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23 Apr 2002 : Column 54WH

Hospital Hygiene

1 pm

Dr. Vincent Cable (Twickenham): I am grateful for the opportunity to debate this subject. The methicillin-resistant staphylococcus aureus or MRSA problem and the broader matter of hospital hygiene are strongly connected. It is appropriate that, in a week when we have been discussing the substantial and extremely welcome increase in resources for the NHS, we should discuss also how to reduce the great waste of resources—the waste of nursing staff and of beds, and the human and financial costs of infection.

My interest in the subject goes back five years to shortly after I was elected to Parliament. A case was raised with me within weeks of May 1997 by a distressed constituent. She was a middle-aged cancer patient being given chemotherapy at her local general hospital, who contracted MRSA in an outbreak of the infection. Her treatment had to be interrupted, and given the severity of her condition, it could have been a life-threatening problem. I did not then appreciate the fact that infection control in hospitals was a major problem. I was brought up to believe that hospitals were inherently clean places, where antiseptics and disinfectants were widely used. However, as a result of the publicity that resulted from that case, I realised that it was indeed a major problem, both locally and nationally.

I appreciate that a great deal has happened on the policy front during the intervening five years. I do not want to rehearse all the Government intervention and the study since then, but I know of the Public Accounts Committee's report and the Government's response and of the helpful work of the National Audit Office, with its follow-up report. The Government have taken a series of welcome initiatives, including mandatory reporting, the setting of standards for hospital trusts and the introduction of guidelines—and have made the cash available. The tranches of £30 million that have gone to hospitals, including my local hospital, will make a welcome contribution. I acknowledge that, and I am not using this debate as an opportunity for bashing the Government for not doing things. I appreciate that policy has been progressing.

I am prompted to raise the subject again because of local experience and a feeling in local hospitals that the problem remains serious. I have two local district general hospitals in my constituency, the West Middlesex and the Kingston. The latter has a generally good record on infection control, and the preliminary statistics on MRSA show that it is pretty low in the national league tables. However, a few weeks ago I learned from a constituent that his mother, Mrs. Tarrant, had died of MRSA during an outbreak at the Kingston hospital.

The West Middlesex hospital has altogether more serious problems. It was the subject of a scathing report by a Government inspection team on hygiene grounds a few months ago, and almost weekly I hear anecdotes and receive letters describing the problems of hospital infection that derive from bad practice on the wards. I shall describe a couple of cases. In a letter to the hospital

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general manager, one gentleman makes a series of complaints about the hospital. He states:

Another local resident, who belongs to the community health council, recently observed, in the course of passing through the hospital, an event that was eloquent testimony in itself. A ward was isolated because of MRSA, with a clear sign saying "Barrier Nursing Do Not Enter". A cleaner promptly walked through the barrier with a cloth and cleaned all the tables in the isolated ward, then took the cloth and used it in other wards. I am reluctant to be too damning and critical about that hospital; it has serious problems and is being rebuilt under the private finance initiative, which I welcome. I hope that a lot of its problems, which stem from antiquated, badly designed fittings will be solved. Nevertheless, I represent two district general hospitals in which bad reports of hygiene, specifically of MRSA, surface weekly. That is what prompted me to seek this debate.

I do not need to rehearse all the arguments about MRSA and hospital hygiene. They have been set out in the NAO reports. Let me just return to the dichotomy between the two issues. MRSA is a distinct problem caused by the overuse of antibiotics and the building up of resistance. It is something that most of us carry around on our skins, not inherently an infection. However, in a hospital it can be very damaging. A great deal more is now known about it. The House of Lords report on resistance to antibiotics has advanced the science considerably and data have emerged revealing the extent to which MRSA is a severe problem, particularly in London. Statistics for the quarter April to June 2001 show that five London hospitals—including some of the most highly regarded such as Guy's and St. Thomas's—had more than 20 incidents of MRSA in that three-month period.

We now know more about MRSA. It is a serious problem in the general area of hospital hygiene. Why is it a problem? First, it is because of its sheer scale. Recent figures have indicated that one in 11 patients acquires an infection in hospital. I believe that statistics are now emerging—partly prompted by the Government's emphasis on monitoring—that suggest that a third of cases have hitherto been undetected, so the real figure is substantially more than one in 11. That translates into about 100,000 cases a year. Some 5,000 deaths a year are directly attributable to hospital-acquired infection. There are bound to be problems of interpretation: one of the complicating factors is that patients are, by definition, vulnerable. However, hospital-acquired infections kill more people a year than, for example, car accidents.

