 hospitals with the worst MRSA infection rates passed cleanliness tests. Two thirds of hospitals with the worst record for controlling MRSA infection had won a "green light" rating for cleanliness, while the remaining third were classified as adequate with an "amber" light.
The noble Lord, Lord Ashley, mentioned the study by Paul Burstow, the Liberal Democrat health spokesman, who looked at 20 specialist and 20 acute hospitals with the highest rates of infection. He said that the Clean Hospital Programme covers 19 different standards of which only one is about cleanliness and none about the control of infection. Mr Burstow said that it proved that not enough was being done to tackle the problem of rising MRSA infections in hospital.
Stringent measures to isolate patients with MRSA infections would control its spread in hospital wards. However, common measures such as hospital doctors and nurses washing their hands scrupulously before and after handling postoperative patients should be implemented. We have heard about the problems that can arise when patients are very ill and that is not done. Epidemiological evidence concludes that bacteria transmitted by the hands of people who care for inpatients are a major contributing factor to hospital infections. Effective hand decontamination results in significant reductions in the carriage of potential bacteria on the hands and would lead to a reduction in infected patients and death from MRSA infections. I can testify to the importance of this simple measure from my professional experience as a paediatrician caring for new-born infants.
Soap and water are as effective as hand-washing preparations containing antimicrobial agents for decontaminating hands. In order to reduce chaffing of the skin through soap and water, alcohol-based hand rub can be used with good effect. Good quality hand-washing by hospital medical staff needs therefore to be monitored to prevent and control infections, particularly in the care of patients such as babies and very ill people who have catheters fitted.
Another issue of importance in the campaign against MRSA infections is that of the careful use of antibiotics particularly in primary care. The Department of Health has printed and distributed information for patients on the appropriate use of antibiotics. It should be available in GP clinic waiting rooms. I have a copy in my hand.
Antibiotics may be unnecessarily demanded by patients for common coughs and colds usually caused by viruses for which they have no therapeutic effect. As large numbers of prescriptions for antibiotics are dispensed in primary care, more should be done to inform patients, nurses and doctors that antibiotics are not effective for treating common viral infections.
General practitioners should be encouraged to take care when prescribing antibiotics for their patients. In some primary care trusts, including the one with which I am involved, this is achieved through seminars where pharmacists inform doctors of trends in prescribing and evidence of good practice.
Patients who have been prescribed antibiotics appropriately should be encouraged to complete their course and not stop when they feel better. A full course of treatment will help prevent bacteria from developing resistance to common antibiotics.
Best practice in treating bacterial infections both in the community and in hospitals is well known. Standard principles for preventing hospital-acquired infections were updated and distributed by the Department of Health and published in The Journal of Hospital Infection two years ago in a supplement. It is easy to read and is available on the Internet.
These measures needed to prevent infections acquired in hospital are also not rocket science. But effective control and treatment of infections and preventing their spread requires all hospital staff to keep to a routine of hand-washing and patients to co-operate by completing their courses of treatment with prescribed antibiotics. Prevention is better than cure. This adage is absolutely essential for MRSA infections. I look forward to the Minister's reply on these important issues to reduce MRSA infections in hospitals.
As other noble Lords have said, MRSA is not the only healthcare acquired infection but it is the most intractable and is often severe, causing up to an estimated 5,000 deaths and, where it was just a contributory factor, 15,000 deaths. Those are slightly
Like the noble Baroness, Lady Masham, I was a member of your Lordships' Select Committee in 1998 which reported on resistance to antibiotics. In fact, the noble Baroness prompted that inquiry because of her repeated parliamentary Questions on the topic. It is gratifying that several of the recommendations of that report five years ago have been acted on. However, in its follow-up report three years later, the committee stated in paragraph 24 on page 7, with regard to the requirements that hospitals should report MRSA incidents:
Although the Department of Health is only too acutely aware of the problems of increasing resistance of micro-organisms to antibiotics, especially MRSA, the changes needed to slow the increase or reverse it need to be taken, as other noble Lords have pointed out, at front-line level, through changes in behaviour or management, mainly by clinical or cleaning staff. Strategies, guidelines and circulars by the department, however well written, are only bureaucratic instruments. Although they are a necessary precursor to changes in action at ground level, they are no substitute for that action, which is what matters.
