Phenylketonuria: Treatment and Support

Nigel Mills Excerpts

Tuesday 26th June 2018 Westminster Hall

[Liz Twist]

I certainly agree with my right hon. Friend. It has become clear, as we have looked into the issue, that there is a very complex way of assessing drugs. Clearly, we want to get the process right, but there needs to be a rigorous look at that process, not just for Kuvan, but for other treatments for rare diseases. PKU perhaps falls between the cracks, because it is not quite rare enough to be in that group, but it is still very rare, and will be pushed to the back of the queue if it goes into a more general group.

For those whom Kuvan will not help, and who still need to manage their diet carefully, there is another issue that must be addressed: access to low-protein foods, which help to maintain the diet. Individuals may be advised through their dietician and their specialist centre that they need a particular level of foodstuff supplies, such as the low-protein flour I mentioned, which I am told can be used in many ways to try to make the diet more palatable. General practitioners, however, may not have a complete understanding of the condition or the dietary needs, and may feel that patients are just trying to get food on the cheap, and they may limit or deny prescriptions for those foodstuffs. They may feel that they are like gluten-free foods, which can be bought at supermarkets.

The fact is that those foods and supplements cannot be bought; they are available only on prescription, and the absence of them creates a real injury to those affected. It is not just that they are not there; it is actually damaging if they are not available. It would be good if the Minister could address how we can ensure that GPs prescribe the specialist foodstuffs that form part of the treatment that those with PKU need, and how we can close the gap between the specialist services, clinical commissioning groups and GPs.

[Nigel Mills (Amber Valley) (Con)]

I add my congratulations to the hon. Lady. Does she agree that there should be clear guidance, so that GPs or CCGs that are thinking about stopping prescribing that stuff can be told quickly and clearly that that is the wrong thing to do, and that there is no other way of getting this bread, and so that if one of them is foolish enough to go down that line, there can be a quick resolution?

[Liz Twist]

I thank the hon. Gentleman for that comment, and I agree. Last week at the APPG meeting, we heard some terrible stories; over the years, people have felt as if they were asking for a favour in asking for those goods. They are not; the goods are absolutely essential, and they cannot be bought over the counter. We must do something about that. We need to square that circle.

Finally, for the 75% who will not benefit from Kuvan, it is important that new, innovative treatments are developed and assessed quickly, so that more people can benefit from treatments that enable them to live well and safely with the condition.

To conclude, it is important that we listen to individuals and families who are living with PKU day in and day out. It is time that this condition was acknowledged, and that we addressed the need for effective treatment. I hope that the Minister can give us positive news that will move us forward in helping those with PKU.

This Thursday, on National PKU Awareness Day, I and many other hon. Members in this room and across the House will undertake the PKU “diet for a day” challenge. We will restrict our protein intake to 10 grams a day, avoid all those things we normally eat without thinking, such as that piece of toast in the morning or Rice Krispies with real milk rather than coconut milk, and drink tea or coffee without milk. We know that we will not really face those restrictions day in, day out, or the relentless grind of getting the diet right to stay well, but we hope that it will help raise public awareness of PKU, and help to bring about change.

Oral Answers to Questions

Nigel Mills Excerpts

Tuesday 19th June 2018 Commons Chamber

[Stephen Barclay]

I am grateful for my hon. Friend’s support on tier 2 visas. She will be aware that clinicians who reach the £1 million lifetime allowance limit can expect a pension of about £44,000, payable at age 60, increasing with inflation, plus a tax-free lump sum of about £132,000. Although these are ultimately issues for the Treasury, it is important that we ensure that tax allowances, two thirds of which go to higher-rate taxpayers, are fair to other taxpayers.

[Nigel Mills (Amber Valley) (Con)]

16. What steps his Department is taking to support the use of innovative drugs and devices in the NHS.

[The Parliamentary Under-Secretary of State for Health and Social Care (Steve Brine)]

The Government are committed to ensuring that innovative healthcare products reach patients faster than ever before. We have established the Accelerated Access Collaborative to identify transformative innovations and help their route to market, and today we have appointed Lord Darzi as the new chair of the AAC to lead this work.

[Nigel Mills]

I welcome the fact that the Prime Minister in her speech yesterday announced much more funding for personalised medicines and new technologies that will transform care. On that basis, will the Minister update the House on when the groundbreaking CAR-T— chimeric antigen receptor T-cell—therapy might be made available to NHS patients suffering from cancer?

