§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. Kevin Hughes.]
7.15 pm§ Dr. Jenny Tonge (Richmond Park)I have wanted to highlight the problem of cleanliness in national health service hospitals for some time and, because of what I shall say, it is fortunate that tomorrow is the anniversary of Florence Nightingale's birthday and also international nurses day, as I am sure the Minister is aware.
By tackling dirt and disorder in the hospitals in the Crimea, Florence Nightingale became, and still is, a national heroine; she is a personal heroine of mine, and always has been. It is worth remembering that, in the first winter of the Crimean war, 40 per cent. of wounded men who were brought to the barrack hospital at Scutari died; it was a no-hope place. The death rate among the general population in Great Britain at that time was 35 per 1,000 people—only 3.5 per cent. After six months' work by Florence Nightingale, the death rate among the wounded in the barrack hospital was 3 per cent. That was an astonishing achievement in a short space of time.
If one wants to learn quickly how Florence Nightingale achieved that, I recommend a trip to the Florence Nightingale museum, which is just across the river in the entrance to St. Thomas's hospital. It is a delightful gem of a place that celebrates the life and work of Florence Nightingale, a formidable lady who, without modern medicines—and despite the often fatal interventions of members of my profession—saved thousands of lives.
Florence Nightingale was in the Crimea for only two years, but she returned to England and for nearly 60 years did the same work in hospitals here. She completely transformed nursing and medical care. She introduced simple hygiene measures, scrupulous cleanliness in her hospitals and efficient nurse training. That is all described in her book, "Notes on Nursing", which is still available, and in many other writings; she was a prolific author and always published her findings. Ministers in the Department of Health should read her book if they have not done so already—I hope that they have.
Florence Nightingale's most quoted remark is quite beautiful. She said:
It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm.That was a revolutionary remark in her time. Some 140 years after the founding of the school of nursing at St. Thomas's hospital by Florence Nightingale, we can no longer say that hospitals do no harm. In hospital, 9 per cent. of patients acquire infections—that is nearly one in 10. Unfortunately, no data are collected centrally on the number of deaths that result from hospital-acquired infections, but probably about 1 per cent. of all deaths are from that cause.The incidence of resistant bacteria has increased. Methicillin resistant staphylococcus aureus—MRSA—is now a huge problem and I pay tribute to my hon. Friend the Member for Twickenham (Dr. Cable), who has raised that issue on several occasions and asked many questions about it. It is resistant to most antibiotics and can kill debilitated patients very quickly. Incidents of MRSA infection—which are defined as three or more patients affected at one time—rose from 342 in 1992 to a peak of 1112 2,364 in 1997. I am glad to say that the number of those incidents is beginning to fall, but we must watch it carefully. The National Audit Office estimates that hospital-acquired infections cost the health service £1 billion a year, which is an awful lot of funding. Only today, I heard that two London teaching hospitals have recently had to close wards because of MRSA infections.
We may not be able to see the bacteria, but spending time in a health service hospital—as I still do—soon reveals why there are so many incidents of infection. I sometimes feel that I am walking into a third-world hospital because the standards of cleanliness are so bad. There are dirty corridors and filthy wards. Swabs and tissues are left lying around patients and uneaten food is left about. One of my constituents complained that the drip stand holding the drip bottle going into her arm was caked in blood all the time that it was in use. Toilets and bathrooms are dirty.
My constituents and others have also seen those things. Indeed, many hon. Members approached me when they found out that this Adjournment debate was to take place to say that their constituents had given them similar examples. An elderly friend of mine who was recently admitted to a well-known hospital for major surgery acquired bedsores and an MRSA infection within a week of her admission.
Florence Nightingale must be turning in her grave. After all that progress, we are slipping back to the dirt and carelessness of previous centuries. Antibiotics and disinfectants are no longer our saviours. What a nonsense it all is. I have worked as a doctor in the health service for many years, and the reasons for the dirtiness are staring me in the face. First, and importantly, cleaners are no longer employed directly by the trusts and are not under the supervision of ward sisters—I am sorry, that is not politically correct, I mean the senior ward nurses—where we are lucky enough to have them.
There is another arrangement instead, of which I have hands-on experience and which used to drive me mad. The trust contracts out the cleaning to the best tenderer, standards slip after the first few weeks as the company cannot live up to expectations, and the ward's senior nurse has to contact the cleaning manager, who contacts the contractor, to renegotiate stiffer terms. There is then a six-month trial period, standards begin to slip again and the whole process starts once more. That is a scandal, as are the wages paid to some of those cleaners.