I am sure that my noble friend will give us an account of the many excellent initiatives taken by the department, but we need to know how far they have led to action on the ground. To find that out, we need adequate and accurate monitoring or, on occasions, specially commissioned research. For instance, I understand that a team from Thames Valley University has carried out a systematic review of how infection control guidelines are implemented. Can my noble friend give us any information or a progress report on that?
As the Select Committee showed in its 1998 report, an attitude among prescribing doctors prior to the 1980s led to antibiotics being over-freely prescribed. Doctors believedI think that I can remember it myselfthat if resistance to one antibiotic developed, another would be discovered. The Select Committee's report had a salutary effect, as did the department's monograph, The path of least resistance. For the past few years, there has been a fall in the prescribing of antibiotics by 9 per cent among GPs, and a more cautious policy in many hospitals.
A further factor, as almost all noble Lords who have spoken have said, has been a fall in standards of ward hygiene. That is not always due to careless attitudes among nurses and doctors or poor work by cleaners. Hand washing between treating patients is often difficult to fit in if the sink is at the other end of the ward and there is extreme pressure of work, which is of course too often the case in acute hospitals. Rapid turnover of patients and more than 100 per cent bed occupancy makes it difficult to clean beds and equipment thoroughly. We have had examples of that from my noble friend Lady Pitkeathley. Those faulty practices are not desirable or excusable, but the present hospital environment, pressure of work and occasional low morale among those under pressure does not help.
It is in that kind of setting that the work of infection control teams is not easy, although vital. The liaison nurses who are supposed to see that good practice prevails in their ward or department may not have the time, or the status among their colleaguesthat is quite importantto be effective. However, even in those circumstances, infection control nurses still play a vital role. Chief executives of trusts increasingly realise that the work of those teams is cost-effective in reducing the average length of hospital admissions.
The results of the first year's surveillance of MRSA bacteraemia for 2001, which was mentioned by other noble Lords, were published last year. The highest levels were in acute teaching hospitals in Birmingham and the South East. That is probably because their case mix contained a high proportion of often elderly patients with complex problems. I do not of course include my noble friend in that category; she had the complex problems but she is not elderly. Some people may have been referred from nursing homes or residential homes and brought their infections with them. I believe that some residential homes act as reservoirs. That is certainly the case in the United States. My noble friend Lady Masham may be pleased that in the bacteraemia surveillance study Stoke Mandeville had one of the lowest rates in the country.
Despite the Question of my noble friend Lord Ashley, I shall be surprised if the Minister will describe any completely new approaches for MRSA control. Many plans are in trainfor instance, to improve the scope of surveillance, to include general practice and the community, to increase the number of infection-control nurses, to increase the number of the excellent "modern matrons" and to ensure that hospital hygiene is improved. There are specific policies for chasing that up.
I wonder whether the Minister can really show us that we are turning the problem around. Research to develop new antibiotics, as other noble Lords have mentioned, is needed. That anticipates the dayI am afraid that we have already reached that daywhen MRSA becomes VMRSA. But even if a new antibiotic were found to replace Vancomycin, that would probably lead only to a temporary respite.
We need basic high-quality infection control, as in the days before antibiotics were available, and careful, "prudent" prescribing. Those two approaches will probably remain the best ways of tackling the problem for the foreseeable future.
Baroness Finlay of Llandaff: My Lords, like other noble Lords, I thank the noble Lord, Lord Ashley of Stoke, for introducing this important debate. I must declare an interest because I am a member of the science and technology sub-committee that is currently examining ways of fighting infections. My remarks do not in any way pre-empt the report. I am concerned that by focusing only on MRSA we may be missing the main point. We should concentrate on all healthcare-acquired infections and, within that, hospital-acquired infections across the board.
