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Nigel Mills (Amber Valley) (Con)
I beg to move,
That this House has considered hand hygiene in the NHS.
I am grateful for the chance to raise these concerns. It is a pleasure to serve under your chairmanship, Sir Alan. I secured this debate to highlight some important issues. The germs that cause infections are spread to patients primarily on the hands of healthcare workers, so cleaning hands is the No. 1 way of reducing the spread of infection. Guidelines and rules are already in place, but they are not followed closely enough and the inspection regimes do not do their job and do not produce meaningful data about hand hygiene compliance levels. This serious issue has a dramatic effect on the health of many thousands of patients a year. For many of them, it could be avoided. There is a way of dramatically improving this issue for patients.
The data on this issue are scary. The 2011 prevalence survey showed that 6.4% of hospital patients—one in every 16—contracted an infection while in hospital. Imagine going to a restaurant where one in 16 customers was made ill by the food. No one would go back again; we would not allow it to stay open. But that is what the data showed for our hospitals five years ago. We should not be willing to accept that.
Infections contracted in hospitals affect 300,000 patients every year and cause 5,000 deaths. They have a dramatic impact on those individuals and a significant impact on the NHS, because patients who contract such infections remain in hospital on average two and a half times longer than patients who do not. They spend an average of 11, and a maximum of 25, extra days in hospital at an estimated cost of about £1 billion a year. It is estimated that 30% of such infections can be avoided simply by better applying the existing rules and practices.
The NHS must improve its performance on this fundamental issue. We should not be willing to accept that level of unnecessary infection. I am not saying that such infections are caused by people deliberately not washing their hands enough. They probably do not realise what they are doing, and their behaviour is not corrected. I suspect that most people in the NHS do not realise how many times they should wash their hands when they see a patient and do not know that they are not doing all they can. I am sure most people are extremely keen to do everything they can to fix this problem and prevent such infections. We must look at what more we can do to put systems in place and enforce them. We should give people support, training, peer pressure and peer reviews to ensure it is happening, rather than blame individuals. This issue will become increasingly important as the problem of antimicrobial resistance grows. We cannot rely on antibiotics to fix such infections and tackle the problem, so it is important that we stop the infections in the first place and prevent the situation from getting worse.
I want to talk about the existing hand-washing rules, the systems for monitoring them and why they do not work. I will look at some things that can be done to improve the situation. I hope the Minister will accept that I do not intend these ideas to be controversial or costly; they are ways of enforcing the rules that are already in place and of using the existing systems.
There is a generally accepted international standard for the number of hand-washing moments when nurses and doctors treat patients. It is not controversial; all nurses and doctors are taught it as part of their training. It is an accepted standard in the NHS and most hospitals around the world. I am not asking for a super gold standard for the UK. I do not want to create anything new, different or complicated. That set of moments when hand-washing is needed is accepted by everybody; it is just a question of how many of them are acted upon.
The National Institute for Health and Care Excellence put in place rules for hospitals to assess compliance with that number of hand-washing moments, so we do not need a new framework or a new duty on hospitals. Hospitals already have a duty to assess how well their staff comply with the rules for the five hand-washing moments when they deal with patients. When the Care Quality Commission audits hospitals, it checks how well those rules are enforced, so the systems are there but they are not working and we are not getting the outcomes we ought to have.
One of the problems is that hospitals check the compliance of their staff mainly through observations carried out by a member of staff on the ward or a member of the team. Normally, a nurse who happens to have half an hour spare one day is asked to review how well her colleagues are performing the five hand-washing moments. If I am doing a job and someone tells me, “Right, today you’re being observed on these criteria,” my performance goes up a bit because I know I am being observed and I do everything I can to comply—far in excess of my normal behaviour.
Another issue is that the staff members conducting the review are not trained in how to do it. They may not be entirely familiar with how many hand-washing moments there are or how many arise in the care of patients, so there is a combination of effects. If the people reviewing their colleagues, perhaps their friends, have not been trained to do so—they are not specialists—and are not fully familiar with the rules, it is not surprising that we do not end up with the most reliable data.
The vast majority of the observations show that the nurses and doctors observed are somewhere in the high 90s for compliance, which means they clean their hands more than 96% of the time, as they are meant to. The problem is that independent assessments carried out by people in a more reliable way suggest that compliance is significantly lower. Those data suggest that the actual compliance levels are somewhere between 18% and 40%. There is a set of rules and a system for checking compliance, but it is producing a dramatic false positive. It suggests that we are in the very high 90s for compliance, when we are nearer 20% compliant. It overstates the results by a factor of nearly five, with the terrible effect that there are more infections than there need to be and patients are suffering.
The NHS and other international health bodies accept that the levels of compliance with the hand-washing rules in the high 90s cannot possibly be right. Everybody knows they are false positives, but they give excessive reassurance to the boards of trusts that their staff are compliant, so further action is not taken. Everybody accepts that there has been progress in recent years in tackling infections, which have been reduced from even higher levels. The measures that were adopted to tackle infections had an effect on clostridium difficile and MRSA, but the problem is that we do not track instances of other infections, so it is hard to get data on how many are being tackled.
