Previous Section Back to Table of Contents Lords Hansard Home Page

Lord Goodhart: If we are talking about the year 2025, of course by that time the number of pensioners

15 May 2000 : Column 88

who will have retired before the introduction of the state second pension, which is proposed in 2002, will be much reduced. So the figure of £1.30 may have to be increased somewhat if one is looking at the lowest 20 per cent of those who retired after 2002. But I doubt if it will be all that much larger.

We will take this amendment away; look at it, and consider whether or not we need to bring it back, either as it stands now or possibly in some more simplified form. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendment No. 124 not moved.]

Baroness Amos: I beg to move that the House be now resumed. In moving this Motion I suggest that the Committee stage of this Bill begin again not before 8.42 p.m.

Moved accordingly, and, on Question, Motion agreed to.

House resumed.

NHS Infection Control

7.42 p.m.

Baroness Masham of Ilton rose to ask Her Majesty's Government what action they are taking to ensure that the Government guidelines on infection control in hospitals are being implemented by National Health Service trusts.

The noble Baroness said: My Lords, in asking this Question tonight I bring to your Lordships a subject which is of immense importance, even though the debate is restricted to one hour. I am delighted that the noble Lord, Lord Turnberg, is making his maiden speech. Welcome.

I thank all those who are speaking this evening, which illustrates their enthusiasm and dedication in trying to help improve the current situation which is causing concern to many people throughout the country who may have to go into hospital for an operation or treatment, especially those patients who are vulnerable.

The House of Lords Select Committee report on Resistance to Antibiotics and other Antimicrobial Agents, identified the growing concern about the rise of MRSA (methicillin resistant staphylococcus aureus) and other hospital infections. It concluded that MRSA poses one of the biggest challenges to infection control and that in many hospitals it is now endemic. This is a world-wide problem. I had the privilege to be one of the Members of your Lordships' House who sat on that committee.

On 17th February 2000 the National Audit Office reported on the management and control of hospital-acquired infections in acute NHS trusts in England. It says that they are becoming harder to treat and hospital-acquired infection may be costing the NHS as much as £1 billion each year. In many NHS trusts, infection control may not have the profile it merits and

15 May 2000 : Column 89

the relationship between health authorities and NHS trusts concerning infection control is not covered as well as it should be.

The Department of Health's 1995 guidance places responsibility for ensuring the provision of effective infection control arrangements on the hospital chief executive. It was also reinforced in the Government's response to our report. To obtain an overview of chief executives' direct involvement in infection control in NHS trusts, the National Audit Office analysed the responses to seven questions in its survey. Those questions, which were designed to test the chief executive's compliance with the department's guidance, were scored on a simple yes/no basis. Sixteen National Health Service trusts scored zero; while 87 (41 per cent) scored yes on four or more questions, only one scored yes on all seven questions. It suggests that chief executives of most trusts are not as directly involved as the guidance suggests they should be. Fifty-eight per cent of chief executives never receive an annual or more regular report on the amount spent on hospital-acquired infections.

The main factors contributing to the direct costs of treating hospital-acquired infections are increased length of stay and additional antibiotic therapy and, where necessary, the need for repeat surgery. Those costs require surveillance and with some infections wards have to be closed. Driving back from York two weeks ago I heard on the local radio that three wards had closed at the York Hospital Trust due to sickness and diarrhoea. Absence from work by staff colonised with MRSA also caused extra expenses.

Hospital infections cause waiting lists to lengthen. I have some questions for the Minister. Many people are very concerned about the cleanliness in hospitals. Why cannot the ward managers, the sisters or charge nurses be in charge of all domestics, even though they are contracted out? Have we got adequate hospital accommodation for patients with infections, including drug-resistant tuberculosis? Are wards designed correctly with enough basins and side wards? Is food poisoning increasing? Is the training of all medical and ancillary staff adequate when dealing with infections and the control of them within the hospitals and the community, including agency staff who move from place to place? Do staff always have enough changes of uniform and gowns when moving around hospitals? Are the changing and washing facilities adequate. The basic need to wash hands has been well publicised. But germs can hide under rings, so great thoroughness is needed.

Health regions have become very remote. There is no doubt that in some hospital trusts there is complacency towards infection control and interest in protecting resistance to antibiotics by careful prescribing. The Government sent out guidelines. They have done a great deal to raise infection control up the health agenda. But they need to do more. Drug resistance is a frightening prospect. Difficult viruses, pathogens, prions and numerous infections have already claimed the lives of many people. With modern travel, the world is small. We must be vigilant.

15 May 2000 : Column 90

This is an extremely complex and difficult matter. It needs a dedicated general to lead the troops into combat against an army of very clever microbes.