The noble Lords, Lord Chan and Lord Rea, outlined the problem but it is unclear whether MRSA is a reliable surrogate marker for healthcare-acquired infections. It may be a distractor from some other sources of infections. We need to know whether an organism is a patient commensal or acquired when it causes a septicaemia. We do not have robust epidemiological data from the community as a whole or from across hospital staff. As the noble Baroness, Lady Masham, requested, research in epidemiological surveys is needed; we also need to determine the amount of antibiotic resistance. There is great concern that antibiotic resistance may and probably will increase. Containing antibiotic prescribing may become more difficult as prescribing is extended to groups other than doctors in the healthcare team.
As the noble Lord, Lord Chan, said, education is requiredit is done for general practitionersbut perhaps education of the public at large is needed. A recent copy of The Big Issue, produced by the homeless, contained an excellent article on the dangers of overusing antibiotics. I believe that the publishers should be commended because they were reaching a group of the population who need that information.
We need to collect robust data on infections and clinical outcomes and not only on the instances of infections. We need to know how many infections lead to death. Laboratory data are not enough. But the importance of laboratories must not be underestimated. We know that there are difficulties in recruiting and retaining laboratory staff as medical scientific officers, yet they are the backbone of the surveillance that will inform clinicians.
Vancomycin resistant staphylococcus aureus may be much more dangerous and is emerging horribly rapidly. If a person has methicillin resistant staphylococcus aureus, it may be possible to treat him with vancomycin, but if he is vancomycin resistant, he really is in very deep water.
Setting crude targets, which unfortunately have caught the public's eye, may be self-defeating. If a hospital is coping badly with infections, it is relatively easy for there to be a 10 per cent improvement. But if
The problem with figures is that they need careful interpretation. Perhaps I may give your Lordships a quick example. I was fortunate enough to have the data for 2002 on the 18 hospitals in Wales. One hospital had the sixth-from-lowest rate per 1,000 bed days for methicillin sensitive staphylococcus aureusthe ordinary staphylococcus aureusin blood cultures. Therefore, it is doing well. But that same hospital comes 12th out of the 18 for MRSA bacteraemia per 1,000 bed days. That is different from some of the other hospitals around. Therefore, one needs to ask what is going on and why, and that is quite complex. Many factors need to be considered: indwelling lines have been alluded to. They are generally associated with sicker patients. Of course, the risk of any bacteraemia is higher in a patient who is immuno-compromised.
There is a great need for good buildingsisolation rooms, adequate space between beds and enough sinks. One sink per bed is the dream of most healthcare workers. Most people are working in places where it is extremely hard to provide care and to carry out their jobs as well as they would like to do. My own ward has lamentably overcrowded bed areas with inadequate sinks. But the major refurbishment, which is badly needed and long overdue, has been competing with the installation of an MRI scanner, the chemotherapy pharmacy bill, covering for staff sickness and locum payments, and so on. We were recently turned down for an NOF bid, and that has left the staff profoundly demoralised. I fear that our infection rates will climb as a result because it is very hard to maintain good infection control at all times, as has already been alluded to.
Since April 2001, a mandatory scheme in Wales has recorded the occurrence of bacteraemias due to all staphylococcus aureus. A recent important Department of Health initiative across the UK, involving all four countries, required mandatory reporting. That has focused on orthopaedic cases, but it now needs to be broadened and rolled out across all areas of healthcare and to cover all healthcare-acquired infections.
We must be able to identify through research the critical areas where interventions have a clinical impact and where matters are improved through the interventions taken. As the noble Baroness, Lady Pitkeathley, said, these are complex issues and no one measure will be the magic bullet. For example, each surgeon needs to know the data on his or her patients for all hospital-acquired infections. However, providing all that data requires resources.
In understanding infection, comparative areas need to share data, identify the reason for their rates and look at the details of their clinical practice, such as the dressings which are used, the way they are put on and so forth. We may need to go away from the current pharmaceutical industry and not put our hope in new antibiotics. All organisms will mutate rapidly and develop resistance.