There have been various studies to try to assess levels of hand hygiene compliance to see what can be done to improve it. I am grateful to the Deb Group, one of the large employers in my constituency, which has an interest in this issue because it makes hand hygiene gel. It has some innovative ideas about how we can monitor hand hygiene compliance. I am grateful for the information it gave me for this debate. I should be clear that I am not advocating any one solution or product; we need a greater recognition in the NHS that this is an issue, and that there are better ways of assessing compliance. We need to encourage greater compliance.
As for recognition of the issue, Sir Mike Richards, the chief inspector of hospitals at the CQC, has highlighted the inaccuracy of local hand hygiene audits, so one would think that action is required. If we recognise that hand hygiene is important and if we recognise that we are nowhere near as compliant as we ought to be, one would think that many hospital trusts would be taking action to try to improve the situation. Sadly, that is not the case. Trusts have a lot on their plates and there are many issues, financial and others, to deal with, so they may decide that an area with compliance levels in the high 90s is not a stone that they want to turn over. They may fear that some proper audits might lead to the discovery that they are only 25% compliant and thus incur some unnecessary wrath.
However, the experience is that hospitals that take the matter seriously do get positive feedback. The CQC report on Burton Hospitals NHS Foundation Trust, which was in special measures until last year and is not too far from my constituency, highlights its use of a method to count the number of hand hygiene moments and the number of times ward staff were complying with the rules. It received some positive feedback in the letter from the chief inspector of hospitals in the report, which states that the hospital was using
“innovative practice to increase hand hygiene, using the latest technology monitoring the use of alcohol in sanitising gel.”
They were not marked down for having discovered an issue; they were complimented. The report states:
“We saw innovation in practice on ward 11 (male surgical ward) where the infection control nurses had worked with staff to reduce infection control risks and increase hand hygiene. The team implemented technology which counted the use of alcohol sanitising gel and compared it against the target of how often it should be used. This was in response to hand hygiene audits which needed improvement.”
On action that the trust must take to improve, the report states:
“The trust must ensure that ward assurance targets, such as hand hygiene practice and recording of patient observations, is achieved at a consistent level in the emergency department.”
We can see from that that if hospitals take the matter seriously, recognise that they are not as compliant as they ought to be and take action, that helps them in these audits.
The big ask here is what more we can do to ensure that CQC reviews identify that hospitals are perhaps fooling themselves into thinking that they are compliant when they are not. Perhaps asking, “Are you really doing accurate and competent monitoring of whether your staff are complying with the hand hygiene rules? Do you have any independent assurance that that data is accurate or are you just relying on surveys done in an idle half an hour by a member of staff who is not really trained, which can produce false positives?” should be a regular feature of all inspections. Work done over a long period to improve levels of hand hygiene compliance in hospitals has produced data showing that when hospitals improve performance and increase the number of hand hygiene moments, infections decrease at a pretty similar rate to the increase in hand hygiene moments. Data exists in the public domain that shows that that is not just a coincidence. If a hospital can increase compliance, infection rates can come down, improving outcomes for patients and reducing costs to the NHS.
My suggestion is not particularly complicated or expensive. It would not lead to the creation of new rules or new burdens that people have not been trained for. I am simply asking that hospital trusts around the country comply with the rules that are already there and monitor whether their staff are complying with the standards that they have been trained in. The NICE guidelines could be tightened up so that hospitals must not only monitor whether staff are compliant, but do so in a competent, independent and impartial manner and not rely on the occasional untrained observation by members of the same team.
When the CQC goes around hospitals assessing cleanliness and patient safety, we should expect it to check whether competent work has been done. If it has not, it should encourage and instruct hospitals to take the matter seriously. When hospitals show higher than average instances of infections, it should check that they took this issue seriously and that the relatively simple and low-cost measures that can be taken to reduce infection were applied. When hospitals are not doing that, it should be regarded as a serious issue.
There are many things in health that we cannot control or fix or that are incredibly expensive, but what we have here is a set of rules that already exist. It is a simple thing that most people are trained in. By doing everything that we can to comply with it, we could save a lot of money and a lot of patient suffering. There is the potential for real improvement. I hope the Minister will accept that this is a serious situation, and that there is more that NICE and the CQC can do and more that hospital trusts can be expected to do, so that the prevalence of infections in the next report is at the lowest possible level.
Sir Alan Meale (in the Chair)
As the debate is only an hour long and we have three quarters of an hour remaining, I want to inform Members that I intend to call Back Benchers first, then the Front-Bench Spokespeople and then the Minister. I will call the Back Benchers who stand.
Mrs Madeleine Moon (Bridgend) (Lab)
It is a pleasure to serve under your chairmanship, Sir Alan. I commend the hon. Member for Amber Valley (Nigel Mills) for calling the debate. It is such a simple issue. We are taught from early childhood to wash our hands, and yet somehow it seems to get lost. It seems to have disappeared out of our daily practices. We are failing on one of the easiest ways of addressing so many conditions that are costing this country a huge amount and causing the NHS a terrible problem.