The statement of the National Audit Office that 5,000 die annually from infections was queried by the Minister, as the noble Lord said that the figure was extrapolated from statistics in the United States. But this surely shows that we need far more information and surveillance; indeed, the figure may be higher. The Government have said:

    "Infection control is a priority for the NHS and is a 'must do'",

in the Modernising Health and Social Services National Priorities Guidance 2000/01-2002/03. It was suggested to the Chief Executive of the National Health Service that the NHS does not monitor compliance with the guidance that it issues. He replied that enforcement was a matter for the Health and Safety Executive. Could this be passing the buck?

I suggest, to help the Government achieve their aim, that they should appoint a "Tsar of Infection Control", who would be similar to the Inspector of Prisons who is wholly independent. He would be a supremo over infections acquired in hospitals and the community and someone who could visit any place at any time.

I was interested to see on the Channel 4 news programme last Thursday a film about cleaning a ward at St. Thomas' Hospital, because of the manifestation of MRSA. Florence Nightingale may be looking down on your Lordships tonight. I think that she would say, "If you don't keep up high standards of care, hygiene and discipline on the wards and feed the patients with good nourishing food, the infections will take over and win the day".

If the Government will ensure that the correct resources are spent on those provisions, it will be an investment for the future and will save much unnecessary suffering to patients and their families. This is a matter that needs addressing urgently. I look forward to listening to the debate and the Minister's reply.

7.52 p.m.

Baroness Young: My Lords, we are all grateful to the noble Baroness, Lady Masham, for tabling this Question tonight. We look forward to hearing the maiden speech of the noble Lord, Lord Turnberg.

This Question raises a very important issue. I am sure that the Minister will recall that I tabled a Question on this very matter quite recently, based on the report of the National Audit Office. I quoted then the figure mentioned in press reports of 5,000 people who die annually as a result of infections picked up while in hospital. Although I entirely accept that the Minister questioned that figure, he did accept that the number of infections caught while in hospital was unacceptably high. It would be helpful if the noble Lord could tell us what the correct figure is this evening. The report also said that, at any one time, 9 per cent of hospital patients are in hospital because of the infections that they have contracted while in

15 May 2000 : Column 91

hospital. As the noble Baroness, Lady Masham, said, the cost to the NHS is enormous; indeed, perhaps as much as £1 billion annually.

It is a very sad fact today that it is not at all unusual to hear people saying that they are quite worried about going into hospital because they are afraid of contracting an infection during their stay. To the most casual observer, hospitals can look very dirty, especially, I am told, bathrooms and lavatories. Quite frequently, the most elementary practices of hygiene are not applied. I am sorry to say that the memorandum that I received from the Royal College of Nursing has not really encouraged me. I know that there are thousands of excellent nurses in the NHS who do a truly professional job. However, what is so frequently needed is not the very highly skilled nurse with technical qualifications, but simply that old quality of tender, loving care; that is, thinking about what the patient actually requires. That applies especially to elderly patients. There is no doubt that some are left to attempt to feed themselves and are unable to do so. One patient known to me actually died of starvation in a national health hospital.

The Royal College of Nursing memorandum talks about the "whole system" approach so that patients' needs are assessed on arrival and monitored during their stay in hospital; and says that stringent hygiene controls should be applied to staff. So far so good, as I am sure we would all agree. But who will see that all this is carried out? So much of the trouble seems to come from a lack of supervision and no one really being in charge. Who is actually responsible for the patient, for hygiene or for cleanliness?

Someone in hospital said to me, "Well, the trouble is that the cleaning has been contracted out". But that is simply not good enough. Whoever the company is, standards ought to be enforced; otherwise, the company should be changed. It is no use pretending that one can pass the buck to someone else. It seems to me that there should be a number of basic rules in hospital, many of which are quite simple and straightforward and could be put into practice immediately.

Many people believe that visiting hours should be looked into. Some patients have visitors all day long and they may bring in infections. I am not an expert, but, if that is the case, should it not be investigated? There should also be proper supervision of the cleaning. In that way, when someone inspects the ward every day, it will be seen to be clean; and that applies also to patients. Dirty cups and saucers should not be ignored; they should be removed. Such practices would be totally unacceptable in one's own home. Moreover, nurses should tie back their hair and wear a clean uniform each day. I understand that some nurses do not wear uniforms. Whatever the standards imposed, they should not be less good that those which would operate in a food factory where standards of cleanliness and hygiene are very high. Surely that is the very least that we can require of the National Health Service.

15 May 2000 : Column 92

7.57 p.m.

Lord Turnberg: My Lords, I am grateful for the opportunity that this debate provides for me to give my first, rather hesitant, speech. I should like to begin by expressing my deepest thanks for all the support and friendship shown to me by officials, Doorkeepers and noble Lords during this first, I have to admit, rather confusing week.

