§ 3.7 p.m.
§ Baroness Gardner of Parkes rose to call attention to government health policies, with particular reference to initiatives designed to reduce hospital-acquired infections; and to move for Papers.
§ The noble Baroness said: My Lords, "hospitalism" is an interesting word, and one that I had never heard until I looked up the biography of Joseph Lister. This debate today could well be called a debate on hospitalism, the name applied in the mid-19th century to often fatal post-operative infection. "The operation was a success, but the patient died", was the famous saying. Now we have hospital-acquired infection.
§ In my days as a dental student, we heard much of Lister, known as the father of antiseptic surgery. I was not aware that he was a Member of your Lordships' House, taking the title Lord Lister of Lyme Regis in 474 1899. Lister noticed that many people survived the trauma of an operation but died shortly after of what was then known as "ward fever".
§ Work on ward cleanliness and the link between germs and health was being studied in Hungary, where Dr Semmelweiss argued that if a doctor went from one patient to another without clean hands, the doctor could pass on to the next visited patient a potentially life-threatening disease. He insisted that doctors washed their hands in disinfectant. Deaths of his patients fell from 12 per cent to just 1 per cent, but he was an isolated pioneer and his findings were ignored. Sadly, he himself died of blood poisoning in 1865.
§ Lister was influenced by his work and that of Louis Pasteur, whose work established the existence of bacteria at about that time. In 1865, Lister was convinced that microbes carried in the air caused diseases to be spread in wards. By disinfecting the air during his operations, the death rate fell from over 45 per cent to 15 per cent.
§ It is interesting to hear that similar ideas are now being suggested to reduce the spread of MRSA. At lunchtime I saw the announcement on television of just such a machine in modern form, which, the Secretary of State says, will solve the problem completely. Lister introduced strict antiseptic procedures into hospital routine. He washed his hands before operations and cleaned the instruments and dressings. That was when there was a great increase in medical provision, higher standards of nursing, larger hospitals and, with the introduction of anaesthetics, many more surgical interventions. The need to keep germs at bay was clear.
§ When I trained as a dentist, instruments were usually sterilised by boiling, although some practitioners continue simply to soak their instruments in an antiseptic solution. Injections of local anaesthetic were made by dropping tablets into sterile water, the solution then being drawn up into the reusable syringe and needle. Those were normal procedures. As hepatitis B became a risk, boiling was no longer effective, and dentists had to move to sealed sterile injections and new disposable needles. Autoclaving became the normal form of sterilisation for instruments and dressings. New infective organisms required new precautions.
§ Penicillin, the miracle drug, widely used by doctors and dentists, was originally effective against staphylococcus aureus infection. In the 1950s, strains of staphylococcus aureus became resistant to penicillin and by the 1960s strains were developing resistance to a stronger antibiotic, methicillin. This resistant strain, methicillin resistant staphylococcus aureus, is now commonly known as MRSA. Almost everyone knows or has heard of someone who has suffered MRSA infection. The stories are harrowing and the outcome too often fatal. The only treatment now is with an even more powerful antibiotic, which has unfortunate renal side effects. Resistance to that, VRSA, is now being reported.
§ The overuse of antibiotics has been one of the causes of the MRSA problem. Patients demand antibiotics from practitioners, even when they are told that they will have no effect on their condition. Education in those matters of patients and practitioners is very important. I 475 am concerned by the commercial promotion at present of all sorts of disinfectants for home use, in washing-up liquid, toilet cleaners, even hand washes. There is a risk that we will destroy the normal immunity that people develop as they contact organisms in everyday life. Homes are not the same as hospitals.
§ MRSA is now endemic in many UK hospitals. MRSA cases have increased by 600 per cent in the past decade. In 2002, it was the listed cause of 800 deaths, although it was believed that there were probably nearer 5,000 cases. Some London hospitals have seven times worse rates than those in the least affected parts of England.
§ A family friend, living until recently in Russia, decided to return to England for the birth of her baby. It was an unlucky decision, as she contracted MRSA. The hospital was dirty. She was put into isolation, in a single room with its own bathroom, the floor of which was dirty and stained with blood, not hers. She was extremely ill and separated from the baby for some weeks. Eventually she recovered, but it made her wonder why she had thought England could offer better care than Russia.
§ Some of the large London teaching hospitals are disadvantaged by the fact that they are tertiary referral centres and patients are sent to them from a wide area. Smaller hospitals cannot handle cases and, concerned by the seriousness of the patient's condition, send them up the line for diagnosis and treatment. As there is a shortage of single rooms where referred cases can be isolated, once a case is diagnosed as MRSA it can necessitate the closure of a whole ward. Tables showing the hospitals with high MRSA infection rates do not make allowance for the fact that many may be referrals.
§ Medicine has continued to make great progress, but harmful organisms have, too, and dealing with those is the challenge today. Mutation of organisms is a major problem, as we know from the constantly changing HIV virus, for which there is treatment but no cure. There have been many cases of haemophiliacs contracting transfusion-transmitted hepatitis B and C and HIV infections through defective blood products.
§ The latest risk is of transmission of new variant Creutzfeld-Jacob disease (vCJD). A number of patients are known to be at risk, as some blood donors developed vCJD and died of it after giving blood. Two recipients of that blood have now developed vCJD. The blood products were used particularly for haemophilia cases. An estimated 6,000 haemophilic patients have received blood products from that plasma.
§ New variant CJD is a major concern for the future, as there is no blood test for the condition and the incubation period remains unknown. The infectious particles are known as "prions". Fortunately, the risk is still considered low and the risk for haemophiliacs is not considered to be more than 1 per cent above that of other citizens.
§ An interesting incident arose when one of those haemophilic patients needed a gastroscopy and biopsy of his stomach a month ago. It was performed routinely by 476 the gastroenterologist, who was then told that the brand-new video endoscope, worth about £35,000, must go immediately into indefinite quarantine. That has compromised the hospital's routine endoscopy service to the disadvantage of many thousands who would have been treated during the planned lifetime of the endoscope. The new rule was implemented without warning or consultation with the gastroenterologists. Was it an over-reaction? The use of recombinant clotting factors for all haemophiliacs would eliminate the risks of transmissible infectious diseases. However, recombinant is still not available for English patients aged over 40.
§ To prevent transmission of vCJD, some measures have been tried and found to be unsatisfactory, such as the use of disposable instruments for tonsillectomies, now discontinued. It is important to keep a sense of proportion when balancing the loss of the endoscopy service against the possible risk. It is not an easy decision.
§ Hospital-acquired infections other than MRSA are also widespread, but the remedy is easier to find. Some years ago my husband contracted salmonella and was admitted to an isolation hospital. As no one knew how to cure the infection, he was treated by "shotgun pharmacy": 35 tablets a day. He was the only patient admitted with salmonella; all the others had picked up the infection in other hospitals, where they were being treated for some entirely different condition. The removal of Crown immunity from hospital kitchens has improved standards of hygiene, but food safety remains highly relevant. There are still too many cases of patients developing malnutrition in hospital, making them more vulnerable to any opportune infection.