We are told every day whether we should take vitamins or whether we should drink red wine, which is either good for us or destroying our lives, and we are told what superfoods to eat, but a simple, life-changing thing that can be added to the daily routine is washing one’s hands on a regular basis. It is one of those bizarre things that came up during a quiz. The question was, “What is the fastest thing that a human being can do?” and the answer was sneezing. Apparently, a sneeze comes out at 100 mph and can spread across a huge area. Most people catch it in their hands and do not then think to wash them. We all know about washing our hands after going to the bathroom, but we somehow cough and sneeze into our hands and pass diseases on, particularly to those who are vulnerable, in the most frightening of ways.
Globally, poor hand-washing leads to 600,000 deaths a year. Another horrible statistic is that 28% of commuters across the UK have faecal bacteria on their hands. I dread to think who found that out and how they did it, but there we are. It takes just 30 seconds of washing to stop an infection being passed on to someone else and it can make huge difference. In Europe alone, 25,000 people a year die from infections resistant to antibiotics. Resistance to antibiotics is on the global agenda and hand hygiene is a way that we can actually reduce our dependence on antibiotics and prevent common illnesses such as food poisoning.
I want to bring to the Minister’s attention today a deeply concerning condition that sadly not many people seem to know about, but hand-washing really can make a difference to it. CMV, or cytomegalovirus, is a common virus that can infect anyone. Most people will not know they carry it, but if a pregnant woman contracts the virus, she can pass it on to her unborn child with catastrophic results. Almost 1,000 children are affected by the condition every year. CMV can cause miscarriage or stillbirth. Five out of 1,000 babies will die in their first year of life, and two to three babies a day are damaged by CMV, which was identified in 1956 by the same research team that discovered polio, mumps and rubella. There is no vaccine to deal with it, but we can prevent passing it on simply by washing our hands.
CMV is responsible for 25% of childhood hearing loss, as well as for vision loss, physical impairment, ADHD—attention deficit hyperactivity disorder—behavioural and learning difficulties, and cerebral palsy. It is passed on by bodily fluids, mainly saliva and urine, often from small children. It is battled simply by washing hands in soap and water and by getting parents to understand that they must not share food, cutlery or drinks with their children. No parents, I hope, would think of changing a child’s nappy without washing their hands, but how many parents wipe a child’s nose without thinking to use a handwashing sanitiser or washing their hands? Parents should ensure that they wash their hands both before and after feeding a child. Those are simple ways to prevent dramatic changes.
Hand-washing can prevent diarrhoea, vomiting, food poisoning, the norovirus and MRSA. It is a simple way to change infection rates. We could save the NHS huge amounts of money. I am pleased that nurses are very conscious of it, but we almost need to have every patient watching for other people’s visitors and ensuring that they use the antibacterial washers as they enter the ward. The statistic mentioned by the hon. Member for Amber Valley—one in 16 patients acquires an infection—is horrific. That is not something that on the whole doctors have to combat; it is something that every one of us as patients, visitors and fellow citizens should take responsibility for tackling. I am delighted that we have had the opportunity to raise the profile of the issue today.
Andrea Jenkyns (Morley and Outwood) (Con)
It is a pleasure to serve under your chairmanship, Sir Alan.
I thank my hon. Friend the Member for Amber Valley (Nigel Mills) for securing the debate and for his support of my campaign on hand hygiene. I also thank the hon. Member for Central Ayrshire (Dr Whitford) who, with the hon. Member for Wolverhampton North East (Emma Reynolds), worked with me on a cross-party campaign on hand hygiene. Recently, we got more than 50 MPs to sign up to it. I ask anyone present who has not signed up to join us, please. Hand hygiene is a bit of a personal crusade of mine. We simply cannot ignore the importance of hand hygiene in hospitals and the community. It is the single most effective, yet simple, way to prevent avoidable infections and so reduce the burden on the NHS.
I will talk a bit about my background and why I am such a fierce advocate of hand hygiene. My father, Clifford, was diagnosed with lung cancer in 2011; the prognosis was good, but he got fluid on his lungs and he went into hospital for a routine operation. The simple procedure should have taken about 20 minutes, but a junior doctor practised reinserting the lung drain with medical students for two hours. My father subsequently became infected with MRSA. What we saw in the hospital was shocking. One nurse walked in, put antibacterial cream on her hands, put something up my father’s nose and did not wash her hands. Basic things were not happening. I constantly observed a failure to follow basic hygiene procedures, which I mentioned to nurses at the time, but I was ignored and even rebuked. A few months later, in November 2011, he died from MRSA.
Afterwards I got in touch with MRSA Action UK, the charity, and became its regional representative. In Parliament, I set up an all-party group for patient safety for the Patients Association—I commend the Minister, the Secretary of State and the shadow Minister, the hon. Member for Ellesmere Port and Neston (Justin Madders), for supporting it. From my conversations with the Secretary of State and other Ministers, I know they are taking hand hygiene seriously and have plans to deal with it.
On areas for improvement, the World Health Organisation has taken a lead in establishing good practice in hand hygiene around the world, although through Dame Sally Davies, our chief medical officer, and the Prime Minister we have put the issue of antimicrobial resistance on to the global agenda. The WHO talks about the five moments for hand hygiene and identifies when medical workers should wash their hands, providing clear guidance that could make a real difference to hand hygiene routines. I commend the work done by everyone at the WHO.
