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Earl Howe: My Lords, it has been a very good debate, and I congratulate and thank my noble friend Lady Gardner, who introduced it so authoritatively
 
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and so well. We have seen from all the contributions this afternoon what a salient and important issue hospital hygiene now is in the minds of the general public. When we speak of the cost of hospital-acquired infections we are talking not simply about money but, more significantly, about human suffering on a very considerable scale.

Of course, it is possible to look at the statistics, as the Secretary of State did recently, and assert with complete accuracy that the incidence of hospital-acquired infections has changed very little over the past 10 or 20 years. Looked at alongside the record of other developed countries, the UK experience is not out of line. What that glosses over is the steep upward graph of the more serious, life-threatening infections such as MRSA. The rate of MRSA, in terms of numbers of patients affected, has more than doubled since 1997 and is still rising. Whereas in the Netherlands and Denmark the proportion of MRSA divided by non-resistant cases of staphylococcus aureus is a mere 1 per cent, here it is 44 per cent. In some hospitals in this country, MRSA is regarded as endemic. Quite rightly, therefore, the Government regard the fight against hospital infection as a priority.

My noble friend was very balanced and fair in her approach, as she always is, and I shall try to emulate her. The first point that I need to acknowledge to the Minister is that the matter is clearly not one that the Government on their own can solve. However, there are surely some tests which the Government have to pass. One is that, in so far as they act as a facilitator of good practice, they should do so efficiently and effectively. The other is that they should not make life more difficult for those trying to deal with the problem in hospitals. We need to look rather critically at whether or how well Ministers and the Department of Health pass those tests.

The striking thing, when one looks at the figures, is how widely the incidence of MRSA varies from hospital to hospital. Some trusts, such as those in York and Peterborough, do really well. Others, which it would be invidious of me to mention, do markedly less well. BUPA has reported that MRSA is negligible in its hospitals. It is unlikely that those variations are solely luck. A lot of work is going into research on the determinants of good performance in the area. We know, as the noble Lord, Lord Hunt, and others reminded us, that hand-washing by doctors and nurses is a major barrier to the spread of infection.

It is not true that higher rates of infection are a simple function of the age of a building, however. The NHS has many older hospitals with creditable infection records, and many modern ones with a bad record. Yet it is generally agreed that the design of new hospitals—in which the National Patient Safety Agency now has a lead role—needs to take into account the desirability of single rooms and adequate isolation facilities. As a very general point, we need to factor into our thinking the fact that patients admitted to hospital are sicker and frailer nowadays than they typically were in the past, and the vulnerability of many to infection is that much greater.
 
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That much, perhaps, is common ground, but there are one or two areas where the Minister and I are likely to disagree. One area that particularly concerns me is the extent to which government target-setting for elective surgery has compromised the ability of trusts to control their rates of infection. I do not say, and do not think that we can possibly say, that the rise in MRSA is all because of targets. However, if we look at rates of bed occupancy, which directly reflect patient throughput, we see that nearly three out of every four NHS trusts with the worst rates of MRSA infection have bed-occupancy levels exceeding that deemed safe by the Health Protection Agency.

It is no accident that the HPA has used the word "safe". It has not said "advisable". If a hospital exceeds a bed-occupancy rate of 85 per cent, it is behaving in a way that is not safe for patients. Professor Barry Cookson of the HPA has said that in terms. Both he and the NAO have pointed to performance targets as militating directly against good infection-control and bed-management practices. The NAO reported this year that 50 per cent of trust senior management had difficulty reconciling targets for in-patient waiting lists with the requirements for infection control.

On one level, we could say that that is simply one of life's problems for hospital management to solve. In practice, however, so long as performance targets remain in place, any request from an infection-control team to close down a ward is almost bound to meet with a refusal. That is what the NAO reported in a number of instances. One has to ask why management should be put in that invidious position in the first place.

A number of noble Lords have spoken about hospital cleanliness. A lot of nonsense appears in the press on the subject. There is no correlation, direct or indirect, between contracting-out of cleaning services and poor infection rates. Still less is there a basis for saying, as John Reid did the other day, that poor hospital cleanliness is really all the fault of the previous Conservative government. Many hospitals with contract cleaners have good rates of infection; some with in-house cleaners have a poor record. My own view, like that of the noble Baroness, Lady Neuberger, is that much depends on how cleaners are treated within the hospital, and if they are contract cleaners how that contract is managed.