§ Hospital standards of cleaning are a matter of great importance in the control of MRSA. It is not just that contract cleaners are used in many hospitals; it is the degree of difficulty that cleaners, whatever pride they take in doing a good job, have in gaining access to the areas to be cleaned. In many hospitals, wards designed as four-bed wards have had an extra bed added. That means that the beds are so much closer together that there is not the necessary physical space for cleaning to be carried out thoroughly. Combine that with the occupancy level—in many cases, it is more than 100 per cent, as hospitals under pressure operate a "hot bed" policy, sometimes using the same bed twice in a day—and you have a recipe for rampant cross-infection.
§ The National Audit Office says that the best estimate for the cost of hospital-acquired infection or my "hospitalism" is around £1 billion a year. Have we returned to the pre-Lister situation? Is it for us to convince all hospital staff of the need to clean their hands between patients by washing or the use of special wipes?
§ Basic hygiene is of the utmost importance. The human skin is nature's barrier to protect us; when it is pierced by surgery, by accident or by equipment, we are vulnerable. That is why it is much more important for those who are injured or are recovering from surgery to avoid contact with infectious organisms. 477 Sterilising equipment and ensuring that cross-infection is avoided in the use of in-dwelling urinary catheters and central venous catheters is essential in minimising the risk to patients.
§ Recognition of the need for basic hygiene in hospital for patients, staff and visitors remains essential and must be put into practice. Combining those old traditional ways with any new ways—such as the new way suggested today, which, I hope, will prove effective—must help to reduce the prevalence of germs and the risk of infection in the hospital. We will need more detail about the announcement made today, but we must all hope that the new spray control method will play a major part in controlling infection. I beg to move for Papers.
§ 3.21 p.m.
§ 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 478 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 479 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.
§ 3.31 p.m.
§ 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 480 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 481 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.
482 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.
§ 3.41 p.m.
§ Lord Eden of Winton
My Lords, this debate has been opened by three noble Lords of great distinction and experience. They have brought to bear a lot of knowledge and counsel in order to inform us. I am sorry to say that I shall rather let the side down. My experience is as a layman and as a hospital patient, although for me the latter was happily a rather limited experience. None the less, it is from the patient's point of view that I want to speak briefly on this subject. The noble Baroness, Lady Murphy, has an immensely powerful track record. Having listened to what she had to say, I am inspired to moderate my own views. The same is true for what was said by the noble Lord, Lord Hunt. I recall very well what an excellent Minister he was when he served in the Department of Health. Moreover, I am sure that all noble Lords are grateful to my noble friend Lady Gardner of Parkes for introducing this subject in such a rounded and measured way.
I am never quite so measured in my approach to subjects under debate and I feel quite strongly about this issue. I have had experience of filthy hospital conditions. I shall mention a small thing. I was about to put on one of those appliances that enable patients 483 to listen to the radio without disturbing anyone else. It was coagulated with dirt and obviously had never been looked at, which is quite unnecessary. As I say, that is a small thing, but it would serve as a means by which infection could so easily be transmitted.
I also noticed the cleaner made only a very superficial act of cleaning with a mop. Gone are the days, apparently, when someone got down on their hands and knees with a scrubbing brush to attend to the dirt on the floor, cleaning and disinfecting it properly. I know that the noble Lord, Lord Hunt, pointed out that it is difficult for doctors to wash their hands every time they move from one patient to another, but surely it is not beyond the realm of human genius to devise a means by which they may do so. A bucket of disinfectant placed at the end of each bed or a device whereby new surgical gloves can be picked up before moving on to the next patient should be possible. I do not know. It is not my job to be a hospital manager, nor is it the Minister's job. It is the hospital manager's job to manage the hospital.
Over the past four or five years we have had a whole series of reports, studies and recommendations, but in the mean time we have not had enough follow-up action. In January 2001, Department of Health guidelines were published on the prevention and control of hospital-acquired infection. They set out a whole series of standard principles covering hospital environment hygiene. In January 2002 we had Getting Ahead of the Curve, in which the Chief Medical Officer made a number of recommendations to tackle hospital-acquired infection. The most important of those recommendations was that:There should be leadership and commitment from the top of all local NHS organisations to ensure that infection control is a core component of clinical governance".So it should be, yet in December 2003 we had yet another publication entitled Winning Ways, explaining the Department of Health's drive to tackle hospital-acquired infection. It proclaimed that every NHS trust was to get a director of infection control and infection control teams. A healthcare commissioner was to be asked to make infection control a key priority when assessing hospital performance.
All that is good, but what has happened? NHS bugs go marching on, apparently becoming more and more virulent and resistant to the treatments that have been devised to tackle them; so much so that, as my noble friend Lady Gardner pointed out, the National Audit Office produced a report in July of this year. It reported that progress on reducing MRSA since 2000 had been "patchy". The NAO went on to comment:If all the recommended measures had been brought in across the NHS in 2000, infections and deaths would have been cut by 15 per cent a year, saving some 750 lives".The NAO report also found that hospital infection teams lacked both the resources and the clout to have an impact. It found high levels of bed occupancy and waiting-list patients accommodated next to those with trauma. There was a lack of isolation facilities and patients were moved about too frequently. I am sure all noble Lords have seen that. Patients are moved along 484 corridors with no attempt to mask them against the possible inhalation of infectious bacteria. I have been taken on a trolley to and from an operating theatre. We entered a lift which visitors to the hospital were also using. It is mind-blowing that that sort of thing still goes on, given all the effort that is supposed to have been put into treating hospital-acquired infection year after year. Why is that?
The report went on to deplore the fact that there is over-prescription of antibiotics, and noted non-compliance with good infection control practices. Not surprisingly, the Auditor-General, Sir John Bourn, commented:I am concerned that, four years on from my original report, the NHS still does not have a proper grasp of the extent and cost of hospital-acquired infection in trusts".Curiously enough, that report was published on virtually the same day last July as that on which the department produced its own publication, Towards Cleaner Hospitals and Lower Rates of Infection. It set out a new charter for hospital matrons. Since then, I believe that I am right in saying that over 3,000 matrons have been appointed with the power to withhold payment for poor cleaning services either from the in-house provider or from the external contractor. They have those powers, but have they been acted on? Has anything been done to use those powers? Has the Minister any evidence that he can bring to the attention of the House of a contractor being dismissed and replaced because of a failure to observe proper standards of cleanliness in the hospital? I know the difficulty of employing contract services, so I have sympathy with the comment made by the noble Lord, Lord Hunt, in that regard. However, they are there and they do not always perform as they should.
Management makes the contract with the contract manager and it appears that the management and not the matron has authority over the cleaners. Management is the key. We do not need any more reports, investigations or elaborate research. We need action and we need action by management that has the responsibility and authority to manage. That means management must have both sanctions and the power to give rewards. One cannot have management without the ability effectively to reward those who do well and punish those who do badly. That is what management is about.
I am afraid that there is too much of the egalitarian ethic in hospitals, which makes it very difficult for managers to exercise proper management. If the matrons are to be held accountable, then matrons should have the powers to discharge their responsibilities. Immediately let us have hospitals being required to publish their inspection control procedures stating who is in charge of delivering a clean and safe environment on a ward-by-ward basis in each hospital.