In England, hand hygiene is most frequently monitored through direct observation—a member of the ward staff will take time to observe colleagues and their adherence to the five moments of hand hygiene. Such studies often produce incredibly high rates of compliance, nudging around 80% or 90%. That is because direct observation is ineffective. Only a minimum of 10 moments have to be observed, which on a busy ward is negligible. Furthermore, staff are aware that they are being monitored and will often change their behaviour—I know that from personal experience.
The APPG had an evidence session at which a lady from the Royal College of Nursing was present. I asked her a simple question—whether she had ever disciplined anyone or taken any of her nursing staff to one side to discipline them on lack of hand hygiene. The answer was no. That was in a 20-year career. We need to ensure a place of consequence if hand-washing is not adhered to.
The hon. Member for Amber Valley and I were presented with some startling statistics at a recent meeting with the Deb Group, which kindly sponsored our cross-party Handz campaign. They included registered rates of hand hygiene compliance as low as 20% to 40% in hospitals in which Deb systems were installed. Such figures are common to other companies offering a similar service in the healthcare sector. We cannot ignore the fact that, although the hospital statistics show a high rate of compliance with the five moments, in reality it is not always the case.
We need to implement a new system for proper observation and monitoring, hand in hand—excuse the pun—with proper awareness of the risks of poor hand hygiene. The hon. Member for Central Ayrshire has told me a lot about the fantastic work being done in NHS Scotland, educating the public with a proactive campaign of posters and information.
Douglas Chapman (Dunfermline and West Fife) (SNP)
As the hon. Member for Bridgend (Mrs Moon) has suggested, there are simple ways in which to improve hand hygiene. Recently, when visiting a school, I noticed that children were washing their hands to the two verses of “Happy Birthday to You”, which seemed to be going down well and was doing the trick. Does the hon. Lady accept that that is a good way of introducing children to hand hygiene at an early age? It is cost-effective, simple, memorable and starts the hand hygiene routine at a very early age.
Andrea Jenkyns
I thank the hon. Gentleman for making that point. With MRSA Action, the charity that I am involved with, I have been going into schools and we use that technique of singing “Happy Birthday” twice. The Handz campaign with the hon. Members for Central Ayrshire and for Wolverhampton North East is about education in schools and promoting hand hygiene from a young age. It is a year-long campaign running through to October and we are also going to go into care homes—there was a recent Westminster Hall debate on care homes—to emphasise the importance of good hand hygiene with the vulnerable in care homes.
Going back to what I was saying, hospitals in Scotland are covered in reminders for people to wash their hands and about the risks brought on to the ward if they do not. I am sure that the hon. Member for Central Ayrshire will mention this herself, but, in Scottish hospitals, people observe staff members when the staff members do not know they are being observed, which is a much better system than the one we use.
To sum up, we need to do a number of different things to improve hand hygiene compliance. First, we need to improve observation and reporting of hand-hygiene breaches so that we can get real and effective reports on compliance. As I said earlier, we need a place of consequence when that does not happen.
Secondly, we need to make it clearer to patients and staff when a ward is not hitting its compliance targets. NHS staff strive for brilliance and we thank them for their hard work, but we need to ensure that they are aware of areas in which they need to improve.
Thirdly, we need to ensure that people are properly aware of the risks of poor hand hygiene compliance in hospitals and elsewhere. Those achievable aims would make a real difference. The hon. Members for Wolverhampton North East, for Central Ayrshire and I are working hard to increase awareness through the Handz campaign and are planning further events.
Hand hygiene goes beyond people catching infections in hospital. More infections means that more antibiotics are needed for treatment, which leads to antimicrobial resistance, which is a huge global threat. Dame Sally Davies, our chief medical officer, has been an advocate on that issue and supported our campaign.
Hand hygiene is incredibly important. I reiterate my thanks to my hon. Friend the Member for Amber Valley for securing the debate, which will make a valuable contribution to discussions on the subject. The UK already leads the fight and it is great to see so many colleagues from the Government and other parties with such great enthusiasm for the subject.
Jim Shannon (Strangford) (DUP)
It is always a pleasure to serve under your chairmanship, Sir Alan. It was especially nice to hear the hon. Member for Amber Valley (Nigel Mills) introduce the debate, and it is good to participate in it. I would like to give some personal knowledge and put forward some viewpoints.
I congratulate the hon. Gentleman on so succinctly setting the scene for the rest of us to follow. To add a bit of background to the debate, patients in the NHS today have a 6.4% chance of catching an infection in UK hospitals. There are 300,000 healthcare-acquired infections annually, of which 5,000 result in mortality. We cannot ignore the mortality rate—5,000 people dying in our hospitals is 5,000 too many. If the figure was one, that would be one too many. If we can take steps to prevent those deaths, we should do so.
