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Lord Warner: My Lords, I, too, congratulate the noble Baroness on securing this debate because tackling healthcare-acquired infections is a key priority for the Government. Indeed, I am leading on this particular issue within the departmental ministerial team and I chair a project team which meets on this issue weekly.

I have to say that if that was the noble Earl, Lord Howe, being non-partisan and balanced, I would not like to get him on a day when he is not. If I may say so, I think that some of his speech showed how long his party has been out of government and how unaware it is of how difficult it is in a big, complex organisation such as the NHS to secure change.

However, I am grateful for the many thoughtful remarks from noble Lords, and I want to set out how the Government are tackling the problem of healthcare-acquired infections, especially MRSA. I am particularly grateful to those who spoke from their personal experiences within the NHS.

We find it a little difficult when we are given lectures on the problems of targets, waiting lists and the difficulties of the NHS when, as was acknowledged very clearly in this debate, it was the party opposite that cut the number of beds by 25 per cent. That is what happened. With regard to the noble Lord, Lord Selsdon, I am pleased to say that I always welcome a sinner who repents. I noticed that the noble Viscount, Lord Bridgeman, acknowledged some of these points. One does not just grow that number of beds overnight; it takes an investment programme and it takes time to produce that investment programme.
 
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If I may continue to work the noble Earl over a little, I thought that his remarks about the implementation of the cleanyourhands campaign typified the lack of reality. It takes time to put this system in place across all the acute wards in the NHS. It requires a management effort for that to happen. It requires supplies of the gel, supplies of the containers and the training of staff. We do not simply click our fingers and make these things happen in Richmond House. It may have been that way in the past, but it is not the way that we try to run the NHS at the moment.

We know that much more needs to be done in this area, and we recognise that the recent NAO report on hospital-acquired infections contained some criticisms, as has been dwelt on today. But, as the NAO report also said, it is also worth recognising that our work in this area has moved infection control up the NHS agenda considerably. That was not mentioned by a number of noble Lords.

The new Chief Nursing Officer—I share the high regard that noble Lords have for Chris Beasley—is building on the work that we have already done by leading our programme to improve both infection control and hospital cleanliness. I am sure that Chris Beasley will pay close attention to comments today about looking at nurse training curriculums, and I shall certainly be discussing this issue with her at our meeting next week.

Let us be clear that these infections are caused by a wide variety of micro-organisms—often bacteria from our own bodies—and, unfortunately, not all hospital-acquired infections are preventable. Many factors contribute to the problem: for example, more susceptible patients, such as those with severe or chronic diseases, are being treated than ever before; and, at the same time, advances in treatment that improve patient survival, such as chemotherapy, can leave them more vulnerable to infections. My noble friend Lady Pitkeathley cited her own example in this area. Other factors, such as increasing antibiotic resistance, are also important.

I assure my noble friend Lord Turnberg that we agree that there is no one simple solution to what is an extremely complex and multifaceted problem. But we believe that the risk of contracting these infections can, in part, be reduced by some relatively simple and effective infection-control measures. However, I emphasise that there are no quick fixes.

As my noble friend Lord Hunt said, healthcare-acquired infections are an international and not just a UK problem. In the United States, Australasia and most European countries, including the UK, the percentage of patients who experience a healthcare-acquired infection come within a remarkably similar range. I acknowledge that there are some notable exceptions in some of those European countries but, across the whole of Europe, that is broadly the picture.

Moreover, hospital-acquired infections are not a new phenomenon. While medical practice has changed and different micro-organisms have been involved, estimates that around 9 per cent of in-patients in
 
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England acquire an infection of some kind have not changed that much since at least 1980. I am grateful for the realism of my noble friend Lady Pitkeathley, whose graphic experience I witnessed when she was in hospital. She has brought home to us the realities of the difficult choices that NHS staff often face in acute hospitals.

Comprehensive and reliable information on most hospital-acquired infections is not available. This Government were the first to act in 2001 to introduce mandatory surveillance for MRSA bloodstream infections. We are extending mandatory surveillance. The information on MRSA shows a slight but not dramatic increase over the past three years of 5 per cent. However, we are not alone in experiencing increasing levels of MRSA. The same problem has been occurring in Austria, Belgium, Germany and Ireland since 1999.

Can we nail the figures on the risk of MRSA in NHS hospitals? We estimate that MRSA affects about 0.3 per cent of patients; that is, three in 1,000. Of course that is three too many in every thousand and we need to reduce it. However, we should be careful not to exaggerate what is a serious problem to such an extent that we alarm patients and the public and make them afraid of going into hospital to seek the treatment that they need.

