Health Protection Agency Bill - Second Reading Debate

- Monday, 21st June 2004

 

Mr. Peter Lilley (Hitchin and Harpenden) (Con): I had intended to follow the excellent example of my hon. Friend the Member for South Cambridgeshire (Mr. Lansley) and focus exclusively on the health policy aspects that the Bill raises, rather than on the bureaucratic reshuffle on which the Under-Secretary of State for Health, the hon. Member for Welwyn Hatfield (Miss Johnson) focused and on which the hon. Member for Erewash (Liz Blackman), who has temporarily left the Chamber, made a thoughtful contribution. However, in view of the Minister‘s failure to answer my question on the powers that this body is being given, I feel it necessary to return to that issue.

The Bill gives as the main functions of the new body




"the protection of the community . . . against infectious disease"

and



"the prevention of the spread of infectious disease".

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That is fine; we all support those objectives. However, the Bill goes on to give the agency apparently unlimited powers to achieve those objectives. It says:



"The Agency may do anything which it thinks is?

(a)



appropriate for facilitating, or

(b)



incidental or conducive to,

the exercise of its functions."


I find that surprisingly open-ended. The Minister, who appeared to be rather unfamiliar with that provision, said that it was intended to enable the body to be independent of the Government, but as my hon. Friend the Member for Buckingham (Mr. Bercow) said, a body does not have to be omnipotent in order to be independent. Clearly, that provision has nothing to do with restraining interference from Ministers.
I would therefore like the Under-Secretary of State for Health, the hon. Member for South Thanet (Dr. Ladyman), when he winds up, to tell the House what powers the agency will actually have. Will it, in its attempts to fulfil its function of preventing the spread of disease, have the power to detain people suspected of being infected? Will it have the power to distrain property thought to be carrying infection? Will it have the power to levy charges or impose fines on those who interfere with its attempts to restrict the spread of infection? Those are important issues. There could be arguments for giving a body such powers, but it would be unusual for the House to give them away without any restraint at all, without specifying in the Bill the circumstances in which they could be used and without any recognition by Ministers that such draconian powers were being conferred on a Government agency, albeit one acting at arm‘s length from the Government.


Dr. Julian Lewis: My right hon. Friend has been in the House much longer than I have. In his long experience, has he ever come across a Bill that has given such an open-ended mandate to an agency in that fashion?


Mr. Lilley: My hon. Friend makes a good point. I have cast my mind back to see if I can remember such a case, but I cannot. That might be?I have some sympathy with the Minister on this?because when one is dealing with a long Bill, one often approaches the Dispatch Box with some trepidation that one might be asked the meaning of one of the obscure and complicated clauses. One therefore tries to focus on what those clauses mean and perhaps misses the more obvious clauses at the beginning, so I may have missed such clauses in other Bills. However, I am not aware of this Bill having any precedent. I hope that the Minister will tell the House why this provision is included in such an unrestrained and draconian fashion.

I really want to focus on the main issue raised by the Bill, which is the prevention of the spread of infections and in particular, the control of hospital-acquired infections?an issue of growing importance to the public, although the Under-Secretary did not mention it in her speech, nor does the publicity material on the Bill issued by the Government. That is a hugely important issue, so it is extraordinary that the relationship between this body and that problem was not discussed at the Dispatch Box.

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We know that nearly one in 10 patients who enter hospital acquire an infection there that they did not have beforehand. We know from the National Audit Office that an estimated 5,000 people at least die every year from superbug infections acquired in hospitals and that up to 20,000 may lose their lives through some involvement of superbugs in complicating other factors. We know from the European Union that the problem is more prevalent in British hospitals than in those of anywhere else in the European Union with the possible exception of Greece. We know, too, that the problem is getting worse more rapidly in this country than anywhere else in Europe. We should like to know what role the Health Protection Agency will play in tackling that important problem.

That is an important aspect of health to which the Government‘s main approach does not appear to be relevant. The Government‘s main approach is that all health problems can be solved by having billions of pounds rolled at them in the hope that they will eventually be tackled. However, if we succeeded in tackling the problem of hospital-acquired infections, far from needing extra resources, we would save many lives, and release vast resources for the treatment of other illnesses or to save the Exchequer money.

