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17 July 2008 : Column GC139

17 July 2008 : Column GC139

Grand Committee

Thursday, 17 July 2008.

The Committee met at two o'clock.

[The Deputy Chairman of Committees (Baroness McIntosh of Hudnall) in the Chair.]

The Deputy Chairman of Committees (Baroness McIntosh of Hudnall): It has been agreed that should any of the Questions for Short Debate not run for their allotted hour this afternoon, the Committee will adjourn during pleasure until the end of the hour. Therefore, each of the Questions for Short Debate will start on the hour. If there is a Division, the Committee will adjourn at the sound of the Division Bell and resume after 10 minutes. The 10 minutes thereby lost from the debate will be added to the debate thereafter.

Health: Hospital-acquired Infections

2.01 pm

Lord Patel asked Her Majesty’s Government what plans they have to reduce hospital-acquired infections.

The noble Lord said: Healthcare-associated infections affect approximately 9 per cent of in-patients, cause at least 5,000 deaths per year and contribute to a further 15,000 deaths a year. Furthermore, 300,000 or more patients acquire non-fatal infections that prolong their stay in hospital. In England alone, this leads to a loss of 3.6 million bed days, at an estimated cost of £1 billion per year.

Regular headlines in the media such as:

cause a great deal of public concern. It is not surprising, therefore, that patients are concerned about going into hospital for treatment for fear of catching these infections, which may prove fatal.

There are several infective agents responsible for healthcare-associated infections. The two that are currently of major concern are meticillin-resistant staphylococcus aureus—MRSA—and Clostridium difficile, or C. diff. Others are glycopeptide-resistant enterococcus—GRE—which can cause blood poisoning; norovirus, which causes mild, short-lived gastroenteritis, the so-called winter bug; and various pseudomonas species, which cause a range of illness, mainly in the elderly. I have no doubt that unless we have a successful strategy for controlling healthcare-acquired infections, there will be other infective agents in the future, possibly even more deadly than the ones we have now.

Government policy currently focuses on infections due chiefly to MRSA and, to a lesser degree, C. diff. Staphylococcus aureus is a common bacterium, found in skin or mucosa. MRSA is a variety resistant to antibiotics, including meticillin. About 3 per cent of people are carriers. Infections occur when bacteria enter the body or bloodstream, usually via a cut or catheter, commonly during surgery via wounds or

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ulcers. They can also do so via intravenous catheters or breathing tubes. They cause deep abscesses or septicaemia.

Clostridium difficile, or C. diff, a bacterium found in the gut of 3 per cent of adults and nearly two-thirds of babies, is harmless in healthy people, but in ill, elderly patients, and in conjunction with antibiotic therapy, can cause severe colitis, perforation of the bowel and death. It is highly infectious and, importantly, spores shed in faeces are hardy and survive for long periods on surfaces such as toilets, sheets, beds and floors. Both MRSA and C. diff are transmitted from person to person and may be picked up from environmental contamination.

From what I have just said about the nature of transmission of infection by these organisms, it is clear that simple measures of cleanliness—personal and environmental—judicious use of antibiotics, and a stringent policy of “search and destroy” can drastically reduce the incidence of such infections from 9 per cent of in-patients to as low as 1 per cent.

The UK is one of the worst countries in western Europe for the incidence of MRSA and C. diff infections. So do we have a policy that will change that? To know whether we have an effective policy, we first need good surveillance. Since the introduction of mandatory reporting of MRSA and now C. diff infections acquired in hospitals, the surveillance of hospital-acquired infection is now reasonably good but not accurate. On the other hand, for healthcare-acquired infections acquired in the community setting, surveillance data are poor. That is particularly important, as more healthcare is now delivered in the community, so I ask what plans the Government have to collect information on community-acquired healthcare infections.

Healthcare-associated infection as a cause of or associated with death is also poorly recorded on death certificates, as was the case in the Clostridium difficile outbreak in the Maidstone and Tunbridge Wells NHS Trust. The death certificates did not indicate that the patients had died of C. diff infections.

What is the extent of MRSA and C. diff infections? For MRSA blood-stream infections—so-called bacteraemia—in the financial year 2006-07 the numbers were 6,381. Data from 2007-08 are not yet available, unless the Minister has them today. The trend has been downwards except for the last quarter, October to December 2007, which showed an increase of 0.6 per cent on the previous quarter. The Government have a target of halving MRSA blood-stream infections from 7,700 in 2003-04 to 3,850 or fewer in 2007-08, unless the target measurement was not as I understood it. Will the Government meet that target? Maybe halving the rate of 2003-04 was ambitious, but it is important to maintain the pressure to drive down the rate.