There is a big cost to the NHS as a result of people having long stays in hospital and operations being cancelled. The NAO estimates that it is about £1 billion a year, some of which is unavoidable, because vulnerable people will acquire infections even in conditions of perfect hygiene. However, between 15 and 30 per cent. of that £1 billion could be saved if practice was improved.

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I should like to ask three groups of questions about where some of the Government's current initiatives might be leading, and about follow-up. The first is about the system of surveillance and monitoring, the second about how national standards operate and can be improved, and the third about resources.

I appreciate that the Government now require hospital trusts to report on internal infections, and specifically on MRSA. I believe that a surveillance exercise was due to be published this month. Is it now available, and if so, in what form? I have two specific questions about monitoring and surveillance. First, is it now possible to get meaningful and useful data on post-discharge infections, which are an important element of the story? Secondly, is it now possible, as a result of international work on the issue, to make meaningful comparisons between British standards and those overseas? I have heard conflicting views in that regard, and while some people say that British hospitals are the dirtiest in Europe, others suggest that they are about in the middle among developed countries. I have no objective basis on which to judge which of those propositions is true, and it would be helpful to know what analysis is being done and what conclusions are emerging from it.

The Government made a big breakthrough a couple of years ago, when they set national standards and tried to push them through at the hospital level, but I have several questions about that. First, do we have any indication whether some of the basic principles of hygiene are being applied in hospitals? I was shocked by comments in the National Audit Office report, which referred in slightly arch language to "a culture of non-compliance" as regards handwashing. The fact that doctors, in particular, rarely wash their hands struck me as rather shocking, perhaps because I was brought up in a traditional way. Clearly, patients and staff are not following elementary practices, and that is responsible for much cross-infection. It would be interesting to know how far the attitude to such practices is changing.

A more important question under the heading of basic hygiene is what happens under the Government's standards in cases of blatant non-compliance. What would happen if my local general hospital was given a caning by an inspection team? Clearly, it would make an effort to improve, but what sanctions could be put in place? Have any been used, and how does the Minister envisage that happening?

On institutional arrangements, the Government's response to the Public Accounts Committee acknowledges that there has been a big improvement in the involvement of chief executives, for example, in infection-control debates in hospitals, which is clearly an advance. Is there, however, any indication that infection-control teams are much more systematically involved in key decisions in hospitals? I noted from one report that a quarter of all infection-control teams are not allowed to have an input into cleaning and catering contracts, which are the heart of the transmission mechanism.

Is there any indication that the structure and organisation of wards is being changed in the way that the Royal College of Nursing strongly advocated? There is a belief that senior sisters should be unambiguously in charge of all activities on their wards, including

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cleaning, that responsibility should not be fragmented and that someone should have overall charge of standards.

Finally, under the general heading of standards, what is the Government's assessment of the utility of screening? I know that it is not a straightforward matter and that costs are involved in screening staff and patients to discover whether they are carrying infections when they come into hospitals. However, is there a potential advantage in terms of cost-effectiveness in extending screening programmes, given the severity of the problem and the associated costs?

My last set of questions relates to resources. I appreciate that more resources are going into the NHS in general and that there has been a specific allocation of funding for infection control, which is welcome. Do the Government have a view on the optimum level of infection-control nursing, and how close are we to achieving it? Will the big new injection of cash into the NHS help with that? Is the issue specifically highlighted, and are the Government trying to achieve a particular target?

On bed occupancy, one reason for the high instance of hospital infection is that beds are being used constantly. There is a rapid turnover in patients with little time for a break. Sheets are changed, but infections can hang around. With less pressure on beds it should be possible to reduce some of the infections associated with intensive use. Have the Government formulated a view on how their big investment programme will affect bed occupancy levels? Is it expected that bed occupancy levels will fall, building some spare capacity into the system? Will the £30 million programme, which has now run for two financial years, continue, and what lessons have been learned from it?

This issue is not politically contentious. I am aware that progress is being made, but it is a matter of real concern. I continue to be shocked, as do many members of the public, to encounter major examples of very poor hygiene and malpractice in public hospitals, and I want to be assured that the Government are on top of the issue.