It is extraordinary how little attention has been paid to that issue until recently. When I compare the uproar at the five people killed in the railway accident at Hatfield near my constituency?every one of whose loss of life was a personal tragedy?to the reaction to the fact that an estimated 5,000 people a year die as I have described in our hospitals, I cannot help but think that the treatment given to the matter by Government, politicians and, until recently, the media, has been disproportionate.

When one thinks of the disparity between the Government‘s pursuit of what turned out to be illusory threats of biological warfare in the middle east and the actual biological warfare being fought and, it would seem, lost in our hospital wards through dirty and unwashed hands, one cannot help feeling that there is a disproportionate failure to recognise the seriousness of the problem.


Dr. Julian Lewis: My right hon. Friend is most generous in giving way. One is tempted to comment on the paradox that he just raised by recalling the statement once made about a small number of deaths being a tragedy and a large number of deaths being a statistic. My right hon. Friend rightly points to basic failures such as not washing hands as being responsible for some deadly infections. Why, then, should we need a Health Protection Agency to put something right, when we all know what is wrong?


Mr. Lilley: My hon. Friend makes another very good point. I hope that we do all know what is wrong, and I intend to investigate further the causes of this problem.

I became interested in the subject partly as a result of cases that I encountered in my own "surgery", as we tend to call our advice bureaux in our constituencies. Over the years, I have met people who lost relatives as a result of infections acquired in the course of hospital operations or who themselves had acquired the infection and been maimed permanently by it. I was sub-consciously aware that there was an issue there.

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Some years ago, I wrote a paper about the health service entitled "Patient Power". While I was working on it, I discovered the National Audit Office estimates of the scale of the problem. I campaigned for the publication of information authority-by-authority, hospital-by-hospital, on these sorts of problems, so that patients would have the power to take informed decisions on the basis of that information. It was as a result of the subsequent publication of such information that I learned that the trusts in my own constituency had very poor records at that time and were near the bottom of the national league table. Indeed, one was virtually at the bottom. I am happy to say that both those trusts now take this issue seriously and that both have improved their ranking markedly?they are now close to the national average.

A little while ago, I had a meeting with the infection control directorate at the East and North Hertfordshire NHS trust, and a lengthy briefing from the clinical standards officer at the West Hertfordshire trust. I am glad that this issue is now being given priority locally: I would like to see it given an even higher priority at the national level and I hope that the HPA will play its role in that.

We have to ask ourselves why, given the manifest dedication of most people who work in the NHS, to whom I pay tribute, does this problem exist, and why have we as a nation been so slow to face up to it? Part of the answer to the latter question lies in the fact that, as a former health Minister said, the NHS has become part of our national religion. As a result, we are reluctant to think that anything can go wrong within it. We do not want to accept or face up to the fact that it can be a place where illnesses are caused and acquired as well as cured and treated, but we must accept it. Moreover, the Government must face up to it. I am afraid that some people in government are still in denial about the problem and believe that it can simply be spun away or ignored, but it cannot and it must not.

I shall not develop at great length?at least, not at this stage?the disgraceful episode that occurred last autumn. The Government issued a statement to try to pretend that they were doing something about the problem, but when asked to bring the statement before the House, they admitted that they were doing nothing new at all. That was symptomatic of the their attempts to deny the problem. The Minister‘s failure even to mention it today in the context of the Bill suggests that some in government are still in denial about the seriousness of the problem.

Dr. Lewis: Does my right hon. Friend feel that one of the reasons why less attention is given to MRSA infection in hospitals than it should is that the people most affected by it are elderly patients? If it carried off larger numbers of younger people, perhaps there would be a stronger lobby. Is it not a disgrace that our elderly people are coming to think of hospitals as places where, if they enter, they may not come out alive?


Mr. Lilley: My hon. Friend‘s critique is valid. It is true that less attention is paid to the problem than would be paid to it if the majority of the victims were not elderly. However, let us not conceal the fact that people in the prime of life are affected, too, including an increasing number of children. All ages will be at risk if we do not tackle the problem vigorously.

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Why is the position getting worse?and getting worse faster?in this country than in most of our continental neighbours‘ countries? A number of explanations have been put forward. When I last spoke about the problem, Government Members suggested that it was due to the privatisation of the cleaning services in hospitals. On this issue, none of us should take refuge in defensive or doctrinal attitudes about what happened in the past. We should not be making partisan points. If the problem did result from the privatisation of the cleaning services, it should be changed. I would fully support that. I want to save lives, not impose a particular doctrinal arrangement on the organisation of the health service. Let us be clear: is this a serious charge? If it is, why have the Government done nothing to alter those arrangements and to bring back the cleaning services in house? Clearly, the Government do not believe that that is the cause of the problem.