Tonight's debate is on a subject in which I have a keen interest. I should explain straightaway that my interest derives from a career as a hospital consultant physician and then as the president of a medical Royal College; but, more pertinently, because I am currently chairman of the board of the Public Health Laboratory Service (the PHLS). This is an organisation whose principal concern is to protect the public from infectious disease, including that acquired in hospital.

Noble Lords will understand why hospital-acquired infection is rearing its ugly head so dramatically of late. The rapid turnover of patients who are more sick and more vulnerable and who receive treatments which suppress their immune mechanisms and which may be given invasively by intravenous drips all increase the risk of infection. The use of antibiotics, although both necessary and widespread, increases the emergence of resistant organisms. All this has led to a situation in which almost 10 per cent of patients in hospital become infected at one time or another. This amounts to some 100,000 patients per annum.

There is relatively little that one can do about the fact that patients are very sick and need intensive treatment. After all, that is what hospitals are for. But there are other reasons for hospital-acquired infections that are much more amenable to prevention. As both noble Baronesses said, top of the list is the environment on the ward. It is quite clear that where dust collects, so infection is harboured. Good evidence exists that removing dust works.

In one hospital I know, an outbreak of methicillin resistant staphylococcus aureus (MRSA) was aborted by an intensive cleaning programme, only for it to recur when the cleaning contract lapsed. A germ was found by the PHLS in the dust on the ward on both occasions--a nice but unfortunate demonstration of the impact of good versus poor cleaning practice.

We have known about the effects of washing hands between seeing patients since the time of Semmelweiss in the 1850s. His findings were neglected in his time, but we have no excuse now. The NHS action plan published last year was a move in the right direction on hand washing. We know that simple measures such as those--this is not rocket science--can reduce infection by as much as 30 per cent.

The last point I wish to make in the small amount of time that is allocated to me concerns the importance of constant monitoring and surveillance in hospitals. If we do not monitor and survey what infections exist and how often they occur, how can we hope to manage them? This surveillance is carried out at two levels: at the hospital trust level, where local infection control teams operate; and at national level, where the Public

15 May 2000 : Column 93

Health Laboratory Service operates by collating data from hospitals across England and Wales so that each hospital can compare itself with others.

Noble Lords may not be surprised to hear me say that more could, and should, be done at both levels given sufficient encouragement and--dare I say it in a non-controversial speech--more resources. That point was emphasised in the National Audit Office report published earlier this year, as the noble Baroness, Lady Masham, mentioned.

I finish by saying that I appreciate the opportunity to speak in this important debate. I know that my noble friend Lord Hunt and the Government take the matter extremely seriously.

8.1 p.m.

Lord Patel: My Lords, it is a great pleasure on behalf of the whole House to congratulate my noble friend and colleague of many years, the noble Lord, Lord Turnberg, on his maiden speech. He speaks with both ability and knowledge. As someone who lists talking as one of his interests in Who's Who, he should quickly feel at home in this House! I join others in thanking the noble Baroness, Lady Masham of Ilton, for initiating this debate. The subject is important and has serious implications for the NHS.

Resources put into improving care of patients with cancers and heart disease will not produce the desired outcome if we cannot reduce the incidence of hospital-acquired infections. The noble Lord, Lord Turnberg, has already mentioned some of the statistics. Some 10 per cent of patients in hospital will acquire infection; 10 per cent of those infected will die of infection. Nearly 30 per cent of those infected may remain carriers. On average, the increase in hospital-acquired infection is 50 per cent every year, year on year. An acute hospital with 800 beds will at any given time have 80 patients infected with antibiotic resistant bacteria. These worrying figures may, if anything, be conservative.

Of course the service requires more resources to combat the problem--I hope that they will be forthcoming--particularly to strengthen microbiology departments. What is required is a commitment at trust level and at primary care level to implement many of the simple policies to contain the problem: training of staff, particularly junior doctors, or for that matter senior doctors; and adherence to hand-washing protocols, as has already been mentioned by the noble Lord, Lord Turnberg. But even these simple measures can take up much time--two hours in a nurse's 12-hour shift. Intensity of work, both for nurses and junior doctors, adds to the problem.

Other measures include meeting the standards of hospital cleanliness; reducing trafficking in hospital wards; the screening of risk patients; and adherence to hospital antibiotic policies, particularly making sure that the infection does not spread to other clean areas in the hospital. These measures in themselves will help to reduce the incidence and contain the problem.