§ 3.52 p.m.
§ Baroness Pitkeathley
My Lords, I too thank the noble Baroness, Lady Gardner, for giving us the opportunity to debate this important issue. Like the noble Lord, Lord Eden, I also speak from my experience as a patient—in fact as a sufferer and, as 485 you see, a recoverer from MRSA. I have shared this experience with your Lordships before, but I make no apology for repeating myself because it is important that we understand the context of hospital-acquired infections as well as appreciate the efforts which are made to deal with them, often in the most difficult of circumstances.
I also think that it is quite easy to be panicked about this issue. I am not in any way minimising the deaths that take place from these infections or the seriousness of the problem. However, we should remember that many hospital patients suffer from hospital-based infections—some, like me, very seriously—but, like me, recover and have absolutely no long-lasting effects.
I join with others in being very concerned not to apportion blame because I am pretty sure that I can pinpoint the moment that I acquired MRSA, and I feel gratitude not blame. I was suffering from a complete body sepsis after surgery for cancer and a bad reaction to chemotherapy drugs. Admitted to the Middlesex Hospital on Christmas Eve, the doctors despaired of my life and told my family to make arrangements for my disposal. 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 even to suggest such a course of action in an apparently hopeless case, even if it had not been, by now, Christmas Day.
Although he could offer only 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. But here was another problem, since I was so ill that even moving me to the operating theatre would surely kill me. So they decided to operate in the room which I was occupying in intensive care. There was no time to ensure the sterility of the room of course—they did the best they could in the short time available—but I can be fairly sure that that was the source of my infection. That operation was not the end of the story; much more surgery and many months of devoted care followed, but I think your Lordships will not be entirely surprised to know that had I been conscious enough to make the decision, the risk of getting MRSA would have been the least of my problems and one that I would have been prepared to take.
I tell this story to illustrate the complex nature of the decisions that surgeons and nurses have to take—often with very little time to spare, often with lives at stake, often involving great risk, and often weighing a least-worst option against another bad option. I too join the calls for more vigilance against the spread of these infections, but we must always remember the practical circumstances of those who are responsible for patient care. I cannot fault the precautions which the staff in intensive care took to try to prevent the spread of infections. Such few visitors as were allowed were always told about washing their hands, wearing aprons and applying disinfectant lotions. However, as 486 we have heard, ward rounds involve doctors and other staff moving from bed to bed, sudden emergencies arise and deliveries of supplies are 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. Patients go endlessly to X-ray, to physio, to ultrasound, and all offer opportunities for infection to spread. But these visits are essential. I was nursed in isolation for much of the time, but there were only two side rooms on the ward, so what happens when more than two patients require barrier nursing, as the noble Baroness asked?
When one is immediately post-operative, the nurses need to keep one under close surveillance. The side ward with its closed door, where MRSA patients are often nursed, is not then the safest place, in spite of the risk of infection. If a crash call comes when a doctor is attending one patient and knows a colleague is alone at the other end of the ward, washing one's hands and changing one's apron may not be the first thing on one's mind, even though we know that they ought to be.
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 sometimes 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 within a few weeks. 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 infection. I offer these examples of difficult decision-making not as excuses but to ensure that we never lose sight of the difficulties faced by the staff to whom I and many others owe their lives.
I am sorry to have to relate that I have had more experience in recent weeks of how we are doing with tackling this problem through the prolonged illness of a member of my family. I have been very struck through observing two hospitals now and two lots of critical care facilities how much progress has been made with this issue in three years. It is very clear that everyone who works in the hospital system is infinitely more aware of the problems we are facing with infection than they were three years ago. There are many more hand-washing facilities and there are notices on wards in what is known as the "rellies" or relatives' room on every ward. The provision of hand-washing and chemical wipes at the entrance to every ward and cartoons on the walls are all serving to bring the dangers more firmly to our attention than hitherto.
The emphasis that the Government have placed on patient and public involvement is clearly bearing fruit in making both patients and the public willing to lake personal responsibility. It is commonplace now in hospitals to see patients and relatives reminding other visitors of the necessity to take hygiene precautions—even people with whom they have no connection at all. 487 I have witnessed that with my own eyes. People say, "Hey! You haven't used the alcohol wipes or washed your hands since you came into this ward". That is the best illustration that one can have of the shift in public attitudes that has taken place since campaigns about the spread of infection have gathered pace.
However, the best way of avoiding hospital-based infections is not to go into hospital at all, or, if one does, to go in for as short a time as possible. In that regard, the Government's policies are to be very much validated. There is increased co-operation between health and social services, and a shortening of the time that it now takes to arrange care in the community, as a result of the Community Care (Delayed Discharges etc.) Act 2003. That effect is noticed particularly by older people who have orthopaedic surgery, because in their postoperative period they are especially prone to infection and it is notoriously difficult to overcome. Moreover, most people want to return home as soon as possible. We are now able to give GPs access to minimum data on patients to allow them to assess a patient seen as an emergency out of hours in his or her own home. Instead of admitting patients to the A&E department, we can provide monitoring at home, thus avoiding the risks of hospitalisation.
Another very important element in the fight against hospital-based infections, to which the Government are committed, is the development of the small diagnostic and treatment centres. They are already established in some parts of the country and many noble Lords will have seen them working very well in the United States. They specialise in cold surgery and patients are in and out in a day. Patients, while sometimes reluctant at first, are almost universally supportive of those systems and of the individual attention that they can bring.
We must continue to improve hygiene in hospitals and to fund appropriate research. I hope that the Minister will be able to say more about the research that is planned on this issue and about plans for further public awareness campaigns. 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 cultures.
I hope that we can all approach the undoubtedly challenging task of tackling hospital-based infections in a way that offers help, not blame, to the NHS and its skilled and devoted staff.
§ 4.1 p.m.
§ Lord Soulsby of Swaffham Prior
My Lords, this House must be very grateful to my noble friend Lady Gardner of Parkes for this debate on hospital-acquired infections at a time when hospital wards will be increasingly busy with the onset of winter, with more elderly people in those wards, more intensive and invasive procedures being performed for diagnostic tests, and, above all, a population of bacteria that are 488 increasingly resistant to antibiotics, many of which are proving to be quite useless in the treatment of infection.
The organism of primary concern has been mentioned—namely, methicillin resistant staphylococcus aureus, or MRSA. This still hits the headlines in the news media. As other noble Lords have said, it is a sobering fact that European Antimicrobial Resistance Surveillance System in 2002 identified the United Kingdom as having the highest level of resistant MRSA bloodstream infections, as a proportion of all staphylococcus aureus bloodstream infections, in Europe—that is, 43.9 per cent. Nearly 50 per cent of all bloodstream aureus infections were resistant. That is compared with the system in Sweden, where the figure is 0.7 per cent, and in Denmark where it is 0.9 per cent.