David Taylor (North-West Leicestershire) (Lab/Co-op): The right hon. Gentleman may be indirectly referring to me, as I sometimes raise that very issue?though not in the arbitrary terms that he suggests. Does he accept that the outsourcing of hospital cleaning can contribute to or worsen problems that already exist on the wards, even though the root cause of the problem may be a lack of adequate hand washing in the wards and elsewhere?


Mr. Lilley: If I accepted that, I would want to do something about it and change it. I am sure that the hon. Gentleman, who is sincere and dedicated, would want to, too. Sometimes, however, I believe that others make the point for purely partisan political purposes. If the Government believed that analysis, they would surely want to change it. They do not believe it. Why not? I suspect that it is because it is not true.

Some colleagues went with the BBC to Germany to investigate the same problem in German hospitals, which were pristine and sparkling clean, as one would expect, and run with Teutonic efficiency. The BBC journalist said that he imagined the Germans had such clean hospitals because they did not privatise their cleaning services, but the German doctors responded by saying, "Of course we do". They wanted expert, specialist people to clean their hospitals; they did not want the job to be left to people such as themselves who were not experts in the matter. The BBC journalist told the German doctors that it was a problem in our country and had led to poor standards, but they responded by saying that if the cleaning companies did not get it right, why did we not change the supplier or the cleaner? One thing that our present system does allow is changing the cleaner to secure a better one. Would it not be best to do that, rather than change the system?

I visited a BUPA hospital and asked the same question. That hospital was also sparkling clean and infection free. I asked how that had been achieved and whether the hospital did all its cleaning in house. I was told that outside cleaners were used, but that the contract was managed properly. The hospital authorities insisted that the contractors had named cleaners responsible for each ward and the responsibilities were more than just for cleaning. They included changing the light bulbs, ensuring the supply of loo paper and so forth. That brought pride of ownership.

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It may be that the structure of the NHS does not allow NHS managers to manage their contracts properly. We should consider whether medical staff should have a greater say in handling such contracts and ensuring that contractors meet the highest possible standards of cleanliness.

The NHS may be too centralised. Indeed, I asked the BUPA manager why he could do what NHS managers seemed unable to do. He said that he had been an NHS manager and the problem was that the NHS was so centralised that all initiative was stifled and it was difficult to introduce the sort of changes that he had made in his smaller hospital. The NHS may have problems that we should tackle, but we should not do so on a partisan, doctrinal or point-scoring basis. We need to get it right and save lives.

Lack of ward cleanliness is not the prime cause of hospital-acquired infections or superbugs. It is essential that wards should be clean, although the impact on infection is probably secondary. However, standards of cleanliness influence the whole climate of a hospital. If one works in a clean, sparkling, bright and fresh environment, where every part of the hospital is clean?the loos and the entrances, as well as the wards; under the beds as well as beside them?one is more likely to be meticulous about observing the protocols for cleaning one‘s hands.

The failure to wash hands between contacts with patients is the main way in which infections are transmitted in hospitals. The National Patient Safety Agency says that the hand-cleaning protocols are observed only 40 per cent. of the time in hospitals. That is a serious matter. Why should it happen? One explanation, which first appeared in a newspaper article and was republished in a pamphlet, is that the hospital authorities?matrons and other staff?do not have the power to discipline and insist that staff adhere to the protocols. The author, Harriet Sergeant, carried out research in hospitals and described one occasion in particular. She wrote that the matron




"had shown me the apron and glove dispenser at the entrance of a side room containing an MRSA patient. Every nurse, she said, had to don a disposable apron and gloves before touching the patient, then remove them before leaving.

As we chatted, I noticed a nurse walk in, see to the patient, then depart. She had not touched the dispenser. This was done in front of the matron and the infection control manager. Neither appeared to notice. In astonishment, I interrupted the two women. Had I misunderstood? It appeared not."


The article goes on to say that the matron



"tut-tutted. ‘You‘ve got to have eyes in the back of your head with these girls,‘ she said. The infection control manager nodded sympathetically?‘Doctors are far worse‘," she added. There was clearly no question of a reprimand for the nurse.