The noble Lord, Lord Colwyn, spoke on this theme at the start of the debate. It may be that old remedies for contained superficial infections, such as venous ulcers, should be used. The use of things such as iodine, honey, yoghurt, icing sugar or maggots to debride necrotic wounds may in the long term be a safer way to go, but long-term research and surveillance is needed. Academic microbiology departments must be encouraged and increased. It is only through high-quality research that the answers will be found. Crude targets have a habit of rebounding badly and consuming resources to appease headline writers rather than improving patient outcomes, and it is on patient outcomes that we need to collect data.
Viscount Bridgeman: My Lords, I am grateful to the noble Lord, Lord Ashley, for initiating the debate. I am also grateful to your Lordships for permitting me to speak during the gap. I declare an interest as chairman of the independent Hospital of St John and St Elizabeth in North London.
I spoke today to Dr Bill Chattopadhyay, who is a consultant microbiologist at the North Middlesex Hospital. He is also a consultant at the Hospital of St John and St Elizabeth and an inspector of the Clinical Pathological Accreditation (CPA). He is acknowledged as one of the foremost experts on MRSA in this country. He suggested I made two very simple points, which I address to the Minister for her consideration and, I hope, implementation.
The first is the washing of hands continually and between dealing with patients. Those points were made by the noble Lord, Lord Ashley, the noble Baronesses, Lady Masham and Lady Pitkeathley, and predictably and at some length by such a distinguished practitioner as the noble Lord, Lord Chan. However, the point Dr Chattaphady wants to make is that in his view there is a lamentably low priority given to this simple subject in the training of junior doctors and health professionals. I hope that that can be implemented in future programmes.
The second point he wants to make concerns the acute shortage of side rooms in hospitals, which are important for the isolation of MRSA. I hope that the department, in its future planning of new hospitals and
Lord Clement-Jones: My Lords, I, too, thank the noble Lord, Lord Ashley, for initiating the debate, for the way he introduced it in such a commanding and comprehensive way which allows us to debate the subject, and for eliciting the speeches that have been made by other noble Lords, which have been a very rich mixture of personal experience and professional expertise.
The view shared by all noble Lords is that it has been clear for some time that hospital-acquired infection in this country is not under proper control. Indeed, now it appears to be spreading beyond the hospital environment. There are clearly major consequences involved in hospital-acquired infection. Patients who have or get HAI stay in hospital on average about three times longer than non-HAI patients. That is equivalent to an extra 14 days per HAI patient. So this is a major cause of delayed discharge. We have heard some pretty harrowing stories from all Benches in this House. The statistics are that an HAI patient is seven times more likely to die in hospital than an uninfected patient. That is a pretty horrifying statistic.
In February 2000, the National Audit Office published a highly critical report on the control of infection in acute hospitals in England. The NAO found that healthcare-acquired infections caused more than 5,000 deaths per year and cost the NHS £1 billion. It subsequently appeared thatand many noble Lords have alluded to thisthe rates of MRSA in 2001 were nearly 50 times higher than they were in 1992.
Several noble Lords have talked about the voluntary reporting statistics. Of course we now have the mandatory statistics which are in many ways even more horrifying. The mandatory figure for the six-month period at the beginning of 2002 stands at 3,515 for MRSA cases. If that trend continues throughout the whole year there will be 7,000 cases of MRSA.
In response to that critical NAO report, the Government responded by initiating what they called a "clean-up drive" for hospitals in the autumn of 2000. That campaignand this is what I want to dwell upon tonightwas comprehensively taken to task by my honourable friend Paul Burstow MP in his report Now wash your hands, which was published in September last year. My honourable friend's concern about this matter arises directly as a result of his spokesmanship and concern for the health and welfare of older people, who are particularly affected by HAI.
The campaign was allocated a sum of £60 million to finance the clean-up of NHS hospitals. Patient Environment Action Teams (PEAT) were formed to inspect wards. These bodies comprised volunteers from within the NHS and some patient groups. Their responsibility was to grade the trust as "red" for poor, "yellow" for acceptable or "green" for excellent.