15 May 2000 : Column 94

I believe that we need a national infection manual which defines roles and responsibilities of health authorities and trusts and healthcare professionals, with advice on infection control in primary care and the acute sector, prevention of infection in patients, including high risk and vulnerable groups, such as the immuno-suppressed, the elderly and patients with in-dwelling catheters and other devices. Such patients are increasing in numbers. Appropriate disposal of clinical waste etc. will help and should be produced. I notice that the National Audit Office also recommended this. It should also help authorities and trusts to establish surveillance policies. I hope that the Minister will comment on that.

I also hope that the establishment of clinical governance and inspection and visits of hospitals by the Commission for Health Improvement and the Clinical Standards Board for Scotland--here I declare an interest--to make sure that there is compliance with protocols will bring about further improvement.

Today I read in the local paper, the Dundee Courier, which is in the Library, a report of a family taking legal action following the death of a relative who died of MRSA following surgery. Increased litigation will follow and put further strains on scarce resources. The problem is serious and getting worse. It needs urgent attention. I hope that today's debate and recent reports will help to achieve that. I too look forward to hearing the Minister's response.

8.6 p.m.

Lord Rea: My Lords, it is a great privilege to follow two professional colleagues who are former presidents of their colleges. I congratulate my noble friend Lord Turnberg on his maiden speech. Both noble Lords have been practical despite their former high office in their professions.

The noble Baroness, Lady Masham, can be compared with a terrier; she will not drop a problem but shakes it until it is laid to rest! Like the noble Baroness, I was privileged to be a Member of your Lordships' Science and Technology Committee which looked into resistance to antibiotics in 1997 and 1998. An important chapter of its report deals with infection control in both hospitals and the community. We spoke to many witnesses from the Department of Health, the Public Health Laboratory Service and the Infection Control Nurses Association and to several experts in the United States, where the problem is equally bad, if not worse.

In four minutes it is impossible to do justice to more than a fraction of the evidence we heard. Running through the British evidence was frequent reference to the Cooke report, to which the noble Baroness refers in her Question. A central part of its guidelines is the setting up of an infection control team (ICT) in every acute NHS hospital trust. This recommendation had to a large extent been implemented by the time we held

15 May 2000 : Column 95

our inquiry. Some of them, of course, had had these teams for many years before that. But not all the teams were functioning well. I quote from the evidence of the Infection Control Nurses Association:

    "The vast majority of ICTs in acute hospital trusts have no budgets whatsoever"--

the service being funded as part of pathology services whose budgets were already overstretched--

    "There are standard infection control measures ... Unfortunately there is often a perception amongst senior clinical medical staff and trust managers that some of these measures are more disruptive than effective [this conception] arising as a result of increasing pressures on hospitals to admit and transfer patients rapidly, especially during the winter months".

If I were to attempt to sum up the problem and its solution in four minutes, it seems clear that, although the science of how to avoid and contain these outbreaks is well understood, action on the ground, both in hospitals and in the community, lags far behind. Chief executives of trusts and some senior clinicians need more compelling continuous data to convince them that they should channel resources into the system laid down in the guidelines, which could cut distressing and expensive outbreaks.

Both my noble friends referred to better surveillance systems which need to be established in hospitals and the community. Time does not allow me to expand on how that proposal should be implemented but the Public Health Laboratory Service was keen that that should be done. The Government have taken some steps to set up such systems.

Buttressing such services financially would be a sensible use of part of the extra funding promised from the National Health Service. It would repay itself quickly. It may save money not only directly--in terms of reducing hospital stays--but indirectly, by reducing litigation and possible expensive compensation, which account for far too high a proportion of the NHS budget.

8.11 p.m.

The Countess of Mar: My Lords, I am grateful to the noble Baroness, Lady Masham, for introducing this topic and although it had to be brief, I much enjoyed the penetrating speech by the noble Lord, Lord Turnberg.

Previous speakers ably demonstrated hazards and deficiencies in the observance of hospital infection control. I shall approach the question from a different angle. Many infections are caused by cross-examination, which usually occurs as a result of shoddy practice at the most basic level. As a specialist cheesemaker, I would not be allowed even to begin producing food in premises where dust was clearly visible, the paintwork was dirty and peeling from the walls, washing facilities were filthy or a mouse watched me from a hole in the ceiling--all experiences I have had in hospitals in the past few years.

Why are hospitals allowed to continue functioning under those circumstances? I acknowledge that my business activities must be regulated and that I must understand the need for hygiene to protect the most

15 May 2000 : Column 96

vulnerable of my prospective customers. Hospital in-patients are by definition vulnerable, yet they are afforded little statutory protection.

We heard the figures for hospital-acquired infections. By contrast, each year fewer than 250 people in the entire population die from food poisoning from all sources--yet businesses can be closed and financial penalties imposed if the cause can be traced to failures by a food producer. Why is there is no public outcry about hospital conditions? Where is the accountability?