[Steve Brine]

Yes, indeed. As the cancer Minister, I consider CAR-T to be one of the most innovative and exciting treatments ever offered on the NHS. NICE is considering the first of the therapies this year and preparations are well under way. We are working closely with NHS England to make these transformative medicines available to cancer patients.

Infection Prevention and Control

Nigel Mills Excerpts

Tuesday 15th May 2018 Westminster Hall

[Nigel Mills (Amber Valley) (Con)]

I congratulate the hon. Member for Strangford (Jim Shannon) on securing this debate. It reminds me of a debate on much the same topic that we had a few months ago. Its aim was to find out from the then Minister when the Government might enforce the strategy they had announced. It is a pity that we are repeating that debate a few months later and we still do not have the answers. The case has been set out very clearly by the previous speakers. There is not much advantage in repeating it, but, just to reinforce the point, we are talking about 5,000 deaths annually. The World Health Organisation estimates that half of those are preventable through effective hand hygiene. I do not know of other situations in UK life where we could have 2,500 people die each year unnecessarily and that would not be a national scandal. We would do anything we possibly could to fix it. There are things we can do to save a large proportion of those lives that are not very difficult or expensive. Our strong message today is: let us get on and do them.

I accept it will not be easy. We are not talking about finding the number of people who do not practise any hand hygiene and making them practise it; we are talking about making sure that as many health staff as possible get up to the very high levels of compliance with hand hygiene rules, rather than being in the middle. I suspect that no health service staff are deliberately not cleaning their hands as often as they ought to. We know they work in high-pressure situations. They do their very best for patients, and occasionally some behaviours creep in that perhaps should not. The important thing is to have processes in place that can identify when performance is perhaps slipping and then remind people, gently and constructively, how important hand hygiene is. That is why we need accurate and sensible monitoring.

We all know what happens when a colleague in a team says, “We have got to do one of these audits today. I’ll go round and watch to make sure you are all practising the right hand hygiene.” We all know what will happen. We have all been in those situations. We are all very careful to make sure we wash our hands as best as we possibly can. We all think we know the same rules, so we all comply with the same things. The person observing probably does not know the rules any better than those being observed. It is no surprise, therefore, that we end up with near 100% compliance. In fact, it is a surprise that we do not end up with 100% compliance in that situation. It is like the driving test. I have never looked in my mirror as much in my life as on my driving test, because I knew I was being checked on that.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

Is there not a simpler approach? Should not the audit be unannounced and carried out by people like secret shoppers, which is a technique that we use in Scotland?

[Nigel Mills]

Yes, that would be clear progress. However, I sense that we would notice an unknown person walking round the ward with a clipboard, which might make someone behave more carefully. I am not sure how easy it is to stop the word going round the hospital that such work is being done, but I accept that that is better than one member of the existing team doing it. The question is: can we find a better way of monitoring compliance and getting the data we need, so that we can work out what is happening, see what the trends are, and see whether they are reflected in infection rates? As hon. Members have pointed out, there are various techniques on the market to do that electronically.

Simply counting how many times the ward dispensers are squeezed will not work because we need to know the type of ward, how many patients there are and how sensitive the work is to know how many times people need to squeeze the dispensers. We need a system that says, “On a ward carrying out this sort of activity with this number of patients, we would have expected this level of hand hygiene-compliant moments, and we actually got this many squeezes on the dispenser. That is only a quarter of what it ought to have been. That tells us there is a big problem on this ward.” Or it might tell us that we got 80%, which is probably a sensible level to get.

In my constituency is the Deb Group, a large employer that produces hand hygiene gel and monitoring techniques. I accept there are many rivals on the market and many different ways of monitoring. Some people prefer to have each member of staff wear a badge with a sensor that can tell how often that member of staff approaches a hand hygiene gel dispenser, so that we can monitor at an individual level rather than a ward level.

All those ideas are out there. We need the Government, and presumably the Care Quality Commission or NHS Improvement, to say to hospitals, “We want you to collect real data. We don’t want you to do stupid observations that give you 99% compliance, which we know is meaningless, just so that you can tick a box to say that you’re compliant. We want you to collect real data. We don’t mind how you do it, and we’re not going to punish you, take money off you, or put you in special measures if that data shows that you’re at 25% or 35% compliance, and all your rivals are at 97% because they’re doing it wrongly. We want you to do it properly, get the data, use the data, and improve your performance where you can see that it is linked to infections being too high.”

