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Lord Hunt of Kings Heath: My Lords, first, I applaud the noble Baroness, Lady Gardner of Parkes, for her initiative in securing the debate today. She has first-hand experience of the NHS as a practitioner and a trust chair. I am sure that we are all indebted to her for the way in which she has presented many of the key issues that we need to debate this afternoon.

I also ought to declare an interest. I have several interests in the health service. They are in the register of interests, but I mention in particular my chairmanship of the National Patient Safety Agency.

The noble Baroness took us on a tour of some of the issues and problems that we face. She mentioned cleanliness, hand washing, instrument sterilisation, antibiotic resistance, blood product issues and food safety. She also suggested, by implication, that the situation on MRSA in Russia might be rather better than the situation in the UK.

We cannot be in any doubt that MRSA is a major problem that we must tackle, but the fact is that MRSA is a problem that many healthcare systems throughout the world are having to face up to. Although we can look abroad for some of the solutions that we need to develop in this country, we should not think that it is purely an NHS problem, to be solved by the NHS alone.

There are many issues, and we will hear today from expert speakers about the many causes of the MRSA problem. The noble Baroness focused on cleanliness issues, and I shall discuss some issues relating to cleanliness. However, I do not accept that it is simply a matter of cleanliness; there are several issues that must be tackled.

Looking back over the past 10 or 20 years, I think that the compulsory competitive tendering of cleaning services was a mistake. There is no doubt that the product of that process was to put all the concentration on cost, at the expense of quality. I have no doubt that, over 20 years, we saw a steady reduction in the quality of cleanliness services.

We must also face up to the loss of authority by nurses, particularly in the ward. It has been disastrous. Coupled with the development of functional management, so that cleanliness became the responsibility of a domestic services manager and food the responsibility of a catering
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manager, we can see the problem that was inherited. Nurses and sisters felt that they had no authority to ensure that their wards were clean or that the food was of a decent standard.

I also fear that the change in the curriculum for nurse training—driven, I am afraid, by the leaders of the nursing profession 10 or 15 years ago—which gave more emphasis to academic issues, as opposed to practical nursing skills, has led to a situation in which, in many places, nurses did not even think that they were responsible for having clean wards or ensuring that patients ate the food that was placed in front of them. Such issues cannot be divorced from the MRSA situation, and we must tackle them.

There has also been a lack of recognition of some of the systematic problems of poor cleanliness. It is desirable that clinicians should wash their hands after having been in contact with a patient. On the traditional NHS wards—the Nightingale wards—there will be perhaps one hand basin in place at the end of the ward. It has been worked out that it would take up about half of an hour of work, if members of staff were to walk from one patient to the hand basin, back to another patient and so on. In such circumstances, lay people, however puzzling we might think it that doctors and nurses do not automatically wash their hands after being in touch with each patient, must also consider the practicalities of the situation. In thinking of solutions for the future, we must ensure that it is made as easy as possible for those staff to wash their hands.

I am encouraged by the progress that has been made in the past few years. The strategies outlined by the department in Winning Ways in 2003 and the policy statement Towards cleaner hospitals and lower rates of infection in 2004 are to be commended. They set out a strategy that ought to be followed by the NHS. I also think that the noble Baroness, Lady Gardner of Parkes, underestimated the progress that has been made in individual trusts towards better cleaning and better food. The work of NHS Estates and of the PEAT teams that have gone in to inspect the cleanliness of hospitals has had a positive effect. The appointment of housekeepers on individual wards to relieve sisters of some of the day-to-day administration has also ensured a better focus on cleanliness. We should not ignore the success of the so-called modern matrons in giving back authority to nurses to sort out problems of cleanliness as they arise, rather than having nurses feel that they have no authority and that there is little that they can do about a poor situation.

The noble Baroness was right to mention food. Again, enormous progress has been made. The work of NHS Estates and the Better Hospital Food programme has undoubtedly led to the provision of better, more nutritious and safer food to many patients. Of course, there is much more to do, but we should not ignore the progress that has been made.

My agency, the National Patient Safety Agency, has been involved in the past few months in the cleanyourhands campaign. It is a focused campaign, and we have had a lot of support from trusts. It is about
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encouraging staff to wash their hands and about making it easy for them to do so. If alcohol hand-held gel is available by every bed, it will be much easier for staff to do the right thing. One's whole approach is to make it as easy as possible for staff to do the right thing.