Slaughterhouses have to be licensed and are inspected by vets; food premises have to be registered and are inspected by environmental health officers. There is no equivalent independent hygiene inspectorate for hospitals. Individually developed hospital hygiene rules are not backed by law.

I ask the Minister to consider a statutory requirement that all hospital staff, including doctors, meet a required standard of understanding of basic hygiene principles and apply them; that practical infection control--I stress "practical", microbiology and general hygiene should be taught to nurses; that hospital-acquired infections should be formally defined; that all incidents and outbreaks should be notifiable, as are food poisoning cases; that there should be an independent inspectorate with statutory powers; and that an equivalent of HACCP should be developed for hospitals.

Finally, I ask the Minister why EUSOL--the acronym for Edinburgh University solution of lime, with its wonderful antiviral as well as antibiotic properties--has been withdrawn. How many patients or nurses have been poisoned by it?

8.14 p.m.

Lord Jenkin of Roding: My Lords, we are grateful to the noble Baroness for her Unstarred Question. In common with her and the noble Lord, Lord Rea, I served on the Select Committee which considered resistance to antibiotics two years ago. The noble Lord mentioned the evidence from the Infection Control Nurses Association, which was some of the most compelling we heard. The ICNA painted a picture of skilled and committed professionals battling against, at best, a lack of resources and, at worst, falling standards of hygiene--all against the background of an alarming rise in antibiotic resistance. Reading the report of the Comptroller and Auditor General, I am not clear that much, if anything, has changed.

The ICNA made this pertinent remark, at paragraph 4.31 of our report:

    "It is difficult to justify the costs incurred from an intervention where the successful outcome measure is an event not occurring".

That profound statement lies at the heart of the difficulty of getting sufficient resources for infection control. The National Audit Office repeated what must be true in the management of a trust, at paragraph 6:

    "It will be important for NHS trusts to justify existing and additional expenditure on infection control against other uses of health resources".

15 May 2000 : Column 97

One in four service agreements with authorities do not cover infection control services at all. Three in four do not require trusts to calculate infection rates. One in three trusts had neither the chief executive nor his representative on the hospital infection control committee. Nearly three out of five chief executives never see reports on the resources spent on hospital-acquired infections; fewer than half receive reports on rates or numbers of hospital-acquired infections.

Contrary to departmental guidance, which requires that all chief executives should approve infection control programmes, the report indicates that only one in 10 do so. If the Audit Commission is right that trusts must justify expenditure on infection control, how can a trust board--I have been chairman of one for six years--"justify" expenditure if our top executive managers do not know what is going on?

Although I have much sympathy with the noble Countess's argument for an external regulator, there is or should be in existence now sufficient management authority to make sure that the right things happen. The National Audit Office report makes it abundantly clear that they are not happening. Our Select Committee sounded a well-justified note of real alarm at the inexorable rise of drug-resistant bacteria. The report makes it depressingly clear that little has happened to implement our recommendations.

8.19 p.m.

Lord Clement-Jones: My Lords, this has been an excellent debate. I was particularly delighted to hear the maiden contribution by the noble Lord, Lord Turnberg, who was effectively the man who saved Bart's--for which many of us will be grateful to him for a long time to come.

I shall not attempt to sum up this debate in four minutes but will make a few points. The anniversary of Florence Nightingale's birthday always coincides with International Nurses Day, which took place last Friday. As my honourable friend Dr Jenny Tonge reminded the other place last week, by tackling dirt and disorder in hospitals during the Crimean war, Florence Nightingale became, and still is, a national heroine. One of my treasured family possessions is a diary entry of a meeting between my great-great-grandfather and Florence Nightingale in 1856 in the hospital in Scutari, arranged by his mother who was worried that he was not telling her how ill he really was.

It is quite extraordinary that, a century and a half later, we are still arguing about the priority given to cleanliness and infection control in hospitals. Florence Nightingale's most quoted remark is,

    "It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm".

We still have a long way to go before that is true of many of our hospitals.

Your Lordships have clearly stated the conclusions of the Public Health Laboratory report published last December and of the National Audit Office report of February of this year. I do not propose to repeat them. But what have the Government done in response to

15 May 2000 : Column 98

those reports? On 5th April, the Secretary of State promulgated a code of cleanliness to be sent to all hospitals, placing part responsibility for its implementation on hospitals' own infection control teams. I welcome this, but what evidence is there that this code will be enforced any more than is the NHS action plan issued last March?