I mention Sweden and Denmark particularly as those two countries have taken very strong measures to control antibiotic resistance in general, including the abolition of the use of antibiotics as growth promoters in livestock. It may to noble Lords seem a very far cry from resistance in hospital wards to staphylococcus aureus, or MRSA, to the use of antibiotics as growth promoters in animal feed. But there most likely is a connection, and the Swedes and Danes will recognise that because there is an increasing and massive environmental contamination of the genes of resistant organisms generally spread throughout the environment, derived from massive use of antibiotics in medical, veterinary and horticultural circumstances.
I tend to call it genetic zoonosis, whereby the genes of the resistant organisms are very widespread. We should remember that when we use antibiotics for the treatment of pathogens in whatever animal, whether human or otherwise, there is a far greater population of bacteria—the commensals—that are also exposed. They become resistant and transmit resistance to other commensals and other pathogens. That is an increasing problem, which I am glad to say Defra is now taking up to study in greater detail.
The statistics of hospital-acquired infections are of course horrendous. They have been mentioned by other noble Lords. At least 100,000 hospital-acquired infections occur per year, and 5,000 deaths are directly attributed to them. Another 15,000 deaths are contributed to substantially by such infections. Those statistics, as stated by the Chief Medical Officer, cannot convey the human toll that goes along with MRSA. There is an abundance of reports of previously healthy people who have become seriously ill or died as a result of hospital-acquired infection. We have just heard the noble Baroness, Lady Pitkeathley, give a graphic account of how near she was to death.
At times, people enter hospital for minor procedures and/or minor surgery, and then suffer from infection. A friend of mine recently told me that she went to a major hospital in an area not too far from here, having broken a bone in her wrist. Following surgery, her whole wrist became infected with MRSA. It was eventually controlled with vancomycin treatment, but she was warned that she might have to have her hand amputated if the treatment was not successful.
489 So what do we have to do about this? There is no doubt that the magic bullets of antibiotics have lost their magic, and many people feel that the bugs are winning. The human toll is growing and the economic burden to the health service must be great. I wonder whether the Minister has any information on that matter. The report from the National Audit Office in 2000 estimated an amount of £1 billion a year. I wonder what that figure is now. Will the Minister give us some idea?
What progress has there been in the reduction of hospital-acquired infections? Mention has been made of the CMO's report of 2003, Winning Ways, which showed that the degree of improvement has been small. In the debate on 8 December 2003, when I had the privilege of introducing the Science and Technology Committee report on fighting infections, it was noted that the new Health Protection Agency would appoint an inspector of microbiology and in addition £12 million would be provided to tackle hospital-acquired infection. What progress has been made by the inspector? Has the funding been adequate, and is it still available for this important area?
While major attention is, rightly, directed towards MRSA, there are other organisms. One of these is the problem of antifungal agents. They have received a low profile in debate, but the yeast candida albicans is an opportunistic fungal pathogen causing severe and potentially fatal disease in immuno-suppressed patients, especially those with AIDS. Fungi differ from bacteria in that the potential for the rapid emergence of resistance is much less with candida than with bacteria. Nevertheless, the fungal infections in AIDS patients are a serious problem, leading to the appalling mouth infections that one occasionally sees.
As a postscript to the currently sad tale of hospital-acquired infections and MRSA, the pipeline for the development of new antibiotics is drying up. Major pharmaceutical companies are increasingly less interested in investing in the development of antibiotics. It is a prolonged and costly business to do so, and the product that is so developed may end up with a very short clinical life due to antibiotic resistance. Can the Minister give us any idea of what encouragement the Government are giving to pharmaceutical companies, large and small, to undertake antimicrobial discovery for the future?
The Infectious Diseases Society of America, which details problems in the United States which are very similar to those we are talking about today, has put out the following cryptic message:As antibiotic discovery stagnates, a public health crisis brews".I believe that we in the United Kingdom are very much in the same position: hospital-acquired infection is a public health crisis and antibiotic discovery is stagnating. Perhaps I may ask the Minister what action he and his department think needs to be taken to alter this situation.
§ 4.11 p.m.
§ Lord Turnberg
My Lords, I too am very pleased to commend the noble Baroness, Lady Gardner of Parkes, on introducing this very important topic. I am 490 also aware that much of what I shall say has been said very eloquently by others. It was hard not to be moved by the speeches of the noble Lord, Lord Eden, and the noble Baroness, Lady Pitkeathley, who so eloquently described what happened to them. I have to express my interest as an ex-physician and as ex-chairman of the Public Health Laboratory Service, now the Health Protection Agency.
It is an opportune time to be debating this topic again because, as we have heard, the Government are trying very hard to get at the causes of hospital-acquired infections. I say "debating this topic again" because, of course, it is not the first time we have discussed it. Indeed, when I was thinking about what I might say, I realised that the reason it was so familiar was that I gave my own maiden speech in a debate on the subject four and a half years ago. Some might say that I am in a rut. But the issue was not new even then, and if the problem was easily soluble we would have done it by now. Certainly quite a lot of effort has gone into it. But just as the causes and contributing factors to these infections are multiple, so their prevention and treatment will have to be multifactorial too.
My overall request to my noble friend the Minister, as he attacks the problem with his customary vigour, is that the Government do not focus too hard on only one or two potential remedies, but look more broadly at a range of simultaneous actions that will be necessary, including the need for more research and information, which is surprisingly lacking in a number of areas.
There are some factors that contribute to the high incidence of hospital-acquired infection which we can do little about. For example, the patients who are most at risk of getting a bacteraemia—that is, the bacteria entering the bloodstream and potentially leading to septicaemia—are likely to be those who are the most sick and the most elderly. Of course it is not only those, but they are the vast majority. It is just those patients who are vulnerable and whose immunity is at its lowest ebb who die of hospital-acquired infections. But it is just those sorts of patients who require the care that only hospitals can provide, as the noble Baroness, Lady Pitkeathley, described. Most younger, fitter patients are treated at home. So we cannot do too much about that.
As other noble Lords have mentioned, there is also not much we can do, in the short term at least, about the horrendously high bed-occupancy rates: over 90 per cent in most hospitals and over 100 per cent in some. I could explain how it is possible to occupy beds over 100 per cent, if anyone so wished. However, these rates are the highest in Europe, where the average is nearer 70 per cent, and that is despite the enormous investment that the Government are making in new hospitals. The investment is making a difference, but we still have some way to go before we can afford what they seem to be able to do in Holland; for example, where they can close wards and even whole hospitals without apparent pain. We can ill afford to do that when waiting list initiatives would be frustrated and managers' jobs are on the line.
491 Although I am delighted to commend the Government on increasing numbers of doctors and nurses in the health service—a very welcome step in the right direction—it is still the case in many hospitals that staff are run off their feet, and washing one's hands while running about is not an easy act. If, for example, you have a doctor doing a ward round of 30 patients, which is an average ward round, and she stops to wash her hands after every patient, which takes on average an estimated two minutes, that would add an extra hour to the ward round, to say nothing of the sore hands.
I know that more staff are in the pipeline, but, meanwhile, high patient throughput and rushed staff under pressure are not conducive to best practice. These background factors form the context in which we have to try to introduce change, and they will in themselves limit what can be achieved by the methods and the measures we can and should introduce.