Although our figures are below the European average, many other developed countries perform better, including the United States at 4.5%, Italy at 4.6%, Slovenia at 4.6% and Norway at 5.1%. I know that the Minister will address that in his response, but if the States, Italy, Norway and Slovenia can do it better, I am sure that we can achieve their levels, which would be a two percentage point drop or thereabouts from our current figure.
Not all healthcare-acquired infections are preventable, but it is believed that approximately 30% of them could be avoided by better application of existing knowledge and realistic infection control practices. Hand hygiene is an essential component of that.
I remember when my brother was in an accident. He liked racing motorbikes, but unfortunately 11 years ago he had a very serious accident that resulted in him being in a coma and in intensive care for some 19 weeks, followed by 2 years of rehabilitation. Whenever we visited him in the Royal Victoria hospital in Belfast, we all had to wash our hands. He was not able to respond to us at that stage, but his family and other people who knew him wanted to go and see him because of the severity of his injury. The nurse was clear: she said, “You have to wash your hands every time you go to that bed, because the risk of infection for someone in that extreme circumstance is very real.” Every time we left the bed and went outside the ward, we had to wash our hands before we went back to the bed—that was clearly outlined.
To me it was clear: we do that because we want to visit the person in the bed, but we may unwittingly have infections on our hands. The hon. Member for Bridgend (Mrs Moon) spoke earlier about sneezing. Unwittingly, we cover our mouth with our hand and then rub our hands. Then we might stick our hands in our pockets and rub them on the pockets. Even when using a hanky, there will still be infection on the hands. That is the point I am trying to make. It is clear that we have to do something.
The infection prevention and control sector claims that basic hand hygiene standards are not being met on many NHS wards. If that is the case, a clear guide needs to be given to those on wards to ensure compliance. The Deb Group claims that although 90% to 100% compliance with hand hygiene standards was reported by UK hospitals—it is easy to say that—the true figures are between 18% and 40%.
As health is a devolved matter, I have asked the Minister responsible for health back home questions on MRSA infections in hospitals, because even though we have few infections, it is clear that something needs to be done. Back home—it is probably the same elsewhere—many would say, “If you’re ill, be careful in hospital, because you have people with open wounds and people whose immune systems are down. If you bring in your colds, flus and coughs, or whatever it may be, that can have an impact.”
Deb also argues that the data collection method is flawed and that direct observation artificially inflates compliance, as nurses observe colleagues meeting the requirements and undertake a tick-box exercise. There needs to be more than that. NICE issues guidance on hand-washing in hospitals and encourages strict hand-washing practices, but it does not include a demand that accurate data be recorded. We want to ensure that that happens. If we record the data, we are making an effort and, if we are doing that, we are washing our hands. There may be some weight to Deb’s concerns, and that should be extremely worrying for all of us.
Good hand hygiene practice in hospitals is the single most effective way to prevent the spread of infection, and we should take action to ensure that more effective records of hand-washing on NHS wards are made in future. That is a simple yet effective way of making our hospitals safer, and with the recent growth in antimicrobial resistance we need to act sooner rather than later to ensure that poor hand hygiene does not further increase the severity of HAIs.
We have had an extensive hand hygiene strategy in Northern Ireland since 2008, and although some problems persist—in all honesty, we cannot stop all infections—we have seen results from simply adopting a thorough hand hygiene regime in our hospitals, with education on the importance and effectiveness of hand hygiene being an essential part of the Department of Health, Social Services and Public Safety’s regional infection control strategy. Like in Scotland and in some individual trusts, we are taking action to address the issue.
Accurate records are the starting point for addressing the problem. There are many examples across the world, but a recent three-year pilot in a hospital in South Carolina in the United States of America found that once staff were trained in how to use electronic hand monitoring systems, compliance with best practice increased and MRSA rates dropped. That saved the hospital $433,644 from April 2014 to March 2015. There was therefore also a financial advantage, and although that is not the reason to do it, it is an example of what can be done to stop infections and address costs.
As we seek to have a more streamlined and cost-effective NHS, those are the sorts of approaches we need to look into. Indeed, the introduction of such a system at Burton Hospitals NHS Foundation Trust drove up hand hygiene compliance by up to 50% in just three months. That is an example from this country, which shows what we can do if we put in the effort.
With 5,000 people dying each year as a result of HAIs, it is clear that action must be taken. With resistance to antimicrobial treatment increasing, we need to get on top of the issue before it is too late. Hand hygiene is the simplest and most effective way to do that, so let us make sure hospitals are doing that right and doing it well.
Sir Alan Meale (in the Chair)
We now move to the Front-Bench Members, and we have only until 5.30 pm. I therefore ask Members to be succinct. Minister, if it is possible, could you give a minute or so at the end to the Member who moved the motion to allow him to wind up the debate?
Dr Philippa Whitford (Central Ayrshire) (SNP)
Thank you for calling me, Sir Alan, in a debate that sounds simple but is important. The education centre in my hospital in Ayrshire is named after Sir Alexander Fleming, because the man who discovered penicillin was an Ayrshire lad. It may be that people have got complacent and think that the age of infections is done with. In earlier generations, children did wash their hands, but then people got too casual.