For C. diff, the surveillance data are difficult to interpret due to changes introduced over time. Between 2004 and 2006, the numbers of C. diff infections rose from 44,000 to 55,000. Quarterly data for October to December 2007 compared to the same period in 2006 showed a 26 per cent reduction. The Government introduced a target for C. diff in 2007 of reducing the number by 30 per cent by March 2011—nearly three

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years away—from baseline 2007-08. Again it is unclear how the target would be measured. I seek clarification from the Minister.

Have we got the policies to achieve the targets and beyond? In 2002, we had the CMO’s Getting Ahead of the Curve strategy, and many other follows. In 2003 there was Winning Ways, in 2004 Towards Cleaner Hospitals, in 2005 Saving Lives, in 2006 Essential Steps to Safe, Clean Care, in 2007 Saving Lives: Reducing Infection, Delivering Clean and Safe Care, and in 2008 Clean, Safe Care: Reducing Infections and Saving Lives. They outline plans to introduce MRSA screening for patients but not staff, deep cleaning and additional specialist staff to tackle infection. In addition, we have the Health Act 2006, requiring NHS trusts to follow recommendations and the Healthcare Commission’s annual checks. There are also financial penalties and incentives. Certainly, there is no lack of commitment to tackle the problem of healthcare-acquired infections.

So are the policies and strategies effective? Despite lack of strong evidence of environmental contamination and infection rates, the policy related to hospital cleanliness and deep cleaning is right. Clean hospitals instil public confidence and a culture of the importance of hygiene in staff. If there are any concerns, it is about whether deep cleaning is carried out in all areas of hospitals, how often it is and should be carried out, and what agents are used.

Countries that have very low levels of healthcare-acquired infections have stringent policies for monitoring levels of environmental contamination and decontamination. While there might be contrasting views of deep cleaning as an effective strategy, there is no doubt that hand hygiene is the single most effective measure for controlling the transmission of infection in all healthcare settings. I declare an interest as chair of the National Patient Safety Agency, which is responsible for the cleanyourhands campaign.

Hand washing with soap and water and use of alcohol gel after each and every patient contact have to be more actively enforced in healthcare, as they are in the food-handling industry. In my view, to cause a death by transmission of infection is in the same category as death caused by wrong diagnosis, treatment or bad surgery. The clinical professions need to accept greater responsibility.

The policy of “bare below the elbows” may facilitate hand washing, but the removal of clean, hospital-provided white coats and nurses’ uniforms on a daily basis is a retrograde step. On the other hand, the wearing of operating-theatre and ward clothing in cafeterias and other public areas in hospitals should be prohibited with sanctions.

The most recent government policy relates to the introduction of patient screening for MRSA for elective admissions in 2008—I do not know when in 2008—and for emergency admissions during the next three years. Countries that have low levels of infection have not only policies of screening all patients and staff but also low bed occupancy, low levels of workload for nursing staff and a strict policy of isolation of infected patients.

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Strategies that we are slowly beginning to adopt have still some way to go. The public are rightly anxious about healthcare-associated infections. Patients fear going into hospitals. Any Government who deliver clean hospitals, healthcare in a clean and safe environment and effective infection control policies, followed and adhered to by all, will remove healthcare and the NHS from politics. Would that not be a prize worth having?

2.12 pm

Baroness Masham of Ilton: I thank my noble friend Lord Patel for this short but important debate. He chairs the National Patient Safety Agency, which campaigns to improve patient safety. What can be more important? One of its projects was cleanyourhands, a national campaign to promote better hand hygiene in hospitals that began in 2005. In 2007, the programme was extended to other providers such as care homes and community clinics. If the campaign does not exist in schools, it should. Children should grow up realising how dangerous it is not to wash their hands, especially when handling food after going to the lavatory. People from eastern Europe whom I employ at home seem to wash their hands much more than British people.

Washing one’s hands with soap and water is the best way of protecting patients, as the gel does not work on the highly infectious Clostridium difficile. I have heard of nurses who have gone from patient to patient while not washing their gloved hands. They think that washing is not necessary if they wear gloves.

The wife of a severely disabled man in Yorkshire who had had MRSA and is fed by a peg in his stomach asked a nurse whether her husband had had a check to see whether he still had MRSA. The nurse said, “Well, if he does have a check and it is positive, it will give us a lot more trouble as he will have to be barrier nursed”. I wonder how many such cases there are across hospital trusts. Infection control nurses should be able to take responsibility and have great support in stopping such dangerous attitudes among such lazy nurses.