It is perfectly possible for the contract to ensure that cleaners who perform poorly are made to account for it, just as it is possible to give day-to-day authority over cleaners to nurses on wards. The trouble is that that is often not done, and accountability for the ward environment is fragmented. The arrival of modern matrons was meant to allow the withholding of payments to cleaners when performance was deemed to be poor. Perhaps the Minister will answer the question posed by my noble friend Lord Eden and tell us to what extent that power has been used. If it has not been used to any great extent, why not?

Part of the difficulty of achieving cleaner hospitals is what many have seen as the decline in the ethos of cleanliness. Visitor access to wards is unrestricted. Staff uniforms are not laundered. Patients are moved between wards. Above all, cleaners are often marginalised rather
 
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than being made to feel, as they should be, a key part of the hospital effort. If cleaners need to feel a sense of ownership for a hospital and its patients, it is equally true that everyone else in the hospital, from the management down, needs to feel a sense of ownership for hospital hygiene. The NAO report of 2000 recommended mandatory MRSA surveillance in the hospital, specialty by specialty. That was seen as the only way in which clinicians would begin to take personal responsibility for trying to reduce infection in their own departments.

Clinicians themselves wanted that type of reporting; but still the only mandatory requirement is for data to be collected across each hospital as a whole. That is a golden excuse for everyone involved to pass the buck because people do not see what happens in the hospital as a whole as being their problem. The NAO was very emphatic on that point, and I have to say that it is an omission that reflects directly on the Government. In the document, Towards Cleaner Hospitals, Ministers proposed the idea of "think clean" days. That approach is absolutely no good because it gives people the idea that hygiene is not something for which they need to assume personal ownership every day of the week.

The NAO was also critical of the Government's snail-like behaviour in instituting the rapid review of new procedures and products, which was heralded last year in the department's document called Winning Ways. It took nine months from that announcement before the rapid review committee even had its first meeting. Meanwhile, applications had been made for a number of products and processes to be assessed for clinical and cost-effectiveness.

If the Government were serious about having a rapid review process, why were they so slow off the mark in putting one in place? Why have they also been so slow to develop and produce a national infection control manual? Again, the department has received a drubbing from the NAO for the lack of progress on an initiative which it started to look at nearly five years ago and which could well provide an extremely valuable template for use by NHS staff.

The list of sins unfortunately goes on. In 2000, the NAO drew attention to the lack of sufficient isolation facilities in NHS trusts. Nearly four years down the track, when the NAO looked again, it found that only a quarter of trusts had obtained the facilities they needed and nearly half had not even carried out a risk assessment. Isolation facilities have been a key part in keeping MRSA at bay in the Netherlands. Why did the Government not ensure with appropriate urgency that trusts were performance-managed on that issue?

Over the past five years, we have seen a succession of launches and relaunches of government initiatives, including the creation of modern matrons, infection control gurus, patient environment action teams, Getting Ahead of the Curve, the clean your hands campaign, Winning Ways, Towards Cleaner Hospitals, and so on. But, so far as I can see, there has been no follow-up appraisal or audit of any of them.

As I said earlier, HAIs are not a problem that government on their own can solve but, equally, government commitment to facilitating the solutions
 
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is indispensable. Why is it, for example, that the target date for placing a tub of cleanser beside each hospital bed is the middle of next year? Why do we not say that it has to be done straight away? The Government's target is to halve rates of MRSA in hospitals by 2008. That would be worth doing but, given that rates have doubled since 1997, that would simply put us back to where we were when Labour came to office. Is that target really ambitious enough?

It may be that with recent announcements—or, rather, reannouncements—the temperature dial has finally been turned up a couple of notches. We now need to see greater commitment from government to the collection of data, the promulgation of practical guidance, a rapid review process for new technologies and the sharing of best practice. We need to give hospital management freedom to deal with a serious outbreak of infection without incurring penalties for non-performance of targets. We need to give control of hygiene on wards to the nurses based on those wards. The key to solving the problem of HAIs is not financial; it is managerial and cultural. It involves government and management and doctors and nurses working together in the knowledge that every day that passes without proper hygiene procedures means patients dying from this public health nuisance. That, indeed, is the justification for this debate. I very much hope that the messages sent to Ministers today are both loud and unambiguous.

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