Is not the key being absolutely clear about who is responsible for the implementation of guidelines? With no clear indication of where responsibility lies, no legal action is likely to be taken and standards will be allowed to slip further. In his evidence to the Health Select Committee, Sir Allan Langlands seemed to believe that the responsibility for enforcement was that of the Health and Safety Executive, not of the NHS Executive. Should it not be firmly with the latter? Should not the Commission for Health Improvement have a major role in this context?

As the noble Lord, Lord Jenkin, said, who is responsible is even less clear at hospital level. In many instances, much of the responsibility for substandard levels of cleanliness in hospitals is placed on the cleaning and catering contractors, who are engaged at the lowest possible rates. Health managers argue that this has arisen from the imposition of so-called "efficiency savings" of 3 per cent year on year. It has clearly been a false economy. Cost savings from these contracts may be seriously outweighed by the additional financial burden generated by hospital-acquired infections.

Should not those responsible for the wards and for patient management have direct responsibility for cleanliness, with the budget to match? A recent article in the Health Service Journal stated that the answer was managerial leadership to solve the problem. Let us give those at ward level the opportunity to do so.

Furthermore, should we not be tracking the spread of infection and the quality of infection control much more carefully, as the noble Baroness, Lady Masham, advocated? Should not infections such as MRSA be made notifiable, as recommended in the report of the House of Lords Select Committee which considered resistance to antibiotics, of which the noble Lords, Lord Rea and Lord Jenkin, were such distinguished members? Will this be taken into account in the Chief Medical Officer's communicable disease strategy which is being developed by the working group on the subject? Should not there be at least a standard reporting system for these types of outbreaks?

I look forward to the Government's response. To date, they have clearly taken certain actions in response to the two reports, but further action needs to be taken. I am taken by the call of the noble Baroness, Lady Masham, for a head of infection control, but I agree with those noble Lords who have said that much of the answer lies directly at ward level in hospitals. I look forward to the Minister's response.

8.23 p.m.

Earl Howe: My Lords, I should like to add my thanks to the noble Baroness, Lady Masham, for giving us the opportunity to debate this important

15 May 2000 : Column 99

subject at greater length than was possible during Starred Questions on 8th March. Like her, I found the report by the National Audit Office a shocking read. It would appear that the postcode lottery in the NHS operates on more than one level. Even if one is lucky enough to live in an area where expensive treatments are routinely available, one may nevertheless find that the record of infection control in one's local hospital makes a visit there as an in-patient a more than usually hazardous enterprise. That is not something that we should tolerate in today's NHS, and the Government are right to have devoted considerable attention and energy to the issue.

What we should not do, it seems to me, is to fall victim to the temptation of trying to identify a single, golden prescription to cure the problem. The striking thing that emerges from successive NAO reports is that the deterioration in standards is not a simple matter. It results from a range of shortcomings, both clinical and managerial, that together give rise to the very worrying statistics to which the noble Baroness has referred.

Responsibility for the control of infection rests at a number of levels. Indeed, it is an issue that, perhaps par excellence, exemplifies the principles inherent in the term "clinical governance". In another place last week, during a debate on hospital hygiene, the Minister, Gisela Stuart, remarked that clinical governance is as important as corporate governance. I would not disagree with her. What I would add, though, is that on an issue such as hospital hygiene it is hard to separate the two. The fact is that a major outbreak of MRSA can deal a body blow not only to the health of patients but also to the budget of a hospital. Any responsible chief executive will wish to minimise that dual threat as far as humanly possible.

There is, however, a lack of clarity as to how the lines of accountability in the NHS really run in matters of health and safety. The noble Baroness asked what the role of the Health and Safety Executive is in the NHS. The question is by no means an abstract one. A clear theme permeating the recent NAO report is that hospital hygiene is a task that suffers from a failure of ownership. At trust level, many hospital chief executives are not taking their responsibilities seriously enough. Some hospitals seem to operate in a way that is positively dysfunctional; no link between infection control teams and cleaning staff; no consultation of infection control teams by the management when awarding contracts for cleaning, catering and laundry; no reporting of infection figures to the chief executive; no direct involvement by the chief executive in the hospital infection control committee. There are of course beacons of good practice, but it is perhaps no wonder that across the NHS as a whole, hard data on the incidence and effects of hospital infections are unavailable. We should have such data.

On 8th March the Minister expressed the view that much of the fault for poor standards of hygiene lies in the policy of contracting out cleaning services to the

15 May 2000 : Column 100

private sector. I respectfully put it to him that the jury is still out on this. It is apparently not a theory which the NAO have thought fit to flag up.

The Minister in another place last Thursday was much more tentative about laying the blame at the door of compulsory market testing. If cleaning staff are failing to deliver a proper standard of cleaning, that is not just a reflection on them; it is a reflection on the way that the contract was awarded and on the standards set; on in-house training; on the monitoring systems within a hospital; on the competence of chief executives; and on clinical staff on the wards.