Much has been done in the past few years and the Government have tried hard to reduce hospital-acquired infections, but there is much more to be done. One still hears of sloppy practices such as that described to me by the wife of a high-lesion tetraplegic man. Her husband had a chest infection and had gone into hospital. On the Friday, when he went home for the weekend, his sputum jar was sitting on a shelf by his bed, but when he returned on Monday morning it was still there and had not been emptied. In the old days, a sister on the ward would have seen that such things were done and jars not left unclean.

The grandson of one of my friends was admitted to the Freeman Hospital in Newcastle for a serious heart condition, aged one. The operation took many hours and was a success, but unfortunately he contracted MRSA. The family cannot praise the hospital team enough and, after many critical days, little George pulled through. Hospital infections put extra strain on everybody. In this case, a dedicated skilful hospital team and the family had much more anxiety due to MRSA. Does the Minister agree that prevention of hospital-acquired infection should be at the top of the agenda?

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It is said that patients should be screened when they come into hospitals or care homes, but should not the medical and nursing staff be screened as well? If they are working with vulnerable patients, how many might become carriers and put patients at risk?

One often hears of bad practice such as clean laundry being brought in and left beside dirty laundry. Surely it is possible with such a large staff to put in a manager who could take responsibility for seeing that good practice takes place.

I am pleased to be associated with the National Concern for Healthcare Infections, which aims to raise awareness, and give support, on patient safety. It asked me to be its patron, and I accepted. Does the Minister agree with the guidelines to tackle hospital-acquired pneumonia? This is the most common hospital-acquired infection in intubated patients, increasing mortality by up to 75 per cent. When hospital-acquired pneumonia is caused by bacteria, treatment will always be with antibiotics. However, the increasing problem of antimicrobial resistance, largely due to inappropriate use of antibiotics, has made its management more complicated and has led to a rise in hospital-acquired infections as a whole.

A key driver in developing the guidelines was to minimise the number of preventable deaths from HAP due to any cause. The new guidelines set out the importance of prevention, diagnosis and early treatment and ensuring the right antibiotic is used at the right time. There should be fast-track testing and results, otherwise wide-spectrum antibiotics will continue to be used. What chance is there of this action happening?

Consideration needs to be given not only to acute NHS trusts which provide general facilities for the public, but to specialist hospitals which treat patients who are susceptible to many other infections, including campylobacter—with almost 50,000 patients affected in 2006.

Many impaired people are susceptible to the development of pressure sores. This presents another avenue for bacteria, such as MRSA, to enter the bloodstream or infect the skin around the lesion. As president of the Spinal Injuries Association, I know the terrible problems pressure sores can have for vulnerable patients treated in hospitals which do not have the correct equipment, such as turning beds and pressure-relieving mattresses. I hope that the new Care Quality Commission will include precautions being taken by healthcare establishments to prevent pressure sores in its assessment and inspection regime.

The terrible problems of the virulent strain of 027 Clostridium difficile have been highlighted by the Healthcare Commission’s reports on Stoke Mandeville Hospital, and Maidstone and Tunbridge Wells. Is C. difficile a notifiable condition? There is some confusion over whether notification is voluntary or statutory. Can the Minister make this clear?

Many infections put patients at risk, such as E. coli, Klebsiella, wound infections other than MRSA and many others. If infection prevention and control measures in hospitals are to be successful, this area of the budget should be ring-fenced, in terms of staff employed in infection control, developing general staff awareness and training in good practice for all staff who directly

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or indirectly come into contact with vulnerable people. Without adequate finance to support measures identified as the result of professional research, these initiatives will flounder.

Many projects need looking at. I have recently had correspondence with Dartex Coating about the product Silver 3, a coating for hospital mattresses for which it is claimed that tests have shown that it kills 99.9 per cent of MRSA within 24 hours. Dartex believes that Silver 3 can play a major role in combating hospital-acquired infections. I hope that more research will be done on these matters.

MRSA does not like cold conditions. Should hospital floors be washed with iced water? The elimination of hospital-acquired infections would improve the dignity of life for vulnerable patients as well as their quality of life, which can be shattered if they get an infection such as Clostridium difficile. The Darzi report stresses the quality of care. If this is to be taken seriously, infection control must be the top priority.

2.23 pm

Lord Teverson: I also thank the noble Lord, Lord Patel, for giving me the opportunity to get involved in this subject, which I do not normally do. I come from a medical family; my father was a GP, my mother was a midwife and my brother is a GP. I was the black sheep of the family who went into commerce and then, even worse, into politics. At least I now have a chance to make a contribution to the area.