When the CQC reviews hospitals and other health environments, it should check that hospitals are collecting that data sensibly and using it to improve performance. The CQC should be very serious about that when it assesses a hospital. Can we see that hospitals know what their performance is, have a plan in place to improve it, and are improving it, and that infection rates are falling? It would be a serious matter if hospitals were not doing that work properly—if they were just having a quick half-hour assessment now and again, and producing data that they must know is complete rubbish.

We have the right plan; we know what we want hospitals to start doing. Let us get it in force, and task the CQC to ensure that hospitals are doing it. Let us set out clearly what we want hospitals to do and ensure that they are not too scared to go down that line, thinking that their data will suddenly get worse and they will be punished for it. Let us do what we know we need to do, and hope that we do not have to come back in another couple of years to talk about the fact that 2,500 people have died because we have not managed to put something in place that is easy and relatively cheap, and that we know works.

Oral Answers to Questions

Nigel Mills Excerpts

Tuesday 20th March 2018 Commons Chamber

[Mr Hunt]

My hon. Friend is right to draw attention to antimicrobial resistance because China is one of the big countries that can make a difference on that, and yes, we have had lots of discussion with Chinese Health Ministers about how we can work together on that.

[Nigel Mills (Amber Valley) (Con)]

9. What progress Public Health England has made on implementing his Department’s policy of publishing data on hand gel usage in NHS trusts as an indicator of hand hygiene compliance.

[The Minister for Care (Caroline Dinenage)]

Patient safety, and particularly infection prevention, are among the Government’s key priorities. Public Health England has carried out some initial analysis of available data. However, currently the data is incomplete and would not give a true reflection of the usage of hand gel. We are working with Public Health England to explore how we can improve that data.

[Nigel Mills]

I am sure the Minister will agree that it is a matter of real importance that all NHS staff wash their hands at all the required five moments of patient contact. Does she agree that it is disappointing that we have not quite got that data published yet, and will she set a date when we will be able to see that data for each trust?

[Caroline Dinenage]

As I have said, we will continue to look at that, but, as my hon. Friend knows, the Department has a really strong track record of tackling infection. Incidents of MRSA are down 54% on 2010. We have published a revised code of practice on hand hygiene and we are working with partners across health and social care to ensure that this remains a focus.

East Midlands Ambulance Service

Nigel Mills Excerpts

Wednesday 21st February 2018 Westminster Hall

[Stephen Barclay]

My right hon. Friend makes a pertinent point. As he mentioned, he is my constituency neighbour and I am very aware of the specific challenges posed by the geography and the road network in Lincolnshire. I am happy to take that specific point forward. It will not surprise him that I have already zeroed in on some of the challenges in Lincolnshire, particularly around United Lincolnshire and Northern Lincolnshire and Goole, how that interplays across the spectrum of primary care, how the patient pathway goes through, the various blockages in the system and how we look at that in a more systemic way.

That issue interplays with a much wider debate, outside the scope of this one, but to give my right hon. Friend one statistic, 43% of beds are occupied by 5% of patients. If we take the average length of stay from 40 to 35, that is the equivalent of 5,000 hospital beds, each at £100,000 per year. We can see how there is an interplay between what we are debating with the ambulance services and the wider Lincolnshire health economy, which is a specific point. I am happy to have further discussions with him on that.

The hon. Member for Bassetlaw (John Mann) raised three points about the report on the disproportionate calls, which were pertinent to a conversation I had just this morning about spikes in care homes and what action might be taken. For example, to what extent can we improve GP access into specific care homes in Lincolnshire through Skype, as one of the mitigations of ambulance demand? We are looking at how we assess the return on investment between the cost of ambulances and emergency admissions and what that investment might do if it were put into a more preventative role—care homes, for example.

On the specific matter of Sports Direct, which I was not aware of, the hon. Gentleman makes a valid point, which I will be keen to look at with officials—where there are peaks of demand, what is driving those peaks and how to mitigate them. He also mentioned the issue of privatisation from 2009. We are looking at how we take a more holistic view across a landscape and how mutual support from different parts of the system can provide assistance to that. It will not surprise the hon. Gentleman, knowing my views on Brexit, that for all the talk of some of the challenges of Brexit, the opportunities of Brexit should not be missed. I share his desire on that.

There is also the geography point—whether it is the way services elsewhere have been reconfigured or the extent to which there are, for example, centres of excellence to which his constituents are being taken. Is the issue the formal geography or how the operating protocols within that geography have evolved? That, again, is a perfectly valid point and one we can look at on a case-by-case basis.