I wonder, though, whether the Minister has taken account of experience in the United States, where during the past decade there has been a marked decline in the number of patients who developed a bacterial infection while being treated in intensive care units. A recent report by the Centers for Disease Control and Prevention stated that since 1990 infection rates have declined by between 31 and 43 per cent in intensive care units at 285 hospitals in 42 states. One reason for this decline is better training programmes and better monitoring by hospitals to prevent infections from occurring. Does the Minister agree that such lessons could be usefully taken on board in the UK, and will he study them?

8.28 p.m.

Lord Hunt of Kings Heath: My Lords, I am grateful to the noble Baroness, Lady Masham, for raising this issue. As she said, it is a subject of immense importance. My noble friend Lord Rea described the noble Baroness as a "terrier", who continually shakes things up to make things happen. As someone who is continually being shaken up by her, I know what my noble friend means.

I also pay tribute to my noble friend Lord Turnberg on his excellent maiden speech. He is a distinguished physician academic; he was an outstanding president of the Royal College of Physicians and is an enormously influential leader of his profession. He is most welcome to our debates on the health service.

I want to reassure all noble Lords who have spoken that the Government take the matter of infection control in hospitals very seriously indeed. It is a matter on which we are determined to continue the action that we have already taken to deal as effectively as we can with the problem.

We are now treating more patients than ever before, including many who, only a few years ago, could not have been treated at all because the technologies did not exist. As my noble friend Lord Turnberg said, these new treatments, while improving people's health, may present a greater opportunity than in the past for infections to get a foothold.

Not all hospital-acquired infection is preventable but undoubtedly a proportion is. The recent NAO report, to which many noble Lords referred, suggested that 15 per cent may be preventable.

It is clear that some people do die either as a direct result of a hospital-acquired infection or with the infection playing a substantial part. The noble

15 May 2000 : Column 101

Baroness, Lady Young, referred to the recent NAO report which quoted figures of 5,000 and 15,000 respectively. As I said in my answer to the noble Baroness's Starred Question a few weeks ago, we need to treat that figure with caution because it was based on a crude comparison drawing on old data from the US. Our recent estimate is that 1,200 deaths a year are caused by hospital-acquired infection and that HAI has contributed to a further 3,500 deaths. Those figures themselves are striking and underline the need for determined action.

As far as costs are concerned, as other noble Lords have mentioned, the NAO report estimated that HAI may be costing the NHS as much as £1 billion per year. Again, we have reservations about the accuracy of those costs because the figure was based on the experience of one hospital and it is simply not possible to derive an accurate estimate of the overall cost to the NHS on that basis.

The total cost of all NHS activity to prevent HAI is almost impossible to assess also because much of this activity needs to be a fundamental, integral and incalculable part of the day-to-day work of doctors, nurses and other healthcare staff. That message was reinforced by many of the comments made by noble Lords tonight. Some estimates of the cost to the NHS of treating hospital-acquired infection have been made and, in 1988, this was estimated to be £111 million annually. Another study in 1993 put the cost in surgical patients at £170 million. Those are substantial figures.

Where infection is avoidable, it is unacceptable that action is not taken to avoid that infection. We have done much already to strengthen infection control. The Department of Health and the Public Health Laboratory Service have jointly funded a national surveillance scheme for hospital-acquired infection which enables hospitals to compare their performance against the national data. I pay tribute here to the work of my noble friend Lord Turnberg as chairman of the Public Health Laboratory Service. I also noted that he rather non-controversially mentioned the issue of resources for the laboratory service. I understand that discussions are ongoing between himself and my ministerial colleagues on that matter.

In 1998, in order to provide the National Health Service with tools to help with the improvement of infection control, the Department of Health commissioned Thames Valley University to develop national evidence-based guidelines for preventing hospital-acquired infection. The three component parts of this first phase will be completed by the end of July. They include general principles for preventing infections in hospitals, which crucially include hand hygiene--something that I will come to in a moment; universal infection control precautions and the isolation of patients with infections--in answer to the point raised by the noble Baroness, Lady Masham.

In addition, in March 1999, following the Government's response to your Lordships' very important Select Committee report on antibiotic

15 May 2000 : Column 102

resistance, the Department of Health issued an action plan on antibiotic resistance which included action to strengthen infection control processes.

Last November, the controls assurance programme was launched. It includes an infection control standard. This standard, which was developed in partnership with infection control specialists, requires acute NHS trusts to ensure that,

    "there is a managed environment, which minimises the risk of infection, to patients, staff and visitors",

and NHS hospitals will be required to produce statements setting out their plans to implement all of the requirements by July 2000. I can assure the noble Countess, Lady Mar, that the progress made by trusts in meeting those plans will be assessed locally by auditors and nationally by the Commission for Health Improvement and the Audit Commission. I think those mechanisms are appropriate to a managed service which is a characteristic of the National Health Service.