So what can we do? First, we have to recognise that the organisms that cause the life-threatening infections may be very widespread on carriers who themselves are not affected by them. Such is the case for staphylococci, which many of us carry in our noses and which of course may be carried by staff and visitors as well as patients. I speak here not of MRSA—not of methicillin resistant staphylococcus—but of sensitive staphs, which means that they are potentially treatable with methicillin. But we should not make the mistake of believing that that is a minor infection. It will kill vulnerable patients just as readily as MRSA if it gets into their bloodstreams and they do not get their methicillin quickly enough. So it is potentially dangerous, but we cannot easily prevent it getting into hospital.
What about MRSA? This seems to be much less widely distributed in the population, but even here we do not know much about its distribution. We can do with more research on that. It is found mainly in hospital patients, most of those affected being carriers, for example, on their wound infections and the like, and in nursing homes. It is most often spread by patients coming from other hospitals and by staff. Incidentally, the high use of agency staff who move around quite a bit from hospital to hospital is a potential risk. I would certainly urge my noble friend to look at whether agency staff present a real risk or simply a theoretical one.
It follows from all of that that the major teaching hospitals and specialised hospitals—which receive most patients from other hospitals, who are often the most sick—are most at risk.
One way of tackling the problem of inter-hospital transmission would be to use a simple, rapid diagnostic test on nasal swabs of all patients on transfer to a new hospital, a test that would have to be available and tell one within a few minutes whether a patient was clear of MRSA. That would be enormously beneficial, but unfortunately such a test is not yet available. There is research into this. Perhaps I may urge my noble friend to invest in the continuing research needed to bring such a test into practice.
492 Perhaps I may also say a few words about MRSA, in contrast to the comments of the noble Lord, Lord Soulsby. I have had conversations with colleagues at the Health Protection Agency about the problem of development of antibiotics. I understand that although MRSA is certainly resistant to methicillin, they believe that it is not untreatable. The picture is somewhat less bleak, in that there are now at least four new antibiotics in use to which MRSA is sensitive and five others are undergoing trials. I am trying not to downplay the dangers of MRSA, but simply to point out that all staphylococci are dangerous if they enter the bloodstream. They are very nasty and need urgent treatment. It is not just MRSA that needs treatment.
I have deliberately steered clear so far of the business of cleanliness—not because it is unimportant, as the noble Lord, Lord Eden, so graphically described; it is clearly very important—but because I wished to put it into the perspective of everything else that needed attention. Clean wards are an entirely desirable basic need; they are the baseline upon which we should be working. Even more important is the thorough cleaning of beds, mattresses, lockers and all the various telephones and attachments which patients use when one patient goes out and another comes in. However, all that comes at a cost—in this case to the patient, who may have to wait another hour on a trolley in the accident and emergency department while all of that is going on, due to high bed-occupancy rates.
Of course, cleaning hands between patients is vital. But washing at a sink is impractical, as other noble Lords have said. But now we have available alcohol gels which are probably much more effective than soap and water. It is an important advance, because hands can be cleaned much more quickly and it is good for the skin, too. I understand that ladies love the gel because it contains glycerol and makes hands feel nice and soft. This is a practice that clearly needs to be spread far and wide and is something that could be monitored, for example, by hospital pharmacists who could keep a note of the ward usage of gels. It is a matter of monitoring.
There are yet more areas that need exploration. Greater attention to aseptic techniques in the insertion and aftercare of intravenous lines, which are a potent cause of bacteraemia, has already been mentioned. There should be a survey of the practices of those hospitals which seem to manage to avoid hospital-acquired infections, at least regarding MRSA. MRSA rates vary enormously, from around 1 per cent to some 50 to 60 per cent of all bacteraemia. It is unclear why there is such a variation. Why has the Homerton Hospital only a 1 per cent rate? That would certainly merit some research. Research into why some carriers of infection seem to be so-called super-shedders, who spread their germs much more widely than others, would be of interest.
There is much that can and should be done. But if we are to surmount the problem we will need to attack it in a number of ways—multi-focused attacks. I hope that I can encourage my noble friend to take a holistic approach.
§ 4.23 p.m.
§ Viscount Bridgeman
My Lords, I am grateful to my noble friend Lady Gardner of Parkes for initiating this debate. Perhaps I may say how heart-warming it was to hear the speech made by the noble Baroness, Lady Pitkeathley, regarding her personal experience of the subject of the debate. All noble Lords rejoice in seeing her very firmly in her place.
I shall start on a possibly provocative note, comparing the experience of hospital-acquired infection between the NHS and the private sector. Your Lordships will be aware that the great majority of consultants practising in the private sector have NHS contracts and many will move between establishments in the two sectors in the course of a day. Their experience of the incidence of HAI between the two is truly startling.
I must declare an interest as the chairman of an independent hospital and hospice. I am certainly not here to blow the trumpet for the independent sector. I am too well aware of the interdependence between the two sectors, which is, happily, growing in their different ways. I should mention that the hospital of which I am chairman has a hospice wing which is wholly within the National Health Service.
In the matter of organisation and accountability of staff, the private sector may well enjoy an advantage but I do not wish to discuss that here. My purpose is simply to show, in a visible way, that there is no clinical reason why hospital-acquired infections cannot be reduced to an acceptable level. So, regarding what I am now about to say, the private sector leaves the scene. There are one or two features of the National Health Service in which cost is not a consideration—they have been so well covered.
I next wanted to raise the washing of hands between seeing patients, but I could not improve on the comments of the noble Lord, Lord Turnburg. However, the problem cannot be ignored. If hospital staff have to do the marathon to the end of nightingale ward, as the noble Lord, Lord Hunt, described, they must do it.
The noble Lord, Lord Turnberg, also referred to my next subject, which is the much wider use of pre-admission screening, where swabs will detect many infections upon which action can be taken before they can cause cross-infection complications in hospitals. Noble Lords have referred to the matter of cleanliness in the wards. We are continually hearing stories of this in the media. And I am sure that I am not alone in finding it difficult to see why this—which amounts to a scandal—cannot be addressed. In any industry or profession where the matter of cleanliness is identified, whether in the office or on the shop floor, something is normally done about it and promptly.
In the National Health Service the majority of cleaning work, as the noble Lord, Lord Hunt, said, is now out to contract, with the best-value criteria being dominated mainly by cost, with delivery taking second place. One hears all too frequently of ward sisters wringing their hands in frustration at the lack of cleanliness on their wards. It affronts their own professional standards, but there is nothing that they can do about it because they have no control over the cleaners. If a supervisor can be found, He, or she, is 494 likely to say that he has very few hours to clean an impossibly large number of wards, but that that is their contract and they cannot do anything about it.
The problem must be addressed with urgency. The tendering system must be changed so that contractors are made more accountable to the nursing management. I compare that with refuse collection by local authorities, which is also almost universally out to tender. Certainly, in my own borough, a complaint to the council is dealt with promptly and, on the whole, effectively, with apparently close communication between council and contractor. The noble Baroness, Lady Murphy, and the noble Lord, Lord Hunt, have referred to welcome initiatives by individual trusts and I hope that that will become a national trend.