We are all aware as citizens of the astounding statistics, of which the noble Lord, Lord Patel, has mentioned a number: the 300,000 cases of hospital-acquired infection per annum; an estimated 5,000 deaths; the UK’s performance being the fifth worst of 29 European nations; and a potential cost of £1 billion to the NHS. Even more important, as the noble Baroness, Lady Masham, said, is the movement of resources and skilled people into coping with those areas rather than those with which they would rather be dealing. Statistics that came out today include some 10,000 C. difficile cases over a quarter year and, over the past four years, 200,000 cases of C. difficile and 20,000 cases of MRSA.

Although those statistics are staggering and abrupt in their own way, the issue is more important than that. These infections, in particular, bring real fear to those who must deal with the NHS and are not well. Over the past couple of years, people have, for the first time, hesitated about being admitted to hospital. We cite the statistics, but there are people who have decided not to have hospital treatment because of their concern about this area.

As people in politics and Parliament, we must ask ourselves whether that is because of the tabloid press scares, like the scare over street crime, which is a real issue in certain areas but does not necessarily affect where we are and our lives. Is people’s fear greater than the risk? I do not think it is, because even I know a person who died and other people who have been affected by these diseases. It is far less remote than many other things that we get involved in.

What are the issues here? One of the causes is the problem with cleanliness, but I have been aware for some time of the abuse and overuse of antibiotics.

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When I was a youngster, I was put on tetracycline—I can still remember its name and think it is an antibiotic, but perhaps it is not—for some three years, just in case I reacquired an infection that I had had earlier. I am sure that practice would not now be acceptable. We used antibiotics regularly in veterinary care. We fed animals antibiotics to make sure that they did not stand a chance of getting infections. Clearly, the mismanagement has meant, as the BMA put it in one of its documents, that life-saving technology has become life-threatening. Is the Minister confident that the management and use of antibiotics for humans and animals means that that is no longer a problem? We have that problem with malaria, in particular.

I am sure that my mother would have been concerned by the way that cleanliness got decoupled from medical care in hospitals and similar establishments. I am sure that the focus on that is much better because we have seen the improving figures on these infections over the past year. However, I question whether cleanliness is at the heart of medical as well as administrative practice. Having been in hospitals a number of times over the past year because of a family member, I was struck by how little the washes, which we do not think are completely effective, were used by visitors and medical staff when moving around hospitals.

Does the Minister believe that screening patients as they come in and isolating them if necessary is successful? Does it need to be applied more? Where are we on that?

My other concern, which comes from my management career, is about judging people against targets. It is right in principle, but there are unintended consequences of keeping targets in place for too long and managing people’s performance too carefully. One aspect of that is the bed occupancy rate. What are the Minister’s views on the correlation between hospital-acquired infections and bed occupancy rates? The evidence seems to show that where the rate is above 85 per cent there is a positive correlation with cases of infection. I should like to know whether the Government accept that correlation. If so, surely that means that we have to manage the whole area of bed occupancy, which in every other way is clearly a measure of a hospital management’s efficiency. It can be fantastic but, if patients are killed on the way, that is not quite so good. It is a question of how we should look at those sorts of targets.

A final area on which I should be interested in hearing from the Government is nursing homes and homes for the elderly. Those come outside the hospital arena and therefore may go slightly beyond the subject of the debate, but they carry the same importance in that they have many vulnerable people facing similar threats. What actions are the Government taking and what plans do they have to deal with the problem in that area, which is not highlighted much, or perhaps greatly understood, in the media? Does the Minister see that as a threat to the reputation of healthcare more generally in this country? Most of all, we all want to see hospitals where patients—you and I—can be confident that they are going to be healed and will not feel that they are risking their lives even more by engaging in their services.

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2.31 pm

Earl Howe: I congratulate the noble Lord, Lord Patel, on having tabled this Question and on the extremely powerful way in which he spoke to it. It is a question of the first importance for healthcare in our country. If we want a comparison to put the matter into proportion, almost three times as many people are killed by hospital-acquired infections every year as are killed on our roads. The figures look as though they may be on a downward trend and some encouraging statistics have been released today, which no doubt the Minister will be able to refer us to in detail. However, over the 15 years from 1990, the graph showed a massive rise. The increase in C. difficile infections was fiftyfold, and looking simply at the five years to 2006, deaths from C. difficile went up by more than 400 per cent.

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