I know my hon. Friend the Member for Boston and Skegness has championed a number of these issues over a period of time. He raised how we can get the ambulance service working together with the other emergency services. I know that is an issue that many police and crime commissioners have also identified, and many within the fire service are keen to ensure that we have a better join-up between the blue-light services.

The hon. Member for Lincoln (Karen Lee) raised the issue of hospital handovers. I assure her that daily reviews are currently being undertaken by NHS England and NHS Improvement. Greater transparency and targeted assistance are being provided, and there are also specific initiatives linked to individual hospitals, particularly including the hospital-ambulance liaison officers.

The hon. Lady also mentioned pay. It is worth reminding the House that the pay band that applies to paramedic staff has been increased from band 5 to band 6, so there has been a recognition in the system of the importance of paramedics, alongside an increase—around 30% since 2010—in the number of paramedics. However, we recognise that there is also an increasing demand, and that this service has been under considerable pressure.

[Nigel Mills (Amber Valley) (Con)]

The Minister has skirted around the issue of breaking up EMAS, which I think some areas might quite like. Does he agree that our priority should be having more paramedics and ambulances, not more chief executives and office buildings?

[Stephen Barclay]

I think most people who observed my questioning during my four years on the Public Accounts Committee will know that organograms and looking at where investment is and how streamlined structures are is extremely important to me.

At the same time, it is important that one does not make a false saving in driving down some of the management costs, so that procurement, IT investment and consultancy spend, for example—some of the big ticket expenditure—is not effectively managed and escalates. There is a balance to be struck between having good leadership of trusts and, as my hon. Friend alludes to, not drifting into areas where additional hires are created in the back office as opposed to services on the frontline, where I think Members from across the House want to see them.

In terms of the service nationally, a number of actions have been taken. Under Sir Bruce Keogh’s review of the NHS urgent and emergency care system, ambulance services are being transformed into mobile treatment centres, making much greater use of “hear and treat”, which is treating patients over the phone, and “see and treat”, which is treating and discharging patients on the scene. While we have heard of some of the challenges faced by the trust, it is also worth placing on the record that it is one of the best-performing trusts for “hear and treat”, and treats and discharges more than three in 10 patients either on the phone or on scene. There are areas of good practice that, for balance, it is only fair to recognise.

I will conclude, to allow the hon. Member for High Peak time to speak. We recognise that the trust has challenges, and I am very happy to work with the hon. Lady and other colleagues as we move forward to address those. In addition to the increase in pay bands and the increase in numbers, an active plan is under way to tackle some of the challenges we have heard about today, which I hope gives some comfort to the hon. Lady.

Adult Social Care Funding

Nigel Mills Excerpts

Thursday 6th July 2017 Commons Chamber

[Steve Brine]

I understand that the hon. Lady wants to play politics with this issue, but as I said in my response to the urgent question, I honestly think that we can do better than that.

[Nigel Mills (Amber Valley) (Con)]

I have found the CQC’s inspections of struggling care homes in Amber Valley to be a very useful way of making sure that they improve care for local people. Is the Minister confident that the CQC is sufficiently resourced and skilled to carry out those inspections in a timely fashion and to a sufficient quality?

[Steve Brine]

Yes, I think that the CQC does a fantastic job. Andrea Sutcliffe, its chief inspector of adult social care, whom Members will have heard on the media this morning, was absolutely right when she talked about services needing to meet the mum test or the dad test. Ultimately, we are all affected—I have ageing parents, like many Members of this House. The mum test or the dad test is what we want, because when people go into adult social care settings we want to feel that they are as well looked after as we could manage ourselves.

Community Pharmacies

Nigel Mills Excerpts

Wednesday 2nd November 2016 Commons Chamber

[Nigel Mills (Amber Valley) (Con)]

I declare an interest, as my wife works as a community pharmacist just outside my constituency. It is probably fair to say that from my discussions with her and with my local pharmacists, I know the valuable work they do and the pressures on them, as well as the changes that they would like so that they can give a better service.

The Public Accounts Committee has had nine or 10 inquiries in the past year or so looking at the pressure on NHS finances and the various deficits in the system. It is therefore quite hard to stand up and say that the Government are completely wrong to try to find some efficiency savings from the pharmacy budget, or that we should just ignore the £3 billion or so paid to pharmacies each year without trying to find some savings. If we are going to hit the efficiency target across the NHS of £22 billion during this Parliament, while having all the services we want, we will have to accept such savings in every area, although it is not going to be easy wherever they fall. I can therefore see the logic of why the Government need to look at the pharmacy budget.