1.15 pm

The Parliamentary Under-Secretary of State for Health (Yvette Cooper) : I congratulate the hon. Member for Twickenham (Dr. Cable) on securing this debate and choosing to discuss hospital hygiene and MRSA. I know that he has a long-standing interest in these important issues and has raised them before. I welcome his approach to the debate, and many of his points, and I will try to respond to his questions. Some of them I can respond to now—they concern systems that are already in place—and others concern issues that are currently being considered as part of a programme of developing work. I will try to explain where we are on the matters about which he is concerned.

As the hon. Gentleman rightly said, hospital-acquired infection in general and MRSA in particular are serious problems for the NHS. These infections associated with health care are difficult and expensive to treat and directly affect patients, causing acute and chronic illness, pain, anxiety, depression, longer stays in hospital—with implications for NHS resources—and sometimes death. They have serious consequences in terms of health care.

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For those reasons, we need to tackle this serious problem. There is much ongoing work to improve the current arrangements for surveillance, infection control, monitoring and action to reduce hospital-acquired infection. As the hon. Gentleman pointed out, the National Audit Office has examined the issue. It estimates that the potential avoidable costs are around £150 million annually. We should treat those figures with caution, because they are based on a study performed in just one hospital and then extrapolated across the NHS, but the issue clearly has a serious impact.

Some hospital-acquired infection is generally viewed as an inevitable consequence of many serious illnesses being treated under one roof and the vulnerability, for different reasons, of patients to infection. However, it is also widely accepted that some of the hospital-acquired infection currently occurring is avoidable and could be prevented through strengthened arrangements. That is what we should aim for.

The hon. Gentleman is right that many people carry the staphylococcus aureus bacterium without any harm being caused. The serious problem arises when methicillin-resistant staphylococcus aureus—MRSA—spreads rapidly in a hospital environment where patients are seriously ill and susceptible to infection and where the use of catheters and other invasive devices allows the bacterium an easy route of entry.

Also, rates of MRSA vary across different NHS trusts. The statistics can be affected by the nature of the patients and conditions being treated. Trusts with more vulnerable patients and those that undertake more invasive and high-risk specialist care are more susceptible to higher rates of MRSA. However, that does not entirely explain the wide variation in levels of MRSA across the country.

What action needs to be taken about the problem? The hon. Gentleman grouped his concerns around surveillance, national standards and what happens when there is non-compliance. He is right in saying that extensive work is being done on surveillance. We should not underestimate how important good surveillance is for serious action to reduce MRSA and hospital-acquired infection. The fundamental element of any strategy to improve the situation is to collect proper data about the level of MRSA and the surveillance operating throughout the country. Since April last year, we have required all acute trusts to collect data on MRSA bloodstream infections. When the hon. Gentleman referred to information to be published in April 2002, I think that he was referring to those data, which were published in February.

The information allows trusts to identify problem areas for more detailed investigation and allows national monitoring and action to tackle the problem. It also provides a base line against which we can measure improvements in hospital-acquired infection. That is the first phase of a compulsory national surveillance system for a broad range of infections associated with health care. It is more comprehensive than systems used in other developed countries and provides us with important information.

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The hon. Gentleman referred to international comparisons, which are in place, but the United Kingdom system is the more extensive, and that has an impact on international comparisons. I am willing to write to him further on the subject.

The data need to be interpreted cautiously because the reasons why there are different levels of MRSA can vary. Trusts may import MRSA from other hospitals, and the many patients who move through tertiary centres as they go between hospitals may bring with them MRSA and other problems. That problem may have affected the London teaching hospitals to which the hon. Gentleman referred.

We have established a programme of work to improve the surveillance system, which involves extending compulsory surveillance and carrying out alert organism surveillance to collect information routinely on specified micro-organisms causing MRSA and other infections. We also intend to monitor adverse patient incidents due to infections, such as outbreaks of salmonella food poisoning in hospitals, and link that to the National Patient Safety Agency. Other systems are in an early stage of development for surgical site surveillance in conjunction with orthopaedic surgeons and surveillance of infection occurring after patients are discharged from hospitals. The hon. Gentleman referred to that post-discharge issue, which is complicated and difficult but important to measure. We shall consider, too, levels of MRSA and health care-acquired infection in the community, which is more difficult to measure than the levels in hospitals but represents an important part of the picture.