It does not help that the cleaners are no longer part of the ward team. They are no longer appreciated or properly supervised. We must bring back directly employed cleaning staff under the supervision of ward sisters and senior nurses. The Royal College of Nursing and the British Medical Association are calling for that, and I hope that the Government are listening.
Medical and nursing staff themselves are not all blameless. I hate to criticise the angels of the NHS—not just nurses, but junior hospital doctors as well—but I must do so. One of the recommendations in the NAO report is that staff should wash their hands, which, apparently, they do not do very often. Eight per cent. of trusts in the NHS do not even have a policy on hand washing. Why one should need such a policy escapes me. Just before I came into the Chamber, I had a phone call from a nurse saying that what I had been saying earlier was absolutely right.
1113 She told me that, again and again, she sees nurses failing to wash their hands before going on to the next patient. That is not a very nice fact.
The NAO's wonderful report recommends hand washing in recommendation 25, but, in case anyone cannot read, it also has a comic strip that shows in pictures how to wash one's hands—quite extraordinary. The report's next recommendation states that routine procedures such as ward cleaning are also important—surprise, surprise; it has taken a long time to come up with those remarkable observations. I find it unbelievable that, in 2000, 150 years after Florence Nightingale, the NAO has to tell people working in the NHS to wash their hands and keep the wards clean.
Nurses and doctors must have more practical training. Theory is all very well, but we appear to have lost touch with practical procedures. We cannot have staff flitting around hospital wards like little mosquitoes, spreading disease between patients. Discipline, hygiene and proper practice must be insisted on. Again, the senior nurse on a ward, who once ruled supreme in such matters, must supervise the nurses on the ward and ensure that those things are done. I have to say that the good old hospital matron used to carry out spot checks relentlessly to ensure that proper practice was observed.
We must do something about the problem. I know that the Government are extremely concerned about the issue, and I have no doubt that the Minister will mention the NAO report and others—but the evidence makes depressing reading. I have been through the whole report: it speaks of infection control teams, infection control nurses and infection control doctors and how many beds they should supervise; it speaks of clerical support to collect statistics and managers to write reports about the teams and the statistics; it speaks of computer hardware and software, and electronic patient record systems; but the only real sense it contains is in the recommendations that should not have had to be there—those on hand washing and cleaning.
Clinical staff would say that more doctors and nurses are needed. It is all very well criticising doctors and nurses for not clearing up after they have carried out a clinical procedure, or for not washing their hands before going on to the next patient, but if their pager is going off and they are rushing off to a patient who will die if they do not get there immediately and there are not enough doctors and nurses to go around, corners sometimes get cut or they forget to do those things. We need better pathology departments, and—hint, hint—better-paid technicians to perform screening tests on patients, and staff to enable infections to be isolated before they spread. I have to pay another tribute to my hon. Friend the Member for Twickenham, who introduced a debate in the House on pay and attracting more technicians and scientists into hospital laboratories.
In a fax sent to me today, the BMA neatly summed up the case, saying
the measures most likely to have an immediate effect in the protection of patients from hospital acquired infections are the hygiene disciplines—practices and procedures commonplace in the food industry—which include—Adequate washing and changing facilities, the provision and laundering of protective clothing, the maintenance and cleaning of premises and the imposition of handwashing disciplines.1114 Florence Nightingale said it all 150 years ago, and we should have been doing all those things ever since.Medicine has progressed in an amazing way in the past 100 years: we do things in health service hospitals now that were undreamt of 30 years ago, when I was a student; I cannot believe the progress that has been made. However, with all the advances, we appear to have thrown out common sense and good clinical practice. Please, let us bring Florence Nightingale back before it is too late.
§ The Parliamentary Under-Secretary of State for Health (Ms Gisela Stuart)I congratulate the hon. Member for Richmond Park (Dr. Tonge) on securing a debate on this important issue. It provides me with an opportunity to demonstrate the Government's commitment to improving the cleanliness of hospitals.
Hospital cleanliness matters to patients, to visitors and to staff. It is as important today as it was in the time of Florence Nightingale, the 180th anniversary of whose birth falls tomorrow, as the hon. Lady said. I cannot promise that we will resurrect Florence Nightingale, but we can do a lot to re-establish some of the principles that she espoused. We will be celebrating the anniversary as part of international nurses day tomorrow, so this is an opportune moment for me to pay tribute to the contribution that nurses have made throughout the years to the comfort and care of patients.
Cleanliness matters for patient comfort and service quality. When we are ill, we have a right to expect high-quality medical care. It is vital that that care is provided in the best possible surroundings. No one should receive treatment or have to recuperate in a dirty or uncared-for environment. Our hospital staff, too, want and deserve an efficient, well-run, clean working environment, because without it they cannot deliver proper care, and in most cases that need for cleanliness is met.