The noble Lord, Lord Hunt, referred to side rooms and single beds, as did the noble Lord, Lord Turnberg. The NHS of the 1980s has received a bad press from the noble Baroness, Lady Murphy. But it is a sad commentary on that period that there was a trend to close side wards and turn them into—wait for it—offices. I am told that there is now a welcome move to reverse that trend and to restore side rooms to their originally intended use.
The matter of over-crowding has also been mentioned. The guideline, as I understand it, is that that there should be one bed's width between each bed. That rule frequently cannot be observed clue to pressure for beds. Associated with it is the matter of segregation and more isolation rooms. Best practice is for surgical and medical cases to be kept separate, with ring-fencing of elective surgical beds, But, again, pressure of admission of patients all too frequently means that a medical case has to be slotted into a spare bed in a surgical ward, and it is in the interface between medical and surgical cases that some of the greatest risks of cross-infection occur.
Perhaps I may briefly refer to surveillance. A large amount of data on HAI is being collected, but there appears to be little evidence that it is being analysed and the findings acted upon. The feeling among the specialists involved in this field is that it is only when the findings have been established and published that the real extent of the problem will become known, and I am told that it is likely to be of frightening magnitude. Many of the statistics which result from surveillance appear to be—dare I say?—deliberately withheld. For instance, in the year to March 2004 there were 7,647 bloodstream infections due to the MRSA bug. I am advised that of that figure, an alarmingly large proportion resulted in the death of older patients; but that figure appears to be closely guarded by the department.
Finally, I turn to drug prescriptions. I assure your Lordships that I am not attempting to put myself forward as an expert on this matter. Indeed, I refer directly to the noble Lord, Lord Soulsby, on this. The NHS needs to develop a strategy on rational antibiotic prescribing. It is well known that in the past 40 years the drug companies have made comparatively little out of new antibiotics, a point made by my noble friend Lord Soulsby. Their money comes from lifetime-use drugs, 495 such as those for blood pressure, arthritis, diabetes or to treat cholesterol. The result is that very little research is going into new antibiotics and such new drugs that come on to the market tend to be clinically useless after a while, as bugs develop resistance, and they have more adverse side effects for patients. Rational antibiotic prescribing involves the use of simple drugs and moving on to the use of broad-spectrum ones only when the simply ones are not effective. A more exhaustive use of this procedure could well result in a cheaper drugs bill and, significantly in the context of this debate, fewer drug-induced infections.
§ 4.31 p.m.
§ Baroness Masham of Ilton
My Lords, I thank the noble Baroness, Lady Gardner of Parkes, for again bringing up this very important matter. In February 1996, I brought up the increasing problem of methicillin resistant staphylococcus aureus in an Unstarred Question in your Lordships' House. I saw it then as a growing disaster. We have had two Select Committees in your Lordships' House, which made many sensible and practical recommendations on infections and resistance to antibiotics. MRSA seems to be like the sea when King Canute told it to go back and it did not do so.
Mr Reid, the Secretary of State for Health, has said that the Government are committed to a relentless campaign to control MRSA. The chief nursing officer, Christine Beasley, has been told to make MRSA her top priority. She has said that more than a million NHS staff would get infection control training. That should have happened a long time ago. It is not just nurses who should be being trained but everyone who is in touch with patients. About three years ago, I was a patient at Stoke Mandeville Hospital, having broken both legs. A young man used to come into my room and clean, but he never cleaned under the bed. So I suggested that he did and explained that germs live in dust and that dust gathers under beds if it is not removed. He said that I was the first person who had told him that. It does not matter whether cleaning staff are in-house or are employed by contract agencies. They all need clear guidelines and training on how to clean. As most of the people doing this work come from all parts of the world, it should be seen that they fully understand. The young man I was dealing with came from Puerto Rico.
The noble Lord, Lord Hunt of Kings Health, used to be asked by some of your Lordships how the process of appointing matrons was progressing. A short time ago, I met a matron from Birmingham who was charming but I wondered whether she was the right person for the job. Perhaps, armed with the new cleaning manual, which should have gone to every NHS hospital, she may manage. Can the Minister say what response has there been to the manual? Is it being used throughout the NHS?
A few weeks ago, I attended an open evening at the Harrogate District Hospital, which is having foundation status. It was showing different departments to the public. The microbiology department ran a clean hands campaign. One scrubbed one's hands, came back and 496 put some gel on them, and then put them under an ultraviolet light that showed whether your hands were clean. If they passed the test, one was presented with a large foam hand with, "My hands are clean, are yours?" on it. I have such a hand with me.
Earlier this year, my husband was in intensive care at a local hospital for three weeks. I was pleased to see that all visitors washed their hands on entry. It was not so in the other wards. The use of gel is more available now but it should be everywhere, with notices telling people why they should use it. The Secretary of State has said that MRSA bloodstream infection rates are to be halved in our hospitals by 2008. As the number of infections is now very high, this is still alarming to anyone going into hospital as they may become one of the statistics.
Can the Minister tell the House about the wonder paint that wards off infection? I read that, while trying to find a substance to counter mould, a British paint firm accidentally invented a disinfectant that fights MRSA. Manchester-based HMG Paints came up with Byotrol, a non-toxic and odourless liquid that repels any bug that lands on it. It works particularly well against MRSA. I ask the Minister whether this paint is effective and, if so, is it being used in our NHS hospitals?
I am absolutely convinced that the majority of the public wants really clean hospitals. For years, there have been concerns about this. Having read about the Lincoln enhancer—a British invention with a high speed cleaning head and a polisher that saves time—I wondered whether effective new devices coming on to the market are tried out by the NHS Purchasing and Supplies Agency and whether it has an approved list of products. That could save millions, if not billions, of pounds. Clean hospitals not only save lives but they also raise morale.
Can the Minister tell the House what progress is being made in creating detergents laced with viruses that could rid hospitals of superbugs? Because new antibiotics to replace those made obsolete by superbugs take so long to develop, researchers at Strathclyde University are trying a different approach and have targeted a special type of virus, called a bacteriophage, which attacks bacteria only. Bacteriophages are the natural-born killers of the microbe world. They can infect and destroy bacteria only and cannot harm humans. The research team has used solids with special surfaces on which bacteriophages can be fixed and where they can thrive. The genetic material that creates hundreds of copies of the phage eventually bursts open and the phages spill out and infect other bacteria and, it is hoped, kill MRSA. This sounds exciting and interesting and I hope that the Government are interested in this type of research too.
I bring the matter of hospital planning and bed space to the notice of your Lordships. Even Florence Nightingale recognised the need for adequate space between beds to lessen the risk of the spread of infection. Guidance from NHS Estates, which oversees design and planning matters, states that the space between hospital beds should be 3.6 metres—11 feet 8 inches—to reduce the spread of infection. But the new 18-storey University 497 College Hospital, which is due to open next year at a cost of almost £422 million, has just 2.7 metres—8 feet 8 inches—between beds. The problem was spotted by an architect when he and other local residents were shown around the hospital this year. After the NHS trust refused to move the beds further apart, he instructed solicitors to take up the case. UCH said that the new building had been agreed and finalised in 2000, two years before the new NHS Estates guidance on bed spacing.