I also accept the logic that although the system we have ended up with, in which we give each pharmacy a fixed establishment payment, may well have been suitable when we had a very controlled regime, under which a licence had to be got to open a new pharmacy, it probably did not fit well with the old 100-hour regime, under which there was a vast expansion in the number of pharmacies across the country. It is right to look at that system. It may also be right to look at the 100-hour pharmacies to see exactly what the rules for them should be.

I welcome the pharmacy access scheme, which is a very welcome improvement on what was originally suggested for this round of cuts. Two pharmacies in my constituency will benefit from it. I met both pharmacists when the cuts were first announced. Those pharmacies provide the only health provision in the villages they serve, so it is vital for them to be saved.

[Steve Rotheram (Liverpool, Walton) (Lab)]

Does the hon. Gentleman agree that it is a false economy to cut services, given that the knock-on effects on GP services and the NHS will cost more, and that it will do nothing to alleviate the problem of health inequalities in this country?

[Nigel Mills]

It would clearly be a false economy if it resulted in losing pharmacies in areas where we need them. Equally, we would have to say to GPs, “I’m sorry. We can’t take the money off the pharmacies. We are taking it off you instead.” That would make it harder for them to deliver the services that they want to deliver. I do not think there are any easy answers. The system is under so much financial pressure that we must find savings wherever we can.

I have a few areas on which I want the Minister to comment when he winds up. The first is the hub-and-spoke model. Such a model would have been a complete disaster for community pharmacies. If the system is to work, we need pharmacists who know and are trusted by their patients so that they can deliver to patients the extra services that they need. If we moved to a hub-and-spoke model, in which the pharmacy knows almost nothing about the patients—the drugs are just prepared in a factory somewhere and then turn up for the patient—we would not have the community advantages from the pharmacy network that we all want. I hope that that idea, which may have been raised by some management consultants, can safely be binned—where most such ideas are probably worth sending.

The second area is the provision of services by pharmacists. I know that my local pharmacies are very keen to deliver more value-added services. They see that as right for the NHS and in the best interests of their patients. As I found out five years ago, when we went through the clinical commissioning group reform, they are not quite so sure that local GPs are keen on commissioning new services from pharmacies, rather than carrying out those services and taking the revenue themselves. We know that there is pressure in the GP sector, so we can see the point of that.

We need to have a vision throughout the country about what core services should be commissioned from pharmacies. I think the word the Government use about the minor ailments scheme, which I generally support, is that we should “encourage” all CCGs to commission such a scheme. I hope we can do something a little stronger than encourage, and that we can have a broader list of services for CCGs to commission from pharmacies. I have seen great work done on that in my constituency. Permission has been given for syringe driver services to be carried out by some pharmacies, rather than hospitals, so that they can be got to the patients needing them much more quickly and cheaply. Some pharmacies do warfarin testing, because it is much more convenient for patients to go to their local pharmacy than to have to trek to the nearest hospital or to their GP. Those services are very patchy and do not even cover a whole constituency, so I hope we will draw up a core list of services that can be done better by pharmacies and which will be used.

I will quickly touch on the third area, which is the variety of opening hours. Quite rightly, we are to start directing patients from the 111 service to their pharmacy rather than to out-of-hours doctors as the first port of call for emergency repeat prescriptions. However, there is an interesting mix in that some pharmacies open for 100 hours a week—perhaps opening at 6 am and closing at midnight—and other pharmacies open from 9 o’clock to 5 o’clock from Monday to Friday and may open for a couple of hours on Saturday morning. How will we commission all pharmacies to carry out such a service if some do not open out of hours? On the flipside, we still require many of them to open for 100 hours a week, even though it is not economic for them to do so during many of those hours. There is therefore scope for a review of the hours during which we expect pharmacies to open.

Community Pharmacy in 2016-17 and Beyond

Nigel Mills Excerpts

1st reading: House of Commons
Thursday 20th October 2016 Commons Chamber

[David Mowat]

Not that I know of, but there may well be. The facts are that the £2.8 billion that we currently spend is for services and for disbursing £8 billion-worth of drugs. It is a valuable service, but it is right that we look to see that that money is spent effectively and as effectively as in other parts of the NHS. It is the Government’s job to make sure that every penny that we give the NHS provides maximum value for patients.