We need to put the matter in perspective. Last year, the second national survey of national health service patients in England asked 112,000 patients suffering from coronary heart disease about their experiences in hospital. We specifically asked about cleanliness in toilets and bathrooms, and 93 per cent. rated them as fairly clean or very clean. We know that we must raise the standards of those few that do not match the majority.
Only this week, my right hon. Friend the Secretary of State for Health stated his commitment not only to consult but to listen and act on the public's views. Through the national plan, patients and the public will be able to have their say on creating a 21st-century NHS. We would be pleased to hear people's views on this important issue.
There are three strands to making our hospitals cleaner. First, people must know what standards they are expected to achieve; secondly, they must have the tools to achieve them; and thirdly, there must be evaluation and monitoring of whether they are being achieved. When this Government came to power, there was a notable absence of all three strands. However, we saw the importance of the issue and we are taking action.
We have made it absolutely clear that clinical governance is as important as corporate governance, and I can demonstrate that we mean business. The Commission for Health Improvement will provide robust, independent scrutiny of NHS arrangements, through a rolling programme of clinical governance reviews.
1115 The commission's expertise and focus will be clinical but its remit will also include important non-clinical, organisational factors. It will work closely with other external review and inspection bodies such as the Health and Safety Executive and the Audit Commission to ensure the comprehensive clinical and non-clinical monitoring of NHS hospitals. Additionally, NHS Estates can offer expert guidance and advice to the commission where the quality of facilities management is in question. Its regional office teams will review performance of non-clinical support.
A vital component of our commitment is our initiative on controls assurance, which will set the framework for standards. The programme sets out national standards in key quality areas. It is part of our overall aim of reducing unacceptable variations across the country and driving up standards. One standard covers infection control and is directly relevant to this debate. Furthermore, we are already developing explicit standards on hospital cleanliness.
The existing controls assurance standards already require a whole hospital approach to infection control. They clearly state that infection control committees should have facilities managers as full members. One specific criterion requires prevention and control of infection to be considered as part of all service development. Trusts are further directed to have robust agreements for service provision, whether in-house or through contract, with regular monitoring of standards. The standards and guidance were issued last year and are expected to deliver improvements in performance.
We have made it absolutely clear what we expect, but we have also taken steps to provide the tools for the job. We have done that with money, with standard setting and by working with the service.
Improving the environment is not just about cleanliness. In his speech to the Royal College of Nursing, my right hon. Friend the Secretary of State announced that ward sisters will control a budget of at least £5,000 to improve their ward environments. That will give them direct power to make the changes necessary to modernise hospital wards, which could include painting walls or replacing worn carpets. Responsibility will hence move away from managers to those who work on the wards.
Better-maintained and better-cleaned wards will ensure that patients feel better, and research shows that where patients rate their environment more highly, they get better more quickly; staff morale also benefits.
We have also helped staff to improve their own services. We have endorsed the excellent work carried out by the Infection Control Nurses Association and the Association of Domestic Managers in producing "Standards for Environmental Cleanliness in Hospitals". The hon. Lady's debate is timely. I have a copy of those standards, hot off the press, which will be distributed by NHS Estates and posted tomorrow to every chief executive in the NHS. After the debate, I shall be happy to give the hon. Lady the first copy to go into public circulation.
The standards are explicit statements of best practice. They have been produced by people working in the NHS. As the hon. Lady commented, people who work in the system know best where it is going wrong and how we can improve it. They understand the problems and know the realities involved in keeping hospitals clean. From tomorrow, all NHS hospitals will be able to use the standards.
1116 Some people argue, and the hon. Lady suggested, that one of the reasons for poor standards of hospital cleanliness is the system of compulsory market testing. In some cases it may be true that standards have fallen because of that, but NHS trusts are required to achieve a high-quality service for their patients. When market-testing a service, the trust should award the contract to the bidder who best meets the quality standards required and offers value for money. On-going evaluation of cleaning standards will be set against the national standards.
§ Dr. TongeI thank the Minister for giving way. May I press her a little further on that point? She must realise that with the tightness of their budgets, trusts invariably go for the cheapest tender, rather than the one that offers the best-quality service.
§ Ms StuartI hope that the hon. Lady will be reassured that the NHS Executive is currently reviewing the policy on market testing. Also, we have put more money into the NHS trusts. We must be clear that we expect value for money, which entails meeting the cleaning standards.
We want to encourage the domestic staff. The hon. Lady mentioned that for some time, cleaning staff have not felt that they were part of the team. They must be seen as part of the ward team delivering services to the patient, and must not feel that their contribution is not appreciated. They should realise that it is an extremely important contribution. It is easy to forget that domestic services staff are the second largest staff group in the NHS, and their contribution is invaluable.