The high levels of hospital-acquired infection are an indictment of NHS management, who have failed at every level to exert authority and pull together the groups involved for the benefit of the patient."


I do not suggest that that story is typical, but it was told by someone who spent much time researching the issue. Ministers should say whether they are satisfied that matrons and others in authority in hospitals have the power to insist that staff follow protocols properly. If Ministers are not satisfied, they should produce proposals to reinforce and enhance the authority of those in charge.
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We should have every sympathy with the nursing and other medical staff involved, because the protocols put considerable demands on them. According to the NPSA, if nurses washed their hands with soap and water, they would have to spend 56 minutes?nearly an hour?of every eight-hour shift washing their hands to meet the requirements of the NICE protocols. If they use alcohol-based rubs, the time is drastically reduced to 18 minutes, but that is still quite a long time. A nurse may have to wash her hands up to 40 times in an hour.

Considerable demands are made on nursing staff and we should investigate whether that could be improved by introducing new products. Since taking an interest in this subject, I have been contacted by several companies that claim to have new products that would disinfect hands better, without chapping them or requiring such frequent application. They say that their products are wonderful and would meet all requirements. I am not here to act on behalf of any pharmaceutical company, but they claim that because the protocols are laid down centrally by NICE, new products, such as those that do not contain alcohol?the protocols specify that hand cleansing must be done either with soap and water or with products that include alcohol?are precluded from consideration, even though they might be gentler on hands and not require such frequent application. The agency should investigate those alternatives and encourage the development of new procedures and innovatory products. That could make it easier for staff to meet the requirements and prevent the transmission of disease from one patient to another.

Since I took up this issue, people email me and share their expertise. A former consultant microbiologist in an NHS hospital sent me an article he had written for the British Medical Journal. It said:




"We have managed to keep MRSA out of our rehabilitation unit by a combination of pre-screening, rigorous hygiene and vigorous treatment. Any patients referred from the acute hospital wards require two clear sets of swabs?and if we find (for they are all swabbed on arrival) that they are MRSA positive then they are isolated and treated until clear."

The email also states that



"we have been put under pressure to relax our criteria because they delay transfers. It has been argued that our policy is out of step with the rest of the hospital; but then so is our infection rate. One patient of ours appeared to acquire the organism on the unit twice, each time after the visit of a surgical team.

My correspondent also says:



"With the imposition of targets, for instance the target to move people out of casualty departments within a set time, infected patients may get moved from ward to ward, thus exposing new staff and patients to the organism."

That is a third explanation: targets are getting in the way of the application of the protocols and causing patients to be put at risk and shuffled around hospitals, which?as the Government‘s chief medical officer admits?is one of the causes of the spread of the disease in hospitals.
Someone else wrote to me claiming that lack of research is the problem. He pointed out that in many other countries, research has been done and use made of bacteriophages, which eat viruses. He said that there is scope for research in that area, which might develop methods of tackling the problem that do not involve the use of antibiotics. Again, the agency could?and in my view should?do work in that area.

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It is also open to question whether we use antibiotics correctly. I do not just mean whether we use them too profusely, which is often suggested to be the problem.

The Academy for Infection Management has been arguing that the delayed use of antibiotics, while waiting for laboratory tests on a particular infection, allows infections to take hold and spread; and that it would be better to use early after the discovery of an infection a broad spectrum antibiotic against the likely range of causative pathogens, especially the sort of agents that do not seem to give rise to resistance to those problems. The seven-year study known as MYSTIC?meropenem yearly susceptibility test information collection?suggests that drugs based on meropenem can do that and that, if used, would cut down the spread of those diseases and vastly reduce the need for people to go into intensive care units.

Thus there are things that could be done. It is sad that, in the context of the Bill, the Government do not mention the problem that I have outlined. It is sad that they seem reluctant to look creatively at what can be done and that, when faced with the problem, they simply regurgitate existing measures, pretending that they are new but admitting on subsequent questioning that they are not. It is sad that they are still in denial about the scale and seriousness of the problem.

My overall conclusion is that if we are to tackle the problem, we must bring the Florence Nightingale culture back to our hospital wards, so that at every level people realise the importance of preventing such infections from taking hold and spreading. We must use every kind of imaginative development to ensure that the process is made easier for the medical staff who, in other respects, serve us so well in our hospitals.

 

 

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Health Protection Agency Bill - Second Reading Debate

 

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