In order to do that, the teams looked at 19 categories. The noble Lord, Lord Chan, alluded to that. But only one category pertained to hygiene or cleanliness and none was about the control of infection. The other standards were made up of such arbitrary subjects as the appearance of linen and décor, the tidy state of public areas, even CCTV in car parks and easy-to-read signage. A hospital that scored one on cleanliness but scored highly in other areas could therefore be rated highly. It is therefore possible for a hospital to be designated "green", or excellent, because it is well decorated and there are clear signposts, even if it receives a low score on cleanliness.
It is obviously appropriate that hospitals should provide a good, safe environment for patients, but for that to be characterised as conforming to standards of "cleanliness" is misleading. It means that the traffic light system seems to have been more about public relations than infection control.
In autumn 2000, all NHS trusts were inspected by PEAT. The results of the inspections were not published but were leaked to The Times in January 2001. The inspections were repeated in the spring and the autumn of 2001, with only 42 "red" hospitals in the spring and none in the autumn. When they were published in October last year, the Secretary of State claimed:
As mentioned by the noble Lord, Lord Ashley, to cap it all, new research from my honourable friend shows that out of the 40 hospitals with the most MRSA cases, not one was classified as a "dirty" hospital under the Government's "Clean Hospital Programme" which Ministers championed as tackling the crisis. The analysis undertaken by my honourable friend looked at the 20 specialist and 20 acute hospitals with the highest rates of infection of MRSA. He found that 28 hospitals were classified as "green" and 12 as "amber", despite having the highest rates of infection in England.
Clearly, the situation cannot continue in this way. Ministers must stop giving the impression that they are on top of this problem and acknowledge that the "Clean Hospital Programme" is nothing of the kind. It
What needs to be done? Infection control must be placed even higher on the Government's agenda. There must be a sustained effort to maintain cleanliness standards, not just a one-off, gimmicky clean-up drive. Infection control teams must be given the resources and authority to undertake their jobs effectively. During our debate on SARS on Monday, the noble Baroness replied to me by saying that of course resources must be provided for infection control teams, but the fact is that there must be an audit, whether by CHI or the SHAs, to ensure that money is getting through and that the teams are properly resourced.
There should be independent inspection of hospital cleanliness and infection controlperhaps by the Commission for Healthcare Audit and Inspectionwhich would give an objective, national picture of the cleanliness of England's hospitals, so that patients can be sure that everything necessary is being done. As several noble Lords have mentioned, there should also be an intensive drive to look for alternatives to antibiotics. I remember five years ago, when we debated the Select Committee's report in 1998, raising the question of progress on bacteriophages. The National Endowment for Science, Technology and the Arts has funded research with £50,000. What research have the Government or the Medical Research Council funded to any significant extent in that area, which seems such a promising line to pursue?
The vigourous tackling of HAI, and MRSA in particular, would do wonders to increase capacity and lower mortality in the health service. Not enough is being done and I look forward to hearing the Minister's reply.
Earl Howe: My Lords, the House will be indebted to the noble Lord, Lord Ashley, for giving us an opportunity to debate an issue that has very serious implications for patients in the National Health Service. The noble Lord brought the facts home to us most powerfully.
Hospital-acquired infections are no joke. For the individual, their effects vary from mild discomfort to prolonged disability and, in some very serious cases, death. The statistics for such matters are always difficult to collate but, in 2000, the National Audit Office estimated that at any one time about 9 per cent of in-patients had a hospital-acquired infection, which equates to at least 100,000 infections a year.
Apart from the cost to human health, there is of course a significant attendant cost to the NHS itself, a good proportion of whichperhaps a third, according to the PHLScould probably be avoided by better hospital procedures. Because of that, there is an opportunity cost in terms of beds that could otherwise be occupied by patients waiting for hospital treatment.
It is not for people such as us, mere parliamentariansof course, I exempt the medical parliamentariansto try to tell NHS managers and the medical professions how to do their job. I venture to say that it is not for Ministers to do that either. We know what the NAO has said about how MRSA is transmitted and how such transmission might be better prevented. We can note that with considerable interest. We can welcome the fact that there are infection control guidelines and that CHI will monitor how they are implemented.