The proposed guidelines will highlight the importance of securing best value for patients. They will stress how important it is to decide what is required in terms of quality and patient satisfaction, as well as cost. In a sense, who provides the service matters less than the quality standards being delivered. If the required quality standards are not reached, the work should be given to someone who can deliver it effectively. Chief executives and trust boards are held accountable for the performance of their support services.
NHS Estates has endorsed a series of good practice guides designed by the Health Facilities Consortium. The guide on cleaning and domestic services has a scoring system for quality, and clear performance measures. It allows trusts to compare performances and to evaluate their own performance.
I share the hon. Lady's incredulity at the National Audit Office report and the comic-strip guidelines about how to wash one's hands, but they are clearly needed if there is a failing. However basic it may seem and however much we may lay ourselves open to ridicule, if that is the way forward, we will take it. Hospital-acquired infection is an important topic, and the report is much appreciated. It is clear that we now treat patients who probably would not have been treated only a decade ago. They are often very sick and vulnerable to infection, and the medical procedures that they undergo may be invasive. The nature of the care they receive may present a greater opportunity than in the past for infections to gain a foothold.
We are taking infection control seriously. Within the controls assurance programme, we have developed 15 infection control criteria. They include the requirement to ensure that infection control teams are in place. The teams are usually led by a medical microbiologist, 1117 and include nurses with specialist training. They are an important part of the chain of influence involved in keeping hospitals clean. The controls assurance standards require infection control teams to be involved at all stages of the contracting process for hotel services. That includes laundry and clinical waste management, as well as cleaning. It means that clinical and quality concerns are kept at the heart of the management process.
Along with those clear guidelines for what trusts should do and how they can achieve it, we have promoted training opportunities for those who make it happen. We know that people who are confident in their expertise will have greater job satisfaction, and will deliver higher standards. That is why I am so keen to support training initiatives for housekeepers and domestic staff. Both the facilities good practice guides and the standards for environmental cleanliness emphasise the role of training, and we expect all trust chief executives to act on them.
That brings me to our final strand of work, which involves improving monitoring, evaluation and implementation. We are tackling that at all levels—from that of the individual housekeeper on the ward to that of data-gathering for the whole NHS. At grass-roots level, we want people to take pride in their work. We know that when people feel ownership of their environment, they take better care of it. We know that training people to explicit standards enables them to judge their own performance. One of the criteria in the Health Facilities Consortium good practice guides relates to the number of domestic staff with national vocational qualifications. By encouraging training, we are encouraging all housekeepers and cleaners to evaluate their own service.
Our latest figures tell me that each acute trust now has an infection control team, but in the past there have been problems. There have not always been clear lines of accountability, and a significant number of trusts have reported that they do not have adequate support. We have therefore taken steps to help infection control teams to carry out their work, and also to monitor progress. The NHS action plan enshrined in health service circular 2000/02 identifies the need to ensure robust arrangements, with specific targets to cover issues related to infection 1118 control teams. We have also made available a patients' journey toolkit from NHS Estates—a simple audit form that tracks patients through their hospital experience. It is filled in by the patient; trusts can use it to identify areas for improvement, and can use it again to measure the impact of their efforts.
Local evaluation is essential, but we must also monitor progress at the centre. All trust chief executives were required to complete baseline assessments in March this year against the controls assurance standards. They must report them to regional offices by July, outlining the actions that they intend to take. We have also introduced monitoring arrangements led by regional directors of public health and performance management. They will be charged with maintaining the reporting system, supporting trusts and—importantly—establishing early warning systems. We have asked the NHS Executive board to monitor progress. We need to measure costs, but also to ensure that management systems are in place.
There is, however, another issue that is worth considering. Even if cleaning had no infection control aspects and did not cost money, it would still matter to this Government, for the simple reason that it matters to patients. It is just not good enough for patients to have to receive care in dirty wards. It is not good enough for visitors to have to negotiate piles of cigarette ends outside hospital entrances, and it is not good enough for staff to carry out their work in substandard conditions.
Those considerations are not just the icing on the cake; we are determined to put them high on the agenda of every trust. I know that the hon. Lady's constituents will be pleased to learn that their local hospitals are receiving practical help from us, in the form of clear standards. That clarity, along with clear lines of accountability, will ensure that dirty hospitals are stamped out.
I thank the hon. Lady for raising the issue, and for giving me an opportunity to assure the House—and her constituents—that across the board we are committed to improving cleanliness, and that we have the means to ensure that that aim is achieved.
§ Question put and agreed to.
§ Adjourned accordingly at fifteen minutes to Eight o'clock.