In Scotland, we began to be much more fixated on hand-washing in 2001, after some of the evidence about the impact of hospital-associated infections came out. In the early 2000s, our uniforms changed: white coats were banned, tops needed short sleeves and eventually we moved to no ties or jackets. We also began to have more audit in the system. We went through a painful experience between 2006 and 2007: a massive clostridium difficile outbreak in the Vale of Leven hospital in which 163 patients were affected and 34 died. Nicola Sturgeon, our First Minister, was the Cabinet Secretary for Health at the time, and she instantly set up a hospital-acquired infection taskforce when the problem became obvious. The whole approach accelerated.
We have several different organisations that are part of driving hand-washing, but it is about the culture. It is not a question of someone facing the threat of losing their job or being sanctioned; it is about getting people to see hand-washing as part of the rhythm of every contact. There is observation, as has been mentioned, and there are also ward champions. The observation is hidden, so no one knows it is happening. I must say, to my chagrin, that in every single audit of staff, doctors were the worst. That fact was published, to shame doctors by showing that we were the slowest to adopt the right practice. We also observe visitors, and there is alcohol gel as people come into wards. My office was on the ward, and it was easy to see physios, nurses, doctors and visitors interacting with the alcohol gel.
I pay tribute to the hon. Member for Morley and Outwood (Andrea Jenkyns) for setting up the APPG for patient safety, which I am part of, and the Handz campaign. In Scotland, we have the “Happy Birthday” hand-washing campaign, which has been running for some time. We already have that campaign in schools, but it is important to raise the issue.
To verify hand-washing, we have the Healthcare Environment Inspectorate, which turns up without anyone knowing it is coming. Its inspectors are down under the beds and poking around in the mattresses on the trolleys. They are observing staff and, believe me, if there is a dusty corner, they will find it. They also look at surfaces—is there a cracked surface or a rough bit of floor that could be difficult to clean? It is about not only hands but the cleanliness of the entire ward.
My hospital was lucky in that it never outsourced cleaning. We never had companies coming and going. We kept our ward maids. It was their patch, in which they took pride. The supervisor comes along, like your mother-in-law, wearing a white glove, to check exactly what everything looks like. They can be seen under the bed, in among the frame, cleaning every pick of it while chatting to the patient. Those are simple things, but we need to do them, because we are moving into what could be a post-antibiotic era. To think that we could lose something that we started using in 1942 after 80 years is absolutely terrifying, so we need to bring that culture back.
In the NHS, every single trust publishes its infection figures every quarter. The hon. Member for Amber Valley (Nigel Mills) mentioned all infections, and as a surgeon I have to admit that infections happen for all sorts of reasons. The reason why C. diff and MRSA are so important is that their root cause is the poor use—prolonged use—of antibiotics, which causes C. diff, and poor hospital hand hygiene, which causes MRSA.
Trusts’ infection rates are published every month and pinned up on the wards, so that visitors can see them. We also put out the reports of the Healthcare Environment Inspectorate. I have shown a critical report on one of our hospitals to the hon. Member for Morley and Outwood, to show how thorough and challenging the inspection is; there are no holds barred. That is what has to be done. There are also infections out in the community. The hon. Member for Bridgend (Mrs Moon) mentioned cytomegalovirus, which, again, can simply be reduced by hand-washing.
We in this place have to realise our part in all of this. We shake hands with hundreds of people. We go and eat our lunch, and I do not see people forming a queue at the ladies or gents to wash their hands. We should all have a bottle of alcohol gel in our bags. I am on the House’s medical panel, and I have put on the agenda that we should have exactly the same dispensers of alcohol gel used in hospitals outside our canteens. We need to set examples, whether that is by visiting local schools or simply by showing all the people we interact with.
The NHS has a responsibility for hand hygiene. We need to change the culture in the NHS, so that if a member of staff is near a patient and touching not only them but their environment, the member of staff washes their hands or uses alcohol gel before their next contact. We in this place also have a role in getting the message out into society.
Justin Madders (Ellesmere Port and Neston) (Lab)
It is a pleasure to serve under your chairmanship, Sir Alan. I congratulate the hon. Member for Amber Valley (Nigel Mills) on securing this important debate. I also pay tribute to the hon. Member for Morley and Outwood (Andrea Jenkyns), who chairs the all-party parliamentary group on patient safety and has been a passionate advocate on the issue. Indeed, infection prevention was the first subject that the APPG decided to focus on. She referred to the startling answer given by an RCN representative at our first meeting that no nurse, in her experience of some 20 years, had been disciplined for failing to wash their hands. I do not know whether that is because this system is, by its nature, self-policing, but it raises questions about whether the issue is treated with the appropriate importance that we would all agree it should be.
There have been excellent contributions today. My hon. Friend the Member for Bridgend (Mrs Moon) and the hon. Member for Strangford (Jim Shannon) rightly said that washing hands after coughing and sneezing is such a simple thing to do, yet so many of us fail to do it. My hon. Friend the Member for Bridgend mentioned the devastating effects that CMV can have, and how easily it can be prevented. There were also excellent comments from the hon. Member for Central Ayrshire (Dr Whitford), who spoke from her personal experience with remarkable candour about which health professionals have the most to do to catch up in this area. She is right: this is all about the culture in which our health professionals work.