The job for the Government is perhaps threefold. It is, surely, to facilitate the compilation of reliable data to enable everyone to be clear about the nature and scale of the problem; to ensure that systems are in place that hold the NHS to account; and to facilitate and encourage research that may one day lead to an elimination of the infection.
On statistics, the Government have made a useful start by making it mandatory for all hospitals to report MRSA infections. The first comprehensive set of annual figures was published last October. What was interestingand alarmingabout those figures was the large increase in the rate and number of infections compared with the old voluntary reporting methods. The statistics also revealed considerable regional variations in prevalence, with London, for example, registering three times the rate seen in the West Midlands. It is clear that, taken as a whole, the UK's record compares unfavourably with that of every other country in the EU apart, I believe, from Greece. That is not a cause for pride, but it is at least a help that we are beginning to get a feel for how extensive the problem is. We have a benchmark.
As we heard, blood infection rates from MRSA vary considerably between hospitals. The rates tend to be higher in the South East and lower in the North. A relatively high rate seen in one hospital is not necessarily a reflection of that hospital's clinical procedures. We must always bear in mind the case mix, the levels of risk typically seen in the hospital's patients and the number of patients transferred from other hospitals or care homes when already infected with MRSA.
It is therefore difficult to compare one hospital with another on a crude basis, but we ought to be able to monitor trends. It is too early to know what progress has been made since March 2002, which marked the end of the first year's mandatory reporting. The noble Lord, Lord Hunt, last month quoted figures that possibly indicated a levelling out of infection rates in the nine months to last September. Since then, press reports have shown a substantial leap in the rates between 2001 and 2002. The PHLS apparently detected a rising trend; the Department of Health, on the other hand, was more cautious in its interpretation.
Whatever trends emerge, it is obviously important that the figures submitted by acute trusts, as in any other area of data-gathering, are subject to audit. It would be helpful if the Minister could tell me how that is being done.
There are still a few antibiotics that can successfully cure MRSA in its more common manifestations. However, as reports come in of bacteria that are resistant even to the last resort antibioticVancomycinwe do not need doctors to tell us that we are living on the edge of a very dangerous precipice. In California, a new strain of MRSA is being spread with alarming ease among healthy people outside hospitals. Although the bug is currently treatable, the fear is that it will soon acquire resistance. It is welcome that much is being done to disseminate good clinical practice by means of workshops in acute trusts and the publication of manuals. I am also conscious that NICE guidelines for infection control and prevention are due for publication very soon if they have not already been published. It would be helpful to hear about those from the Minister.
More research is needed. MRSA is a scourge affecting just about every country in the world. Can the Minister give any indication of what research programmes are being conducted in the UK, or abroad, in this field? I read recently of some promising work being done at Strathclyde University. It involves introducing water-borne viruses into dressings and stitches. Those benign viruses have been created to target and kill the three most common strains of MRSA found in UK hospitals. I understand that the initial trials are due to take place on animals and that if those are successful, studies on patients could be conducted within three years or so. The particular technique has been patented by the university and may have many other applications in combating infectious diseases.
Research is long term and its results uncertain. Nevertheless, I am sure that it is essential for there to be no defeatism about MRSA. A report by Eurosurveillance, a body funded by the European Commission, stated unequivocally that,
But positive thinking should never be obscured by false expectations. The public should not be led to believeas I fear that they have beenthat salvation lies in improving standards of hospital cleanliness. As the noble Lord, Lord Clement-Jones, said, it is striking that 13 of the top 20 worst offending trusts for MRSA received the highest cleanliness rating. Hospital cleanliness is vital, but there is no direct correlation between the general standards of cleanliness on wards and the prevalence of MRSA, and Ministers should not allow anyone to believe that there is.
The direction of travel that the Government have charted for the NHS will enable difficult problems such as MRSA to be tackled even more effectively. I refer to the drive towards greater local accountability, the devolution of budgets and, in particular, the foundation trusts. Best practice must be disseminated, but it will make its presence felt most effectively if hospital doctors, nurses and managers claim ownership of it and can see its direct relevance for them, for their hospital and for their patients.