[Nigel Mills (Amber Valley) (Con)]

May I declare an interest, in that my wife is a community pharmacist? I should therefore probably be cautious in welcoming this statement, for obvious reasons. Will the Minister confirm that the proposals to have a hub-and-spoke model, which would have been even more damaging to community pharmacies, are not part of this step forward?

[David Mowat]

I can confirm that no part of what we are talking about today is in respect of the hub-and-spoke model that my hon. Friend talks about.

Hand Hygiene: NHS

Nigel Mills Excerpts

Wednesday 13th January 2016 Westminster Hall

[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.

--- Later in debate ---

[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—

Cities and Local Government Devolution Bill [Lords]

Nigel Mills Excerpts

Monday 7th December 2015 Commons Chamber

[Mr Betts]

Standing the test of time is about what works economically and what works for growth, because that is the purpose of devolution in the first place.

[Nigel Mills (Amber Valley) (Con)]

I think I agree with the main thrust of the hon. Gentleman’s argument, but we might well grant the elected mayors powers to replace the police and crime commissioners, and if, for example, Chesterfield chose to join Sheffield rather than Derbyshire, the people would presumably lose the right to vote for the person who holds their police force to account. I am not sure that, in those circumstances, the Secretary of State could make his decision solely on the basis of economic powers.

[Mr Betts]

That is an added complication. At present, three separate police and crime commissioners cover the Sheffield city region: one for south Yorkshire, one for Derbyshire and one for Nottinghamshire. Those issues might be considered at some point way down the line, but the leaders of the Sheffield combined authority have— sensibly, in my view—decided not to incorporate the police and crime commissioners’ powers in their devolution deal, probably because that would lead to exactly the sort of further complications to which the hon. Gentleman has referred. They have confined their deal to economic, transport, skills and growth issues, which are precisely the issues to which the Secretary of State will have to give particular consideration if there is a decision to be made about which combined authority the districts are to go into.

--- Later in debate ---

[Mr Rees-Mogg]

That is exactly the point I am making. That is why there has been affection for the Mayors, even from people who do not share their political sympathies. It is felt that they have a legitimacy to do what they have done. I voted against having a mayor for London, because I thought that another tier of government was quite unnecessary; we already have far too many. However, because London had a referendum and the referendum was won, there is a legitimacy. The great city that I neighbour, the city of Bristol, elected a mayor, having decided to do so through a referendum. Therefore, the people of Bristol have invested in that office and given legitimacy to it. I cannot think of anything worse than having an elected mayor covering Somerset, and I would oppose it tooth and nail. The watchwords will be, “Somerset will fight, and Somerset will be right.”

[Nigel Mills (Amber Valley) (Con)]

May I suggest something that might be even worse to my hon. Friend? It is that the outcome of the amendment might be that there is no mayor, but a new combined authority with devolved powers being run by a politburo of leaders of other councils, the policies of which people will have no direct say in.

[Mr Rees-Mogg]

If Madam Deputy Speaker will indulge me, I compare that with the Council of Ministers in the context of the European Union. It has democratic legitimacy derived from its constituent parts, whereas a mayor imposed, without a referendum, lacks that fundamental legitimacy. It is more like the President of the European Commission. To have a system that has an imposed mayor is to move away from legitimacy.

[Nigel Mills]

Just to continue that thought, will my hon. Friend not join me in having some concern that the people who will be taking the decisions, spending the money and exercising the power will not have been elected for that purpose, but for some very different position on a very different authority that could be on a much smaller scale?

[Mr Rees-Mogg]

I do not accept that. I am not a big-is-good advocate. I think that small can well be beautiful. The individual leaders of councils are the doughty defenders of the interests of the population that has chosen them, and they are in their way like Members of Parliament in that they represent a specific area and a specific interest, and they can combine with others to see how decisions can be made. I see no lack of democracy in a group of people coming together, each one of whom has an individual mandate. Indeed that can be a better democratic mandate than having a highfalutin mayor.

--- Later in debate ---

[Mr Rees-Mogg]

The hon. Gentleman makes my point for me. They got exactly what they wanted. They got a referendum that decided that they would remain part of the United Kingdom and then they voted for champions to come to this place and represent them constituency by constituency. That is how first past the post works. I wish that they had all voted Conservative; it is a great shame that they did not. The system worked effectively to represent what most people in Scotland wanted. Sadly, most people in Scotland did not want the Conservatives to have 56 MPs. How that aberration could have come about, I do not know, and I am sure that in time it will change.