During my Christmas break, I spent a Saturday night shadowing an emergency medicine consultant at the Countess of Chester hospital. It was an incredibly busy environment, and the pace was relentless. Despite the extremely challenging circumstances faced by staff, there was a continual focus on hygiene at every stage. Hands, as well as equipment, were constantly cleaned and sanitised before and after every contact with patients. Indeed, I am now something of an expert at cleaning trolleys.
My experience, however, was not an isolated one. The importance of compliance with hand hygiene is something that NHS staff treat with a high level of importance, and it is worth recognising that, despite the difficulties highlighted today, most staff in the NHS do the right thing and do a fantastic job.
Despite the improvements in recent years, the rates of healthcare-acquired infections in England remain stubbornly high, with what can only be described as inadequate checks on compliance with hand hygiene best practice. As the hon. Member for Amber Valley said in his opening remarks, around 300,000 people per year—or, to put it another way, one in 16 people—get an infection while being cared for in the NHS in England. As he rightly pointed out, if that was our experience at a restaurant, we would not consider it acceptable.
As well as the devastating impact on the patients who are immediately affected, those infections have a significant financial impact on the NHS—the most recent reliable estimate derived from the Plowman report puts the figure at £1 billion per year—and lengthen hospital stays.
The growing threat of antimicrobial resistance adds to the seriousness of the matter and the urgent need for the Government to act. Antimicrobial resistance-associated deaths are projected to increase 2,000-fold by 2050. A report by the World Health Organisation states that resistance is very frequent in bacteria isolated in healthcare facilities and that, at present, antibiotic-resistant bacteria are the cause of over half of all surgical site infections.
Given the clear scientific evidence that good hand hygiene by health workers reduces infections, and in particular MRSA, it is clear that hospital workers are on the frontline against this threat. We therefore need more action to bring about improved hand hygiene to avoid problems in future.
Of course, not all hospital-acquired infections are preventable, but it is believed that around 30% could be avoided by better application of existing knowledge and good practice. It is also widely accepted that good hygiene practice in hospitals is the single most effective method of preventing the spread of infections. That was recognised by NICE in early 2014 when it issued a new quality standard, which included six statements designed to reduce infection rates, with the central aim being that all patients should be looked after by healthcare workers who always clean their hands thoroughly, both before and immediately after contact or care.
While those aspirations are laudable, since the publication of NICE’s guidance, the positive progress made in recent years appears to have stalled, and in some cases possibly reversed. The most recent figures I have seen make worrying reading, with C. diff showing no reduction in the past year, the rate of MSSA increasing and the rate of MRSA increasing by a worrying 14%. For all its aspiration, the NICE guidance is seriously flawed, not least because it relies upon monitoring by direct observation by nurses, which not only takes up valuable nursing time but has been found to overstate compliance rates.
The chief inspector of hospitals for the Care Quality Commission, Mike Richards, has drawn attention to the inaccuracy of local hand hygiene audits. The high compliance rates reported by hospitals simply are not supported when we look at the levels of hospital-acquired infections. We have heard that the compliance rate is more likely to be 18% to 40%, rather than the 90% to 100% reported by hospitals. As the hon. Member for Amber Valley set out with great clarity, there are possibly a great number of reasons for such a discrepancy, and there seems to be an element of self-fulfilment about how assessments are carried out. The trials that have been undertaken to ensure that there are more accurate data have also been shown to improve compliance with best practice.
The introduction of electronic monitoring equipment at Burton hospitals NHS foundation trust was found to improve hand hygiene compliance by 50% within three months. I would therefore welcome an expansion in the use of data and electronic monitoring, and I would be grateful if the Minister could set out in his response how he intends to address that. There is clearly a role for the Care Quality Commission. A key element of every inspection needs to be an assurance that proper checks on hand-washing are carried out. The greater use of data would also enable a new era of transparency to be ushered in. Patients should have the right to meaningful information about hand infection control and hygiene.
Another cause of the recent increase in infection rates is the chronic shortage of nurses on many hospital wards and the increased use of agency staff, caused in part by the Government’s decision to slash the number of nurse training places after taking office in 2010, as well as the worrying retention trends. Significantly, when there is a high turnover of staff, it is much more difficult for best practice to be instilled, monitored and ingrained into the culture of a hospital. I hope that when the Minister responds, he will say a little more than he was able to last week at the Dispatch Box about improving the retention rates for nursing staff.
Finally, as well as improving practices within the NHS, we need to improve hand hygiene among the public at large. Studies have shown that, despite awareness about good hand-washing practices being widespread, one in five people do not wash their hands after using the toilet. According to the Royal Society for Public Health, one of the major barriers has been an assumption by people that they do not carry any diseases. However, on average, studies have shown that hands can carry about 3,000 different bacteria, so we also need to explore what more we can do to improve good hand-washing practices among the public. The cross-party Handz campaign, which was launched by the hon. Member for Morley and Outwood, has already done very good work to raise awareness of these issues, and I hope it will provide a catalyst to drive forward improvements both inside and outside the NHS.