With the rising hospital infection rates and the Government's challenge to bring down the rates, surely they must see that their guidelines are adhered to. Surely the safety of patients should be paramount. If the private finance initiative is not following the Government's guidelines throughout the country when building new hospitals, what are the Government going to do about it?
There are many infections such as E. coli, TB, legionnaires' disease, HIV, salmonella, pseudomonas, enteritis, hepatitis, and so on, which are dangerous to vulnerable patients in hospital, but MRSA is by far the most prevalent. Hospitals are under immense pressure, and infections increase this pressure. Therefore, there must be better hygiene and discipline all round.
Last year, yet again, I broke a leg in two places in your Lordships' House by getting it stuck in a door. As I am classed as a vulnerable patient, it was suggested that I did not have the leg operated on at St Thomas's Hospital because of the risk of MRSA. I was treated at St John and St Elizabeth, the hospital chaired by the noble Viscount, Lord Bridgeman. Because I had a single room in that hospital, I was thankful to avoid MRSA, but it is a serious matter when patients have to dodge MRSA by moving hospital.
§ 4.42 p.m.
§ Lord Selsdon
My Lords, we have talked of Lister, Florence Nightingale and Canute in this debate, and I suppose it would be right for me to go back even further. I shall explain to your Lordships the reasons why I speak.
I was for many years a director of a company called Terme di Porretta, the oldest spa company in the world, whose technical team found Aquae Sulis and operated many of the Roman baths around the world. We did not cure people, we rehabilitated and treated them. We were taught that disease could be spread by water, by air, by touch, by food and, in war, by blood. Plus ca change. As I look at the right reverend Prelate the Bishop of Portsmouth, I recall that next year is the year of Nelson and Trafalgar. People would lose their legs and their limbs because of splinters from cannonballs, not from the cannonballs themselves, and from septicaemia and amputation.
In our spa company, the one thing we used, even in ancient days, was fire, because fire would burn everything. Later, we even used maggots; they were used extensively in the First World War and are coming back into use. That is the first reason I speak.
The second reason is that my wife had a small operation on her leg in one of the private hospitals. We went away for Christmas and while we were away, she was ill. She was in great pain and seemed to be infected.
498 We took her to a very elderly doctor, the only one who was available at the time, who used to fish in Scotland and enjoy quite an amount of whisky. He said, "This is rather like the war. It is a question of gangrene. We could try maggots, but I think it may be a disease special to the United Kingdom, and you should take your wife back immediately to London. Drive in the fast lane because it is smoother and will be less bumpy for her".
My wife's own doctor's son had a car accident and went to a similar hospital to have a metal plate inserted. He now finds that MRSA is incorporated within the stainless steel in the pits thereof, and the whole thing may have to come out.
This morning, in preparation for this debate, I went to see the Health Foundation. I was reminded, very gently, with a piece of paper, that 44,000 people are killed in hospitals every year, due to the wrong prescription of medication, the wrong treatment or through hospital-borne diseases. That is 110 people per day, more than are killed by road accidents or accidents at work. So this is a broad problem, before we come to the individual technicalities of the disease.
In my international world, I have been exposed to legionnaires' disease, SARS, blackwater fever, polio and meningitis, but I was never frightened until I went to the AIDS ward in Barts, where they have wonderful treatment. Somehow, going on that dark night, with rain and not much light, you thought you had walked hack into the past.
When I learnt about MRSA, I began to be frightened even to go into hospitals. I was brought up at a time when there was no central heating, you had a cold bath in the morning and were brought up to believe that coughs and sneezes spread diseases and, as the 1942 campaign said, you should trap the germs in your handkerchief. This is a long time ago, but I have been fortunate enough not to have had to go to hospital; I do not seem to suffer much. But when I see the fear of people who need a minor operation that they may contract something serious in hospital, that is worrying. I worry that even this debate may create too much fear.
We have various initiatives. The noble Lord, Lord Hunt, spoke about the Government spending £4 million on patient protection, but, fundamentally, certain changes have to be made. I shall now try to make a speech as though I were a Minister, which I never have been and never will be. But if I were, I would say that we have more hospital beds per thousand of the population than the United States, Canada, Australia and much of Scandinavia. We have 3.9—less than in Scotland, where they have 4.1. Even more importantly, we have more people employed per acute bed than any other OECD nation. We have between five and six, whereas France and Germany have between one and two.
I do not make this point to say that there is anything wrong, because four members of my family have worked in the National Health Service—one is working in it now. I have learnt an awful lot from them over time, and I have a great respect for the NHS. However, if any of us were ever ill, we were always 499 advised to go to a vet because they had wider experience of diseases that could be carried by mammals, and a longer period of training, particularly in Scotland.
What is the Government's plan? What plan is there? We see the biggest level of proposed investment in the health service of any nation for years. In programmes of rehabilitation, St Mary's alone cost £800 million or more. So at some time in the future, things will be all right, but how do we cure the present situation? My microbiologist, as I am proud to call him, advised me that effectively, 25 per cent of people carry MRSA. As the noble Lord, Lord Turnberg, said, it is in your nose but it is also principally in your armpits and, believe it or not, it used to be and still can be, under the wigs of eminent members of the legal profession, where it festers. But it does not cause any harm until it spreads. The skin shedding that takes place in hospitals, where skin mixes into the dust, is a method of transferring the disease.
When we look at the hospital beds in the private and the public sector, they are all integrated in one way. We have 192,000 beds in the public sector in the United Kingdom; we need 100,000 more. Of those 192,000, it is sad to realise that only half are available for acute patients; many are for those with mental or learning difficulties, or for geriatrics. The occupancy rates are around 85 per cent or even more and, in some cases, over 100 per cent because of people going in and out twice in one day.
We need new hospitals and improved facilities, and these will come over time. In the mean time, is it a question of cleanliness? Not necessarily, I am advised. Eighty per cent of all hospitals have MRSA. This is third-party advice, and I can never take third-party liability. So what is the problem? I am told that cleaning the hospitals could reduce that figure by 25 per cent, but the infection would still be there. The possibility lies in decontamination, which is what we used to get rid of cockroaches in ships, but even that was not very successful. Alternatively, you build a whole range of new hospitals and hope that in time the disease may not have mutated yet again.
I am advised that there are different types of bug in different parts of the country, according to weather and people. If you need an operation, you might be better to go further away where there will be a different type of bug. It is no different to the different types of mosquitoes that can resist DDT.
It is, if one thinks dispassionately, an interesting subject. There is no political division on it; none at all. I hope that the noble Lord, Lord Warner, will not attack those on our Benches for getting things wrong. If we cannot get the investment in the health service and in its restructuring, these diseases will fester and may even continue to expand.
I wish the health service well; I feel sorry for all those who work in it who know that they need more facilities. We know that there is little that can be done in the short term, other than to be aware of the dangers, of which we must all be aware in the coming years.
§ 4.50 p.m.
§ Baroness Neuberger
My Lords, like other noble Lords I welcome and applaud the initiative of the noble Baroness, Lady Gardner, in calling for this debate. Also, like the noble Viscount, Lord Bridgeman, I was particularly moved to hear the personal story of the noble Baroness, Lady Pitkeathley, about her encounter with MRSA.