[Nigel Mills]

It was worse in ’97.

[Mr Rees-Mogg]

It was indeed worse in 1997.

However, the majority in each constituency, or at least a plurality in each constituency, got exactly what they voted for and not one of the three Unionist parties in those constituencies was able to compete. That seems perfectly fair.

--- Later in debate ---

[Sir Edward Leigh]

It is of course a pleasure to follow my hon. Friend the Member for North East Somerset (Mr Rees-Mogg), with whom I normally agree. I quite understand his enthusiasm for referendums, which in one sense surprises me, because a traditionalist like him would normally have opposed the concept of referendums. He would have opposed them in the past because it was felt—this point has been made many times in the House of Commons—that they were a fundamentally unparliamentary device that has often been used by Governments who are dictatorships to impose extreme changes on society.

I understand where my hon. Friend is coming from, however, because in recent years referendums have been seen as a fundamentally conservative force. Generally, the people vote against change. I understand his arguments and I understand why the Government are wary of accepting any amendment promoting a referendum, because they have looked at what has happened in the past, particularly in the north-east, where people voted against change. The Government are determined to drive change forward and fear that if there is a proposal for a referendum, people will usually vote no. This is a very interesting argument.

I want to dwell on amendment 56, which was tabled by my hon. Friend—and indeed real friend—the Member for Cleethorpes (Martin Vickers). Normally I agree with him about most things, but on this occasion his amendment concerns me, and I want to make a few points about the situation in Lincolnshire and give the Minister the opportunity to reply.

My hon. Friend represents north-east Lincolnshire, and I represent Lincolnshire. Lincolnshire is a very conservative county. It is so conservative that the Gainsborough constituency—which I am proud to represent—has had only three MPs in 90 years, and all three have been Conservative. People do not like change in Lincolnshire, and they are wary of any device such as that in amendment 56. The Government appear to have accepted the amendment, albeit with a sunset clause, and it is quite unusual for a Back Bencher to table an amendment that the Government then accept.

People in Lincolnshire—and, I suspect, other rural counties—want to proceed by consent, which seems an admirably conservative point of view. Normally, proceeding by consent means dealing with the tried and tested, and taking things forward together. Many people are scarred—this has already been referred to—by the events of the 1970s, when ancient counties were swept away. There were different enthusiasms then. They may not have been in favour of elected mayors, referendums or unitary authorities, but everything was done on the basis of Heath-ite efficiency. We now know that that drive towards Heath-ite efficiency was fundamentally wrong and unpopular, and it imposed Whitehall centrist ideas on what local people wanted. I see that my hon. Friend the Member for Beverley and Holderness (Graham Stuart) is here. As a result of 1974, we created the ludicrous county of Humberside, destroying Lincolnshire, East Yorkshire—what madness. We know that is not the right approach.

Speaking as a Conservative—not just as a party politician, but as someone who tries to understand Conservative values—I appeal to the Minister to proceed with great caution and to take people with him on this matter. Now, elected mayors are all the rage, but a few years ago so were police and crime commissioners. We had a mixed history with that—low turnouts, lack of interest, and not necessarily democratic accountability.

Lincolnshire County Council is generally well run, popular, and has been in place for 130 years. The district councils have been in place for more than 40 years. It is not for me to speak for local councillors in Lincolnshire, but since they cannot speak in this place and have only me to say these things, I hope nobody minds if I say that we do not want a solution imposed on us. What worries me about the amendment—and the Government’s ready acceptance of it—is that, as the county council and district councils recognise, in terms of unitary authorities, elected mayors and devolution, we do not want a bruising battle over many years between district and county councils about which should be abolished.

We want to proceed by consent and to get together. We are happy with the idea of central Government devolving more powers to a county such as Lincolnshire, but we recognise that we are not Manchester, Birmingham or London. We are a large, quite poor county with a low rate base and a scattered population. There is no question that we could run the NHS or anything like that; we are not in the business of devo-max. We want to leave the present structure in place with district councils and county councils, and perhaps form a new body on which those will be represented. We would then accept new powers for that body. That is how we want to proceed by consent. Given many of our discussions so far, I am worried that in our rush for change and innovation, we may ride roughshod over what local people and councillors want. Being sensible people and knowing their area, they generally want to proceed slowly, cautiously, and by consent. With that, I feel that I have made my arguments and I will let others speak. I am sure they will be far more interesting than me.

