§ Order for Second Reading read.4.32 pm
§ The Parliamentary Under-Secretary of State for Health (Miss Melanie Johnson)
I beg to move, That the Bill be now read a Second time.
I am pleased to have this opportunity to open the debate on the Second Reading of the Health Protection Agency Bill. The Bill establishes the Health Protection Agency as an executive non-departmental public body. I will start by outlining the background to explain why we need the Bill, given that the Health Protection Agency special health authority is already in existence.
The establishment of the Health Protection Agency was first proposed in "Getting Ahead of the Curve", the chief medical officer's strategy for infectious disease and other aspects of health promotion, which was published in January 2002. The strategy brought together a number of proposals to establish a more systematic approach to health protection, of which the HPA is the centrepiece. From June to September 2002, the Department of Health conducted an extensive consultation exercise on the creation of the agency, to which it received 215 written responses.
Following that exercise, in November 2002, the then Minister, my hon. Friend the Member for Salford (Ms Blears), announced the decision to create the agency through a two-stage process. The first stage was to create the agency as a special health authority in England and Wales, which is able to carry out functions under the National Health Service Act 1977. The second stage, which will be put into effect by this Bill, is to establish the agency as a non-departmental public body, which will be able to carry out a wider range of functions.
The two-stage approach enabled us to move speedily to set up the agency as a special health authority covering England and Wales on 1 April 2003. It also provided the necessary time for the Scottish Executive to complete its own consultation exercise to help determine what role the agency might have in Scotland, before we started the second stage. The rationale for creating the HPA was the recognition that the existing structure for health protection in this country was both fragmented and outdated. The shortcomings of the system were highlighted by the diversity and constantly changing nature of the threats to public health.
We are all aware that killer diseases such as tuberculosis and HIV/AIDS are still prevalent in this country, while the recurrence of SARS—severe acute respiratory syndrome—in China just last month serves as a timely reminder of the threat posed by the emergence of new diseases and by infections being imported into this country. Alongside those naturally occurring threats, we are also faced with the possibility of the deliberate release of biological, chemical or radioactive agents. Continued vigilance, combined with a strong and coherent response, is required to manage those diverse threats.
Despite the need for a coherent response to meet the challenges, the specialist support for health protection on which the NHS and local authorities relied was 1098 fragmented among a number of different bodies. Advice on infectious disease generally came from the Public Health Laboratory Service. Support on chemical hazards was provided by the national focus for chemical incidents and regional service provider units. The health aspects of emergency planning were provided by regional advisers. Much of the action at local level in relation to infectious disease and other hazards was the responsibility of consultants in communicable disease control and their teams in primary care trusts, while advice on radiological hazards was provided by the National Radiological Protection Board. Additional services were provided by the National Poisons Information Service and the Centre for Applied Microbiology and Research.
§ Mr. John Bercow (Buckingham) (Con)
In respect of the application of the negative and affirmative procedures of the House flowing from different regulations applicable to individual clauses of the Bill, would the Minister take care to tell the House what the criteria were that informed the choice of one rather than the other in each case?
§ Miss Johnson
I believe that these matters are normally determined on the basis of advice from parliamentary counsel on what would be most appropriate, rather than on any decisions by the Government. We are normally advised in relation to these matters whether something will require the affirmative procedure.
None of those bodies was providing a poor service, but the whole system needed rationalising and strengthening in order to meet the challenges to health protection in the 21st century. It led us to conclude that the best way to strengthen the delivery of health protection services at both local and national levels was to merge responsibility for all those functions and individuals into a single organisation.
That wide-ranging role for the agency is an important development because, when an incident occurs, it is not always immediately clear whether it has a chemical, radiological or an infectious source. The agency can function as a "one-stop shop", capable of providing the necessary expertise for dealing with any scenario involving a biological, chemical or radiation hazard. It should also enable greater cross-fertilisation of good ideas and good practice between the different sectors of health protection.
That approach is consistent with the aims of the Department of Health's review of its arm's length bodies. The objective of the review is to rationalise the Department's ALBs and to reshape them for consistency with a modernised NHS. Many were set up to focus action in key areas and to respond to specific concerns. Now that many of the problems are being tackled effectively, it is time to rationalise the sector, reduce costs and return resources to front-line services.