Baroness Andrews: My Lords, I am grateful to my noble friend Lord Ashley of Stoke for creating, in his usual far-sighted and committed way, another opportunity for us to address one of the most serious problems facing hospitals. As I expected, we have had an expert debate. There has been lateral thinking, as well as expert thinking, and I am grateful to your Lordships who brought to the debate not only expertise and great knowledge but telling personal experience of being in hospital. The desire to make abstract generalisations falls away when one hears about people's actual experiences in hospital. I am grateful that noble Lords were able to share that with us, and I am delighted that they are with us to do so.
I shall scrap the first few pages of my speech, as the issues have been covered so admirably in so many different ways. I start by saying that, as my noble friend Lady Pitkeathley said, we have robust strategies to reduce infection rates, but we must acknowledge that the best practice cannot prevent everything. My noble friend said that she could not fault the staff, but our knowledge suggests that we can prevent only about 30 per cent of hospital-acquired infections. We must examine the issue, and I take the point that the noble Baroness, Lady Finlay of Llandaff, made. She said that we must not forget that the context is all hospital-acquired infections. That is important.
In the short time that I have, I want to focus on action and implementation. I hope that I can reassure noble Lords that this is a priority for action and not simply for the promotion and production of guidelines and advice. I want to deal with that.
My noble friend Lord Ashley of Stoke and the noble Earl, Lord Howe, referred to the potential for new strains to emerge. We must acknowledge that MRSA infections are a particular problem not only because they are difficult to treat but because they spread, not least because we have been so clever in inventing new technologies and new treatments and delivering them through the National Health Service in the past 20 years. In a way, our success in developing invasive devices has created new and easy routes of entry for infection. There are new strains. I think the noble Earl referred to recent community outbreaks in the United States caused by the Panton Valentine leukocidin or PVL-producing strain. It is extremely nasty and produces painful boils and skin abscesses. The Health Protection Agency recently summarised the data available on that strain and is investigating the
I shall briefly consider the issue of data. This is the first year of our mandatory reporting system. It is important that we are clear that it has been introduced, because of the unreliability of the voluntary data collecting system that we have had to date. Noble Lords quoted differing figures of 4,000 and 7,000 cases. The figures produced in the first year of the mandatory system showed 7,227 reports of MRSA. I think that the 4,000 figure was for the same year but was based on the voluntary collection system.
Therefore, it is important to be clear. As the noble Lord said, that illustrates that one of the chief tasks of government is to collect proper data. The media do not appreciate this. The reference made to recent reports in the media, which suggested that there had been a great hike in the number of cases, was the result of monthly figures being cited as weekly figures. So we must be extremely careful in what we read and how we interpret information.
We cannot fail to acknowledge that our rates of MRSA are high compared with northern Europe. It may be that this is, in part, because of our ability to treat more vulnerable people, such as the elderly, with new techniques. It may be because isolation is not easy. I think that noble Lords who raised the need for isolation would agree that it depends entirely on the circumstances and facilities of the hospital. Certainly, in our new-build hospitals, built under consumer guidance, there is more space and provision for hand-washing. I am sure that we shall see the evidence of that as the service is provided.
Of course, we recognise the pressure of life on the wards. My noble friends Lord Rea and Lady Pitkeathley gave some very telling examples of what that means. It is not an excuse to say that hygiene can be short-circuited, but it is an illustration of the pressure. Some of these issues are being addressed, such as smaller wards, more space around beds and improved procedures. But we must ensure that the guidelines issued in January 2001 are implemented, that infection control and basic hygiene, at the heart of good management, are in place and that the vanguard infection control teams are there.
The implementation workshops are a very serious attempt to ensure that people who need to be refreshed and refocused on this work get the chance to be retrained and obtain additional advice. The workshops are just starting and will involve front-line hospital staff.