MRSA has become more of a problem in the UK for a number of interrelated reasons. They include the fact that the strains responsible for most infections in the UK are particularly well adapted to spreading between patients. MRSA was relatively uncommon through the 1960s and 1970s. A few more appeared in the 1980s, but the problem exploded in the mid-1990s when particular epidemic strains of MRSA became established in hospitals in the UK.

I have to tell the noble Earl, Lord Howe, that the major surge was between 1993 and 1997. The epidemic strains have the property of easy transmissibility and they readily spread between patients. Moreover, they have the capacity to cause serious disease which means that they are virulent. These are the ones that now represent over 40 per cent of the staphylococcus aureus causing bloodstream infections in England.

MRSA infections are not spread, as a number of noble Lords have said, equally across the NHS. One fifth of trusts account for almost half of all MRSA bloodstream infections and around 80 per cent of all MRSA cases are concentrated in around 50 per cent of hospital trusts. We will be working closely with those who have the greatest problems. We want to help them to learn from those who have the better track records in this area.

While we know that not all these infections can be prevented, we are acting on this important patient safety issue. We are committed to being completely open with the public about the matter and have published the level of MRSA infections in every NHS trust since 2001. We are working in partnership with patients and their carers; for example, Ministers have met the patient MRSA support group and hope to work with it in the future.
 
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The noble Baroness, Lady Murphy, drew attention to the damage done to NHS capacity in the 1980s. As I said earlier, I welcome repentance in that area from the Benches opposite. That is why we are having to create the extra capacity needed to ensure that better patient care is available. By 2007–08 public expenditure on the NHS is set to rise to £90 billion a year, compared with about £33 billion a year in 1997. We are putting more doctors and nurses and 40 new hospitals in place and there are still about 30 to come. Those improvements will help us to reduce healthcare-associated infections, as I believe the noble Baroness, Lady Murphy, indicated.

We know that there is no quick fix. I am grateful to my noble friend Lord Hunt for his support for our plans for reducing infection rates, as set out in the Chief Medical Officer's document Winning Ways and our 2004 document Towards cleaner hospitals and lower rates of infection, published in July. We are actively implementing this programme; for example, we are providing £12 million over three years to support the work of hospital clinical pharmacists who are monitoring compliance with antibiotic prescribing policies.

I am grateful for the support from the noble Baroness, Lady Murphy, for the major new initiative that we have taken in the introduction of our only—I emphasise "only"—new target which is halving MRSA bloodstream infections by 2008. We know that having a target ensures that the issue is given priority in the NHS and the NAO report, mentioned by noble Lords, indicated that the introduction of mandatory MRSA surveillance raised the profile of infection control with senior managers. We believe that the new target will act in a similar way.

A number of noble Lords have drawn attention to the importance of hand hygiene. It is an important part of infection control and in September we funded and launched what we believe to be the first ever national hand hygiene campaign. The cleanyourhands campaign is based on a thorough, successful pilot study undertaken by the National Patient Safety Agency. I pay tribute to my noble friend Lord Hunt for the leadership that he has shown in that area. That evidence-based campaign is tackling what has been an intractable problem for healthcare systems worldwide and its impact on infection rates will be carefully evaluated. It is stopping journeys across the ward to wash hands, as my noble friend Lord Hunt described so graphically, by putting alcohol gels easily accessible at all bedsides in acute hospitals.

I can assure my noble friend Lady Pitkeathley that we are also taking a proactive approach to research. We shall host a science summit later this month of leading scientists from home and abroad to consider how their research can influence our healthcare-associated infections programme. That will identify work that has the potential to be applied shortly and new research priorities. Money has been identified and our research programme will be expanded as proposed in Winning Ways. I can reassure my noble friend Lord Turnberg that we want to find a speedier test for
 
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establishing MRSA in patients, but that is not an easy thing to achieve. We need much help from scientists in this area.

We are actively supporting NHS staff to achieve those changes; for instance, the new audit tool developed with the Infection Control Nurses Association will help acute trusts to monitor and to improve infection control. That will help NHS staff to assess compliance on policies such as hand hygiene, decontamination of patient equipment, linen and waste handling and clinical practice. I can tell my noble friend Lord Turnberg that we are looking at the evidence on agency staff, which is fairly complex to pin down.

Another area where we are helping the NHS is in assessing products that claim to help to control and to prevent healthcare-associated infections. I have a steady postbag from people offering me every conceivable answer to this problem. That is why we asked the Health Protection Agency to establish a rapid review panel for such products. Perhaps with hindsight the title of that panel was a little misguided. The panel's remit is to provide a prompt assessment of new equipment, materials and other products or protocols that may be of value to the NHS in improving hospital cleanliness, hygiene and infection control. It is true that the first results have taken some time to emerge from the panel, but it is under no misapprehension that we expect the process to be carried out more speedily. The first results from the panel were released this morning and will be of interest to the NHS. They were actually covered on the ITN news this lunchtime. The silver-coated hydrogel catheter may be of particular interest. We hope that the second wave of results will be available before the end of this year.