[Nigel Mills]

I am in the unfortunate position of not only having to follow my hon. Friends the Members for Gainsborough (Sir Edward Leigh) and for North East Somerset (Mr Rees-Mogg), but disagreeing with them both. I always thought that if I disagreed with my hon. Friend the Member for North East Somerset, I should sit down and think again. In this case, however, I disagree with his arguments, because I think that when electing an individual who will have significant powers, we should try to ensure that they are elected with a larger proportion of the vote than is required by first past the post.

I suspect that no one would want some kind of extremist to win a powerful mayoralty in a fluke election where there were 14 candidates and the winner ended up with 16% of the vote. I accept that that is unlikely, but it would be a horrible situation. I am sure that the people of France, having seen their election results over the weekend, are glad that they will have a run-off in their presidential election. If the Front National were to win the first round, people will get a chance to elect a non-extreme president. I disagree with my hon. Friend, because when electing an individual who will have power, I am not sure that first past the post is the right answer. We should have the system currently used for the London Mayor and police commissioners, where there is a run-off after the original vote to ensure that the person who wins commands 50% of the vote.

I also disagree with my hon. Friend that not having an elected mayor is the least worst thing. If we are to devolve significant amounts of money and power to a new body, that body must be accountable directly to the people. We need people standing and being elected on the basis of how they will use that power and money.

When people elect a leader of a district council that has a small £10 million budget and mainly does planning and refuse collection, I am not convinced that they will be thinking, “The party I am voting for will choose the leader of the council and will effectively have a veto over the new super body that covers at least two counties in my area.” That is not accountable to the people, and I think it is bad for democracy. We risk recreating the police authority model that we did not think worked, but on a much larger scale and with more powers. That would be a retrograde step for our constituents’ democratic accountability over key public services, and that is why I do not support the amendment.

On amendment 56, I am a supporter of devolution to English regions. The hon. Member for Sheffield South East (Mr Betts) made the right arguments, because areas such as Nottinghamshire and Derbyshire do not have a long-standing, coherent geography that makes people think, “That’s a natural body of government I identify with.” We must proceed carefully, and ensure that we produce Government bodies that people identify with and say, “Yes, I see a coherent natural fit. That is where I look to for decisions to be taken.”

The hon. Gentleman is right to suggest that some parts of north Derbyshire and north Nottinghamshire might feel better suited to the Sheffield region than to Nottinghamshire and Derbyshire. I am pretty certain that Amber Valley, which runs along the boundary between Nottinghamshire and Derbyshire and has the strapline “The Heart of Derbyshire” sees itself firmly in the Nottinghamshire and Derbyshire area, rather than somewhere else, but it is right for individual local districts to have the democratic right to say, “We represent our people, and we think that that region is the right place for us to be.” If people vote for that, that is what should happen, and there should not be a veto from a higher authority that covers a different area.

In exercising that right and making that decision, the Secretary of State should try to achieve consensus, consider the broader picture, and ensure that we do not achieve some strange, farcical democratic situation where, if the people of Bolsover choose to go with Sheffield, they suddenly have no say in holding their own police force to account because that is handled by the elected mayor for Nottinghamshire and Derbyshire. We must proceed with caution regarding what powers go to the mayors. If they are mainly economic powers and interests, and perhaps transport, perhaps elected mayors should not replace the police commissioners if we are to vary the geography, as that could be a dangerous step.

I know that people in Nottinghamshire and Derbyshire are keen to replace their police and crime commissioners, but I am not sure how one person can hold to account two different police forces. That seems a little strange, because someone could be using one mandate to hold to account two forces with very different policies. We must think carefully about such functions. We ought to think properly about the geography, not just rely on some historical, centuries-old set of local government boundaries that may not make sense in the modern world. We should step back and think about what a good system of local government would look like if we added that extra tier. I am not sure that our constituents would thank us if we had four different tiers of local government.

My constituents in Heanor or Ripley elect 21 town councillors and 45 borough councillors. They elect two councillors to the county council, which has more than 60 councillors. I am not sure that they will fancy electing a new mayor and another tier of government, and paying for all that as well. I am not sure that many of them understand exactly what functions those three council tiers have, and what a fourth one on top would do. They would probably think that all four had some role in economic development and regeneration, largely because that features significantly in most of the election literature that we see.