My right hon. Friend the Secretary of State for Health announced on 20 May that the first stage of the review had been completed and that the parameters for the next stage would be a 50 per cent. reduction in the number of ALBs; a saving in expenditure by ALBs of some £0.5 billion by 2007–08; and a reduction in posts of 25 per cent. in the same period.
§ Mr. Andrew Lansley (South Cambridgeshire) (Con)
The Secretary of State's announcement in May came after the passage of the legislation in another place. During the passage of the Bill so far, its expenditure and manpower implications have been stated as being neutral—no increase in expenditure or manpower—but it is relevant if the Government intend in the space of days, or perhaps weeks to announce changes in staffing and expenditure, or indeed changes in arm's length bodies going beyond what has already been proposed and what the hon. Lady has already described. Does she plan to say anything more about changes in arm's length bodies affecting the HPA which the House should know about now?
§ Miss Johnson
I do not believe so. May I clarify, for the hon. Gentleman's information, the fact that the Bill does not entail any additional public expenditure or changes to public service manpower? We expect that as the agency is a non-departmental public body, its costs will be met from within existing resources available to the Department of Health and the national health service—and indeed, we might expect some savings.
§ Mr. Lansley
I am grateful for that answer, although I am not sure that the hon. Lady has quite taken my point. The Secretary of State announced a review of 42 bodies, two of which—the National Radiological Protection Board and the remaining functions of the Public Health Laboratory Service—were due to go into the Health Protection Agency anyway. Is the Minister telling us that although those bodies were cited among the 42 to be reviewed, they are not to be reviewed? Is no process of reviewing their structures, manpower or expenditure under way?
§ Miss Johnson
Obviously, I shall not pre-empt any announcement that will be forthcoming fairly soon, but I have already given the hon. Gentleman my answer about the HPA and the National Radiological Protection Board. The point of creating the agency is that it is wholly consistent with the review of the arm's-length bodies, not least because it enables us, as he has acknowledged, to replace two bodies—the HPA special health authority and the National Radiological Protection Board—with one.
§ Mr. Lansley
I am grateful to the Minister for giving way to me one more time—at least, on this subject; there may be others. Let us suppose that it was argued that some of the functions of the National Patient Safety Agency were duplicatory, or at least would benefit from being managed together with those of the Health Protection Agency. Is the hon. Lady saying that that might happen, and there could be an announcement weeks from now, so the House will have been debating the Bill on one basis, and then within weeks the Secretary of State or the Minister may propose that everything will change?
§ Miss Johnson
No, I am not saying that. The hon. Gentleman is working hard to find something to 1100 comment on, but he is not succeeding. We do not expect to amend the Bill in the light of the review; I have already said that, and I can only reiterate it. There is nothing for the hon. Gentleman to get excited about—although he is doing his best.
The HPA special health authority has now been in existence for just over a year. During that time, it has successfully passed the test—
§ Mr. Peter Lilley (Hitchin and Harpenden) (Con)
On the subject of things to get excited about, the hon. Lady says that those are arm's-length bodies, yet she seems to have given them pretty well unlimited powers. Clause 4(2) says:The Agency may do anything which it thinks is… appropriate for facilitating, or… incidental or conducive to… the exercise of its functions".Does that mean that, for example, it will be able to detain people carrying an infection, to seize materials that it thinks are infected, or to impose charges and taxes? What is the limit on the powers conferred by the Bill?
§ Miss Johnson
The point of that provision is to make it plain that the new agency will be completely or largely independent of Government in its functions. As the Bill passed through its nine and a half hours of consideration in another place, we responded to their lordships' concerns about ensuring that it has sufficient independence. I appreciate that the hon. Gentleman comes from the other angle in such matters, but we are ensuring that the body is sufficiently independent.