There are other areas. I welcome the appointment of Chris Beasley as the new Chief Nursing Officer. She is just the sort of person who we need to sort such problems out. I welcome the responsibility that she has been given for cleanliness. Getting leadership at the top to sort out the problem is very important.

I hope that my noble friend will encourage the Chief Nursing Officer to look at the curriculum for nurse training. One of the problems that we face is that all the academics currently involved in nurse training are very much committed to the kind of curriculum that we have had for the past 10 years. Yet patients and experienced nurses say that they are very concerned that nurses being trained do not have the necessary practical skills for dealing with those kinds of problems.

Much as I admire the deans and academics in charge of nurse training and the curriculum, left to them, nothing will change. I hope that my noble friend will give a remit to the Chief Nursing Officer to lay down the law to those people and say, "This has got to change. We have got to produce nurses in the future who really understand the basic skills of caring, which are so essential in the nursing function".

In conclusion, there is one other aspect to which we must come back; that is, the use of more single-bed units. Of course, there is an expense involved, but MRSA is very expensive. It is expensive in terms of personal consequences for patients who are affected. But it also costs the health service a huge amount of resources in treating those patients who have to stay in hospital for much longer.

It would be cost-effective in the long term for us to look again at how we can get many more single-bed units in the health service. Overall, we all recognise that that is a problem, but I am encouraged by the action taken by the Government. I very much will encourage them to do more in the future.

Baroness Murphy: My Lords, I speak unashamedly today from my position as an NHS chairman of a strategic health authority where we are tackling the problem of hospital-acquired infection vigorously. Before I comment further I too should like to thank the noble Baroness, Lady Gardner of Parkes, for raising this important issue and for bringing it on to the agenda. Undoubtedly, debates like this will focus health authorities like mine on tackling the issues further.

We need no reminder today—World AIDS Day—of the devastating effect of infection on the populations of the world. To go back to the pre-Listerian era would be devastating. I have seen a quiet transformation of the
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general cleanliness of the hospitals in my patch—east and north-east London. We have seen a behaviour change that is beginning to have an impact.

However, the current state of affairs in the NHS is unacceptable, and I am not here to defend it. As we all know, many western European countries do better than us. I regret that there is ample evidence that effective countermeasures are not being implemented effectively or rigorously enough across all NHS hospitals.

Assumptions about what is necessary to move from where we are now have often been simplistic. Hand-washing is vital in the control of infection, but it is sometimes widely believed that the failure of staff to wash between seeing patients or on moving from ward to ward is due to laziness, carelessness or wilful ignorance.

I echo strongly what the noble Lord, Lord Hunt of Kings Heath, said about the avoidance of blame. One cannot exhort people to behave responsibly or punish them when they do not do the action required. Research and experience elsewhere simply points away from the efficacy of such an approach. A large number of barriers to proper hand hygiene have been identified. Some are the result of lack of training and skills, but others are due to inadequate facilities, lack of time in a crisis, overcrowding and the poor provision of hand-hygiene agents, such as alcohol gel bottles, being conveniently placed.

Last week, I visited the stroke unit of a hospital in my patch where frail patients are most at risk of succumbing to opportunistic infection. I noticed that the gel bottle at the entrance to the ward was on the opposite wall to that which would be most convenient when going in. I mentioned that to the ward sister. She said, "Yes, it is terrible, isn't it? I have asked them to come back and change it". We need such things to be in places where people can use them.

However, we should remember that the bugs are getting cleverer. There are three major strains of multi-resistant bacteria emerging—MRSA is just one. Vancomycin-resistant enterococci and penicillin-resistant strep pneumoniae are also making headlines now. But escalating antibiotic resistance is likely to produce many more in the future. Our task will probably get more challenging, no matter how effectively we tackle the current difficulties.