The hon. Gentleman asked about national standards. There are two relevant sets of standards. First, the controls assurance standard on infection control requires chief executives to ensure that effective policies to tackle hospital-acquired infection are in place and are implemented. The standard requires acute NHS trusts to ensure that people work in a managed environment in which the risk of infection to patients, staff and visitors is minimised. There are 15 supporting criteria for hospital infection control, including the work of infection-control teams and their supervision by local infection-control committees that incorporate local consultants in communicable disease control.

Secondly, all hospitals were required to introduce national standards of cleanliness for the NHS by February and to implement a regular programme of monitoring to ensure that the standards are met. All trusts with in-patients in England received guidelines on implementing the standards, which will be added to the performance assessment framework in July. The NHS plan recognises that hospital cleanliness is a major issue for patients, their families and visitors. That is why the clean hospitals programme was launched. We should recognise that there is not a strict relationship between hospital cleanliness and MRSA. Of course, it is an important consideration, but there are many other complicating factors involved.

To support those standards, extra investment is being put into the NHS. The hon. Gentleman referred in particular to investment to support the clean hospitals programme and to improve the patient environment—

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£62 million over two years is being provided. Another £200 million is being provided to improve standards of decontamination. In addition, there has been broader investment in the NHS. Substantial additional investment has already been made over the past couple of years, but the extra investment set out in the Budget will provide for an increase in the capacity of the NHS.

The hon. Gentleman asked about capacity. Local flexibility is necessary, because trusts need to be responsive to the nature of the problems that they confront. The capacity that they need will depend, in part, on the level of their problems, but also on the sort of hospital or unit involved. It is important to provide national guidelines on infection control and hospital-acquired infection. Although a considerable number of guidelines are already in place, and work undertaking infection-control audits against standards of national guidelines is being carried out to update local guidelines for hospital infection control, it is important to take stock now of the work that has gone on so far and to consider what further action needs to be taken. That is where much of the work being carried out as part of the chief medical officer's strategy for combating infectious diseases comes in, and I shall say a little more about that in a moment.

The hon. Gentleman also asked what happens in cases of non-compliance, where hospitals are clearly struggling with MRSA or doing badly compared with similar hospitals. Action is already under way, but we need to review that as part of the chief medical officer's strategy. Regional directors of public health play an important role. They have already been instrumental in collecting and collating data from trusts in their regions, and they arrange peer review visits, in conjunction with the regional epidemiologist, regional meetings with infection-control teams and support from regional infection-control nurses. Where MRSA rates give cause for concern, regional directors of public health will work with a trust to review its infection control arrangements.

A range of enhanced initiatives are under way, which include reviewing the adequacy of infection-control resources; raising awareness of health care-associated infections and control measures in hospitals, reinforced by training and education of staff; undertaking infection-control audits; updating local guidelines; reinforcing specific measures, such as handwashing, which the hon. Gentleman mentioned; promoting ward cleanliness initiatives and training; equipping wards for better handwashing and cleaning; and assessing the degree of importation of MRSA from the community. One of the 10 responsibilities of modern matrons is to prevent hospital-acquired infection by ensuring that infection-control measures are properly applied by all staff.

Much work is already being done, but there is an extra enforcement and inspection role to be undertaken by the Commission for Health Improvement and by the new Commission for Healthcare Audit and Inspection. We have tried independently to review and monitor the uptake of the national controls assurance standards for hospital-acquired infection during the routine reviews of an organisation's system and processes for monitoring and improving services. Obviously, the work done in that inspection process feeds into the national enforcement system and the wider programme.

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As I said, there is forward-looking work to be done, as part of the chief medical officer's strategy for combating infectious diseases, "Getting Ahead of the Curve", published in January 2002. The chief medical officer has identified a small number of priority areas including health care-associated infection and antimicrobial resistance, and said that we need particular additional action in those areas. New updated action plans are currently being drawn up for health care-associated infection and three other areas, which will be ready by the end of the year. For each action, they will set out who is responsible, who is to implement it, what the output will be and in what time scale it will happen. That important further action builds on the progress that we have made so far on an important matter that is of concern to people throughout the country.

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