To reinforce the work aimed at strengthening infection control, we have set out an action plan which we sent to trusts in February. The aim of this plan is to strengthen services to prevent and control communicable diseases, especially HAI, and to take action to reduce antimicrobial resistance including the particularly serious problem of MRSA. We are doing that by strengthening prevention and control of infections in hospitals; securing appropriate healthcare services for patients with infection; improving surveillance of hospital-acquired infection--here I very much agree with my noble friend Lord Turnberg and the noble Lord, Lord Patel--and monitoring and optimising antimicrobial prescribing. The plan sets out a detailed timetable for specific actions to ensure that the criteria set out in the controls assurance standard on infection control are met. Early feedback suggests that solid improvements are already being made. I refer, for example, to the direct involvement of chief executives in infection control issues and to the securing of additional resources.

The noble Earl, Lord Howe, asked about the work of the Chief Medical Officer in relation to communicable disease strategy. This is a major piece of work which is being led by the Chief Medical Officer. I can assure the noble Lords that infection control and surveillance will be identified as a priority for action.

The noble Baroness, Lady Masham, prayed in aid Florence Nightingale looking down on the standard of cleanliness in hospital wards and, more generally, the noble Baroness, Lady Young, called it "tender loving care". I believe that there is no doubt that this represents a major challenge for the health service. Hand washing is one of the simplest yet one of the most important actions to help to prevent infection. I understand that this is not just an issue for the National Health Service; it is a challenge facing many other healthcare systems too. We gave clear guidance to the NHS a few months ago on this matter and the control assurance programme to which I have referred requires hand-washing policies to be in place and audit programmes to pick them up; but I accept the point

15 May 2000 : Column 103

that, in all of this, particularly senior doctors and nurses have to lead by example. I shall not debate with the noble Earl, Lord Howe, his view of market testing and its impact on cleanliness, but I do believe that this is a major area which we have to target to improve the standard of cleanliness on the wards. I also very much accept that ward sisters have a crucial leadership role in this. That is why we are giving each ward £5,000 directly to empower ward sisters to improve the environment. Just a week ago, we sent out national standards for environmental cleanliness in hospitals. By issuing those national guidelines, we are giving ward sisters a key tool to bring about local improvements.

Tackling hospital-acquired infection is an area where action needs to be taken at local level. In that, collecting data is important to provide a national picture against which to monitor trends and performance. I very much accept the points that noble Lords have made concerning the issue of surveillance.

Time presses on and I think I ought to come to the issue around what I might describe as "performance management". I have listened very carefully to the comments of noble Lords. My noble friend Lord Rea talked about the need for senior management support for infection control teams. The noble Lord, Lord Patel, raised the issue of the commitment of the boards of NHS trusts to take effective action. The noble Lord, Lord Clement-Jones, asked whether clear accountability is in the system to ensure that the action required is taken. I am satisfied that we have the tools and the management processes to ensure that the appropriate action is taken.

There can be no running away from responsibility. I do not seek to take responsibility away from the department, the NHS Executive or senior managers at trust board level. I have noted carefully the suggestion of the noble Baroness, Lady Masham, that a general or a tsar be appointed. I certainly understand the concerns that she and other noble Lords have raised about whether chief executives are sufficiently committed to driving and leading change and to the necessary procedures and monitoring in this area. I agree that the report of the National Audit Office was not at all positive or helpful in that respect. The lack of perceived control and involvement at chief executive level has to be seen against a background where, in the past, infection control and infectious diseases have been considered a rather unfashionable area. Sometimes the task was delegated to junior officers, and boards received reports on the matter of infection control.

In conclusion, I want to assure noble Lords that in the NHS action plan and through controls assurance chief executives of trusts have specifically been made personally accountable for hospital-acquired infection. It is a "must do" for the NHS, as set out in the national priorities guidance. Trust chief executives are personally accountable for dealing with this issue. In addition, regional directors of public health are working with regional directors of performance management and are charged with ensuring that the

15 May 2000 : Column 104

NHS has robust infection control arrangements in place, including the implementation of clinical governance arrangements and the achievement of controls assurance standards within appropriate time-scales.

In this very short debate I have not been able to answer all the points put to me, but I hope that I have assured all noble Lords that the Government take this matter extremely seriously; that we have put in place a number of policies and procedures designed to reduce infection as much as it can be reduced; and that we have robust performance management measures in place to ensure that they are acted on.

Next Section Back to Table of Contents Lords Hansard Home Page