Our programme is one in which local action is crucial. The requirement in Winning Ways for each trust to designate a director of infection prevention and control is helping to change the culture so that infection control is everybody's business. That is a critical point to be made throughout the NHS. There is not one group of staff who on their own will be able to change the situation. The directors report directly to the chief executive and the board and will thus be able to bring about local change. Let me assure the noble Lord, Lord Eden, that we shall be looking to trust boards and chief executives to exercise leadership and to change the local culture in this area and to get everyone to include infection control on his personal development plan.

I can also tell the noble Lord that off the top of my head I can think of two specific examples where the contractors have been changed—the Oxford Radcliffe Hospitals NHS Trust and the Chelsea and Westminster Hospital. I think that there may well be other hospitals which have taken that decision.

The noble Baroness, Lady Masham, and the noble Baroness, Lady Neuberger, said that the new Chief Nursing Officer had made clear that we will want to improve infection control training for all staff. We recognise that this is a top priority and that we are engaged on a major change programme. We are
 
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talking about 1.3 million staff in the NHS. Again, I gently remind the noble Earl, Lord Howe, that these things take time to organise and to put into practice. He may have forgotten that from his time in government.

We are also working to improve both infection control and cleanliness, since even in the absence of unequivocal scientific evidence, common sense suggests that there is a link between the two. Due to a drop in investment for cleaning in a previous period, between 2000 and 2003 the Government have invested an additional £68 million in a nationwide hospital clean-up campaign and have initiated a programme of unannounced visits by independent teams. Patient Environment Action Teams assessments, which involve patients' representatives, continue today and their results are used to help determine a trust's star rating.

The cleanliness figures from 2003 show that 78 per cent of trusts were assessed as "good" on cleanliness and 22 per cent as "acceptable". That shows a significant improvement on previous periods. The noble Earl, Lord Howe, invited me to disagree with my right honourable friend's remarks about contract cleaning. I think the point that my right honourable friend was making—and I always hesitate to disagree with him—is similar to the point touched upon by the noble Lord, Lord Hunt, that the fact of contracting out of cleaning in a past era drove down the investment in this particular area. That is an important issue which we need to get to the bottom of.

I accept that the PEAT scores suggest not a great deal of difference between the performance of trusts which have contracted out cleaning and those with in-house contracts. Some contracts are not very smartly set up to ensure rapid response where there are particular problems. Some have operated in a way that excludes nurses from the agenda of remedying deficiencies in the cleaning arrangements.

We have issued a cleaning manual to the NHS, setting out the best ways to clean hospitals. That will be updated when the results of our research on new cleaning methods and technologies become available. We will provide recommended cleaning standards and minimum cleaning frequencies to achieve these standards and ways of measuring them. I think that that will help both in-house teams and contracted out services to perform more effectively.

A number of noble Lords have mentioned—I thought on one or two occasions not totally kindly—our launch of the new matron's charter. This document will help modern matrons and others to raise standards. It sets out 10 key commitments that everyone can sign up to, no matter how cleaning services are organised. It was written with the support of seven partner organisations, including the Royal College of Nursing.

We will also be supporting a series of activities aimed at ensuring that cleanliness is at the forefront of everyone's mind, for example, involving frontline staff in a "Think Clean" programme. I do not think that this
 
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initiative is about a one-off event; it seeks to establish in people's minds that cleaning is a top priority in the way they do their job. We are developing training materials in this particular area and will be working with the professional bodies on the whole area of the curricula of undergraduate and postgraduate training.

It has been suggested that our success in treating more patients has impacted on our ability to control infection rates. A number of trusts—Sheffield Teaching Hospitals NHS Trust, Harrogate Health Care NHS Trust and Taunton & Somerset NHS Trust, to name a few—have achieved waiting list targets and maintained low rates for MRSA. The two are not incompatible.

This is a local decision. It is up to people locally to manage their services in the most effective way. Our job is to establish the right direction and to invest in the quality of local leadership. We have put in place the new Directors of Infection Prevention and Control. We think that they will provide good advice. We have been absolutely clear on our view that clinical priorities and clinical need should take precedence and guide the actions and decisions of those deciding on the closure of beds, wards and hospitals. We have not deviated from that position. People must make their own judgments. My noble friend Lady Pitkeathley put the matter very well. She said that in some cases you are faced with situations of real emergency that you have to make decisions on and you have to balance that against some of the issues around infection control.

In conclusion, we are determined to reduce healthcare-associated infections by creating extra capacity in the NHS and implementing an evidence-based programme to identify the actions which will make a difference and drive these forward by setting clear targets and offering support to trusts which need help.

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