The Secretary of State for Health is to be congratulated for his announcement on 5 November of a new target of halving super-bug infections by 2008. I am not normally one to be positive about targets because they tend to have perverse consequences. However, this target was announced at the Chief Nurses' Conference, and the new Chief Nursing Officer, as other noble Lords have already said, is a wonderful and remarkable woman. She is an old colleague and a friend to the King's Fund, where I was formerly chief executive. She has been given a remarkable target of halving that infection rate. I am sure that she will take a practical lead, as the noble Lord, Lord Hunt, has suggested, in issues of nursing style. She is fairly formidable and fairly practical—the noble Baroness, Lady Murphy, has already alluded to that.
Many noble Lords who have already spoken have said much of what I wanted to say. However, some areas have not been touched on yet. Christine Beasley has taken on the need for training more than one million National Health Service staff in the area of infection control and hospital-acquired infections. Of course, that is only really the beginning, vast though it is.
She will also have to look at other areas—particularly infection control in care homes because so many people in care homes go in and out of hospital. We know that much of the MRSA comes in from patients who have it already. At the moment, the Commission for Social Care Inspection looks at infection rates but not specifically at MRSA. Unless we look at the issue adequately in care homes we will not get some of the information that we need in considering how MRSA comes into our hospitals. That needs to be added to Christine Beasley's already vast list.
As regards hand-washing, I should say to the noble Lord, Lord Turnberg, that, yes, the ladies do very much like the gels. The real problem is that they like them so much they keep disappearing. Therefore, there is a real issue in regard to hand gels because finding one when you need one is actually quite difficult.
There is a separate issue about the washing of hospital uniforms in hospitals. It is a big problem in the NHS. We appear to be different from many other European countries and from much of the private and voluntary sector in that regard. Uniforms should only be washed in hospitals; they should not go home to domestic washing machines, which is still very much the practice in the UK. We do not know for certain whether this is one of the ways in which MRSA continues, but it is clearly poor practice because the temperature of domestic washing machines is not adequate. There are others who know far more about 501 this than I do. I am told that the temperature of domestic washing machines is not adequate and that you can pick up infection as uniforms are transferred from home to hospital, back home again, and so on.
I want to pick up on the issue of the private finance initiative and hospital building and design. The noble Baroness, Lady Masham, made an important point. There has been a great deal in the news about UCLH and the gap between beds, but this is a much broader issue. There were not enough adequate break clauses in the early PFI contracts and so, as design needed to change—for instance, to deal with hospital-acquired infections we needed to have more single rooms or greater distance between beds—there was not the capacity to break the contract and to say that there needed to be a change in provision.
It seems to me that the Government need to look closely at that to see if we can renegotiate with some of the PFI providers to change the way in which the contract is delivered. We simply cannot have beds too close together or an inadequate supply of single rooms when we are seeing the trend of hospital-acquired infections still going up. Tony Harrison did some work for the King's Fund some years ago now and it was clear that the absence of break clauses made it difficult to allow for new design developments. It is clear that this is the case in this area.
I have experience of cleaning staff from my time chairing an NHS trust. I was the chair of Camden and Islington community health services at the same time as the noble Baroness, Lady Gardner of Parkes, was chairing the Royal Free and the noble Baroness, Lady Murphy, was chairing one of the north-east London community trusts. We gathered together to bemoan our fate on many occasions. Against all instructions from on high, I resisted contracting out our cleaning services in the mid-1990s—not because there was a principled objection to it but because we wanted to keep our cleaning staff who were a key part of the teams, particularly when working with the elderly mentally ill and the very frail elderly, for whom we had some 600 beds. If we had contracted out, our cleaning staff would not have remained with us.
It is vital that we are clear that it is not an issue of whether cleaning staff are contracted out or whether they are employed by an NHS trust; it is about whether they are included in the teams and whether they have some say in how the work is carried out. It is not adequate to say that nurses should manage cleaners. If they are given some responsibility, the cleaners themselves will take a lead. We still have a very hierarchical attitude in our NHS and the cleaning staff are seen as the lowest of the low. That probably does not encourage them to do the kind of job that we wish to see.
There is an issue about the cleaning staff being part of the team, being included in the new training and being encouraged to make their views known, including when they see doctors and nurses not washing their hands and not carrying out adequate infection control procedures. They, too, can see what is going on. Anecdotally, many people will say that if you really want to know what is 502 going on in a hospital, ask the cleaners. They see everything—although perhaps not always the dirt under the beds.
I say to the noble Baroness, Lady Murphy, that things were quite bad in the 1980s and 1990s, but they were not that good in the 1960s and 1970s either. In the psycho-geriatric units, I certainly remember walking through absolute filth on the floors because no-one thought that those hospitals were worth bothering about. We have had a long spell of inadequate concern about cleanliness.
Because we have no centrally held statistics on care homes and the admission of patients from care homes with MRSA or other hospital-acquired infection, we are missing a trick. I suspect that we need to merge the collection of data between the Commission for Social Care Inspection and the Healthcare Commission, who should look at the whole picture through a national review of the state of infection control in the NHS in England. That must include community services. Perhaps that would give us a clearer picture of what precisely is going on.
I want to address the question of urgency. I know that before I came here your Lordships debated the issue of hospital-acquired infections on several occasions. One year ago, the Chief Medical Officer issued a plan, Winning Ways; Working Together to Reduce Healthcare Associated Infection in England. He admitted then that,healthcare associated infection has in the past not been as high a priority for action as some other aspects of healthcare".That is right. The targets have been elsewhere, which has led to perverse behaviours. Admissions times have been terribly important, as have accident and emergency waiting times.
The real problem is that there has been a lack of time for those concerned with infection control to wipe down mattresses between one person leaving a bed and another person coming into it. There has also been a paucity of hand hygiene agents. In that case, the lack of time is absurd.
There has to be a decision about whether it is more important to get the infection rates down—in which case we will have to leave a gap between patients, which might mean that waiting times go up—or to keep the waiting times down, which will make it very difficult to keep infection rates down. We often have to make choices in public policy; the Government have to make that decision. It does not seem possible at the moment to have it both ways. We cannot keep waiting times and infection rates right down. Will the Minister address the issue of what choices the Government will make in that area?
People are now talking the problem up and making it into a great national scandal. It is serious, but it is not a scandal. There are wonderful people working within the NHS and outside trying to make things better.
§ 5.1 p.m.
§ 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 503 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.
504 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 505 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 506 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.
§ 5.14 p.m.
§ 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 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.
507 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 508 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.
509 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 510 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 511 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 512 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.
§ 5.36 p.m.
§ Baroness Gardner of Parkes
My Lords, I thank all noble Lords who have taken part in the debate. I am most grateful to them. We have only two minutes left so I can say very little. We have had some excellent contributions. I thought that the Minister gave a very cautious welcome to the new idea which the ITV news today implied was going to solve the whole thing in a puff. So I am rather disappointed that he still seems to think there is a long way to go. But every step forward in the battle against MRSA is very important. I beg leave to withdraw the Motion for Papers.
§ Motion for Papers, by leave, withdrawn.