The good news is that we know what is effective. We know that the position has been reversed in much of the Netherlands and Scandinavia. Some parts of the NHS are making very good progress too—in particular, the Oxford Radcliffe Hospitals NHS Trust, which has a number of really effective schemes in progress. In my patch, Homerton Hospital in Hackney does consistently well and compares well internationally. Moorfields Eye Hospital, although it has less of a risk because it is a single-specialty hospital, has the distinction of having zero MRSA bacteraemic infections since monitoring began in 2001. I hope that that is not a hostage to fortune for Moorfields Eye Hospital.

In my view, there are two very helpful Department of Health initiatives. The first was the establishment of compulsory monitoring of hospital-acquired
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bloodstream infection rates hospital by hospital. That means that every quarter trusts and health authorities can benchmark performance against similar institutions across the country and focus their efforts specifically on internal areas giving cause for concern.

That feedback and the ammunition that it gives to managers and nurses charged with reversing the trend is very helpful. This Government are the first to do that. The target set for reducing by half the infection rates in acute hospitals by 2008 is challenging but, in my view, it is achievable if our current plans are allowed to bear fruit.

The second good thing is the appointment of the Chief Nursing Officer, Chris Beasley, who the noble Lord, Lord Hunt, has already mentioned. She has been charged with leading on this matter. The noble Lord approves of her appointment. For those who know her, she is one of those rare characters who has all the admired qualities of the old-fashioned matron and, just as importantly, none of the bad. Her "street cred" in the NHS is very high indeed. Her leadership of half a million nurses in the NHS—that figure reminds us of the size of the task of turning round the NHS "Ark Royal"—is a significant asset.

So what is happening in practice that will make a difference? The first important step is to eradicate as far as possible new incidents of infection. In our strategic health authority—I believe others are following the same track—we have a special action team that is led by one of our more experienced hospital chief executives and our chief nurse, which has now audited in detail the worst sites and has instituted targeted training programmes.

New incidents have already dropped in the specific areas looked at. I am proud to say that currently in our health authority we compare quite well with the rest of London. All induction training courses will now include a session on basic hygiene. But we need to involve visitors too so that they understand why hand hygiene is important. We also need to educate the local public, councillors and MPs, for example, about the true situation; for example, why we should not panic, what is doable and what is not. Some of the myths need to be exploded. I am delighted to say that we have made some progress in, for example, the Barking, Havering and Redbridge area. We meet regularly with MPs in order to let them know what is happening.

The action plan for cleaner hospitals covers the basics, but will work only if all hospitals have the kind of inspirational nursing leadership that shows by example, an identified lead person responsible for monitoring those targets and, as has already been said, a ward management system that includes permanent cleaning staff as key members of the team working under the ward manager's direction. It makes no difference whether cleaners are contracted out or in, it is who directs their day-to-day work that counts.

So why, if we know how to do it—frankly, we have always known how to do it—has it not been done before? The advent of antibiotics in the 1940s, 1950s and 1960s before these new strains appeared undoubtedly lulled us into a false sense of security.
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Secondly, the effective management of wards was demolished by the ill-thought-out centralisation of domestic services. This had nothing to do with contracting out, which merely perpetuated what was already bad. The problem of parallel lines of management affected other professional staffs too, which militated against good multi-disciplinary work and effective unit management.

Can anyone here remember the dreaded "cogwheel" system? It was a ghastly recipe for managerial stagnation and we are still in the throes of reversing that disaster.

However, during the 1980s and early 1990s we saw the decline of the National Health Service system. I can remember personally the cutting of 25 per cent of the beds in London in 1984. That took place over a two-year period. Occupancy rates rocketed and have continued to do so. Patients were admitted to the wrong units, were moved about daily, which led to junior doctors running around each morning trying to find their patients, no doubt carrying infection with them. Infection thrives in overcrowded, high-turnover hospitals.

Lastly, staffing levels among nursing and domestic staff in many hospitals were often lamentable during the 1980s. The general decline in the NHS combined with the inability of ward managers to effect change undoubtedly added to the problems of poor recruitment and an ever-changing number of disengaged, low-morale agency and transient staff.

A healthy, infection-free hospital depends on the quality of its professional and management leaders, and their effective use of the tools now provided for them. I hope that this House recognises the excellent work now being done to tackle the complex problems of hospital-acquired infections in the NHS, and would not simply add tabloid headlines to a topic which deserves a more serious consideration of all its complex aspects.

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