The Parliamentary Under-Secretary of State for Health (Ben Gummer)
I thank my hon. Friend the Member for Amber Valley (Nigel Mills) for bringing this important matter to the notice of the House, and I thank hon. Members on both sides of the Chamber for their speeches and contributions.
Hand-washing is an interesting thing, is it not? For the majority of human history, from Pontius Pilate to Lady Macbeth, it was associated with a bad act. Hand-washing was what someone did after they had done something wrong. It was only through the transformation in clinical knowledge in the 19th century that the understanding of hand-washing and its criticality in reducing infection rates became commonplace, but it was a long fight. It is worth remembering that Ignaz Semmelweis, the man who made people understand that washing their hands in obstetric and maternity settings reduced the risk of infection, was so criticised by his colleagues that it drove him to insanity, and eventually to death in an asylum. This was a hard-won victory, and I utterly endorse the wise comments made by the hon. Member for Central Ayrshire (Dr Whitford): perhaps it is because it has become such a commonplace part of our modern understanding of hygiene that we have forgotten its central importance in reducing infection.
My hon. Friend the Member for Morley and Outwood (Andrea Jenkyns) came to the Department of Health a few months ago and sat in on one of the Secretary of State’s Monday morning care meetings to discuss her Handz campaign and the fact that she wanted to set up an all-party parliamentary group on hand hygiene. I know that her personal testimony brought acuity to our understanding of why this is important. It is all too easy to see MRSA, E. coli and C. diff rates plotted on a chart and to forget that, actually, the result of those infections can lead to the tragic and completely unnecessary loss of life. However, even if it does not lead to that, it can often mean a very extended stay in hospital, with serious injury sometimes incurred as a result of infection.
The overall story of infection caused by poor hand-washing has been good over the last decade. Rates of MRSA, MSSA, C. diff and E. coli have all come down— very considerably in some circumstances—but, as the shadow Minister, the hon. Member for Ellesmere Port and Neston (Justin Madders), rightly noted, we have plateaued in almost all of those, and worryingly so. In fact, in the case of MRSA, there has been a worrying, albeit slight, increase in rates in hospitals. That has now been consistent enough to constitute a trend.
We have to be clear that, from the Government’s perspective, we are still not entirely sure in each case why the reductions have not continued. To some extent, it is clear that an increasing role is played by community infection and community onset, or expression, of infection. We do not yet have a full understanding of the relationship between community settings and hospitals, and the chief medical officer is working very hard to try and understand it. Therefore, this is a pressing moment, not least because of the problems of antimicrobial resistance, which the hon. Member for Central Ayrshire mentioned, and which is why we have to be particularly vigilant.
Overall, the one thing that will guarantee that we do not make more progress is if I make a central directive from Richmond House and then ensure compliance through a massive, bureaucratic reporting mechanism. The only point on which I differed from anyone in their observations was when the shadow Minister, in his generally very wise comments, talked about the relationship to staff retention. That was because, although general infection control should be part of how teams work, it should be part of the personal, professional responsibility of a clinician, no matter where they work—whether in the community or between hospitals as a bank nurse or clinician—to take infection control very seriously.
How do we improve matters? How do we make sure that, as in so much of the NHS—to copy Bevan’s words, which I do not tire of using—we are “universalising the best” and lifting poor performers, of which there are several, up to the best standards in the country, some of which can be found with our neighbours in Scotland?
Dr Philippa Whitford
I have not worked in a hospital in England, but the poster campaign that the hon. Member for Morley and Outwood (Andrea Jenkyns) referred to involved massive posters that were in the lifts and targeted at visitors, porters, nurses and doctors. The five points of contact were above every sink and in every room. If we are trying to change a culture, I wonder whether the first thing is actually just to try to get the campaign out there among staff and visitors.
Ben Gummer
I take the hon. Lady’s point, and I agree that we have to re-educate the public that we have not won the battle and that we have to re-engage. I will take her comments to the chief medical officer and talk to her about what more we can do to re-engage the public in the debate on hospital-acquired infections.
Douglas Chapman
My hon. Friend the Member for Central Ayrshire (Dr Whitford) has outlined some of the initiatives taken by the Scottish Government and the NHS in Scotland. Despite those measures, hospital-acquired infections in Scotland still cost the NHS £183 million a year. If we managed to reduce those infections by 20%, that would give us a saving of £36 million. A 40% reduction would give us £73 million. Does the Minister agree that there is a huge financial incentive to reducing the infection figures as much as we can, especially in these times of public spending restraint?
Ben Gummer
The finances follow the far bigger win, which is the benefit to patients and the saving of lives.
One further thing that I will attack quickly is compliance monitoring. It is a very interesting area, and I would encourage local trusts to look at it in detail. The CQC has it as one of its main targets and, in the new inspection round, which will come very soon, it will want to look at the area as a central part of its monitoring.
Nigel Mills
I thank everyone who joined in the debate. We have raised an important issue, and I thank the Minister for his recognition of its seriousness. We were never asking him to issue a direction from Richmond House. However, we have a set of rules and instructions to trusts that they should be checking this, and I think we want to see those rules enforced—