I turn now to the impact that reportsnot least the Health Select Committee report on which the noble Lord played such a key role and the NAO reporthad on our strategy. As a result we introduced our first national strategy for getting ahead of infection, entitled, Getting Ahead of the Curve. That is now being translated into local targeted action plans which we are expecting to be ready in the next few months. They will set out different levels of operation nationally and locallyas well as internationallyon how we build on current work that is under way. Therefore, we have
It is important to understand that that is the first step. It will provide the means to monitor and tackle hospital acquired infections as a whole. As it develops, we shall be able to look at a whole range of issues. The National Institute for Clinical Excellence guidelines are expected to be published in the summer. We are confident that they will make a difference to the way in which people in the community, in care homes and in intermediate care are able to draw on the experience of hospital infection work in the acute sector and that there will be a much more effective transfer of information.
How do we ensure that this reaches the heart of the problem? Many noble Lords asked how we know that our policies are working. We already require chief executives, through the controls assurance standard, to ensure that effective policies are in place and are implemented. However, we recognised that more needed to be done. We recognised that chief executives had to be focused. That is why healthcare-associated infection is in the NHS performance management system. That has been done. Those procedures, MRSA improvement score and infection control are now performance indicators. They will contribute to the star ratings and will ensure that attention is focused on infection control. That must be the most effective thing we can do.
We are seeking to build partnerships by working with the professions to roll out practical solutions. I cannot go through all the activities because they form rather a long list, but I shall mention the position in relation to hand hygiene. There is no doubt that good hand hygiene is absolutely critical. I can tell the noble Viscount, Lord Bridgeman, that the National Patient Safety Agency has set up a project on hand hygiene, developing guidance for trusts on ways on improve compliance. although every trust should have its own policy. We are presently identifying pilot sites in order to gather even more information to feed back on better practice.
As the noble Baroness, Lady Masham, pointed out, other strategies must be employed, such as access to alcohol rubs. Such procedures are very simple, but effective. I take the points made by the noble Earl, Lord Howe, in his long list of what can be done. Most important, however, is that all the information is brought together. Further work is being done to produce a national infection control manual which will bring together all the different elements of information and guidance. It will be on the Web to access.
On the issue of the over-prescription of antibiotics, I can tell all noble Lords who referred to this that our campaign on antibiotic prescribing and overuse is still in place. While I would not like to say that it has had a direct impact, we have seen a drop in GP prescribing. However, I am sure that my noble friend Lord Ashley will appreciate that the campaign is up and running strongly.
Much emphasis has been placed on research during this debate. I could not agree more that we need more systematic research. We are spending around £4.7 million on research; of that, we have just put out a new call of £2.5 million for new proposals. We have commissioned, for example, new research on antimicrobial resistance. Furthermore, we have a commissioned health technology assessment review of isolation screening policies which is to be published shortly. Southampton University Hospital Trust is looking at ways of developing a rapid test for MRSA. I did not know about the Strathclyde University research mentioned by the noble Earl. It sounds extremely interesting and we would like to follow it up. The ozone research mentioned by the noble Lord, Lord Colwyn, is particularly interesting. It is not lateral thinking but I am sure that the department would want to look at the points raised by the noble Lord.
Turning to the points raised in regard to the pharmaceutical industry, we want to extend our dialogue across the industry. Although that is probably not enough for my noble friend Lord Ashley, it is evidence of our concern to work with the industry. I take the point made by the noble Lord, Lord Chan, that hospital pharmacists have a key role to play in helping to reduce over-prescribing in hospitals.
Along with other noble Lords, while I take the point that there is no apparent correlation between increases in the rate of MRSA infection and poor levels of cleanliness, common sense would suggest that there could be a link. We intend to examine the existing evidence in more detail.
We are now seeing real changes in hospital procedures, being driven not least by the modern matrons and ward housekeepers. It is their job to ensure that someone is told to dust under the beds. Indeed, the public perception now is that hospital cleanliness is improving.
I hope that, with better knowledge, better measurement and better enforcement, along with collective and coherent action, we shall make a difference in seeking to reduce the incidence of this appalling infection.
|Back to Table of Contents
|Lords Hansard Home Page