§ Mr. Bercow
I am grateful to the Minister because she has been generous in giving way, but I am afraid that her answer to my right hon. Friend the Member for Hitchin and Harpenden (Mr. Lilley) simply will not do. Does the hon. Lady not accept that there is a cast-iron distinction between granting independence to an organisation and conferring unfettered power on it? If she does not recognise the difference, I wonder why she is at the Dispatch Box.
§ Miss Johnson
I think that the hon. Gentleman, too, is trying to make something out of a very little matter. The Bill's intention is to transfer the functions of the National Radiological Protection Board into the organisation of the HPA—as he and his right hon. Friend the Member for Hitchin and Harpenden (Mr. Lilley) know well—and to ensure that the organisations can do their job with broadly the same sort of remit that they now have. As I have said, however, the intention is also to ensure that the bodies' independence is guaranteed. That was felt by their noble lordships in another place to be a key element of making sure that the public's interest was protected by this move.
I turn to the fact that we have had the—
§ Miss Johnson
I said that I wanted to make progress on my speech.
During the time that the Health Protection Agency has been in existence, which is just over a year, it has successfully passed the test of ensuring effective business continuity from its predecessor bodies. That is no small achievement considering that it took on nearly 3,000 staff from about 80 previous employers. It has also taken the opportunity to establish itself as a modern, forward-looking organisation. It has committed itself to transparency and openness, to high standards of corporate governance, integrity and value for money and to working in partnership with other organisations to develop and deliver programmes and policies and ensure public involvement. Its work is based on the best available evidence together with high clinical and public health standards.
The proof of that success can be seen in the way in which the HPA has handled a number of major incidents, the most serious being the emergence of SARS in 2003. From day one of the outbreak, the HPA special health authority was at the heart of the international effort to control the spread of the disease and played a central role in characterising what was then a new pathogen. The agency had representatives in China, Hong Kong, Vietnam and Canada and at the World Health Organisation where it led the modelling of SARS. A senior WHO official reported that the WHO would not have been able to manage that work without the UK input.
At national level, the agency issued advice to the Government, health professionals and the general public on measures to control the disease. The implementation of those measures prevented the onward transmission of SARS from the few cases that appeared in this country.
As well as addressing high-profile threats such as SARS, the agency has quietly got on with the job of improving day-to-day service delivery at local level. In particular, it has memorandums of understanding in place with every primary care trust in England, and has set up nine regional and 36 local health protection teams to bring a more unified and consistent response in health protection across the country. The new relationships and networks take time to bed down, and the HPA, the national health service and local government are continuing to work together to improve them. The special health authority is in the process of reviewing all its memorandums of understanding to ensure that for 2004–05, all PCTs will have access to a service that is responsive to their needs. We expect those arrangements to be taken over by the agency that is established by the Bill.
The HPA has also strengthened our ability to respond to threats from chemical and biological terrorism. In particular, it has co-ordinated a number of training exercises and has recently issued a set of "clinical action cards" for GPs, which contain advice on identifying and treating victims of chemical or biological attack.
1102 In addition, the authority has established an international presence, enabling the UK to make an integrated contribution to a range of international initiatives. For example, it is working to ensure that there is effective international co-operation in the surveillance of emerging infections. That has enhanced the high reputation for health protection that was established by the authority's predecessor bodies.
In that snapshot of what the HPA special health authority has achieved, we are demonstrating that it is now providing better co-ordinated arrangements for health protection than we had in the past, and that it is contributing to the delivery of an improved service at local level. That is a tribute to the hard work of all the staff who have been involved in its creation.
§ Mr. Lansley
I refer back to the point that the Minister made about the HPA's regional services. Will she explain on what basis the HPA is structuring its health protection units? In some parts of the country, such as mine, those appear to be directly related to county and police structures while in others, such as London, they seem to be related to strategic health authorities. Is there a decided pattern to that?
§ Miss Johnson
I would like to provide a more detailed response to the hon. Gentleman's point in writing. However, I am sure I hat the organisation will be based on what is deemed to be most effective locally and regionally. Also the organisation has inherited some slightly different arrangements from the various bodies that I mentioned—and they have become the HPA, in any case. It varied from area to area, so there was not a common starting point for the structures.
§ Mr. Lansley
I am sure that the Minister takes a close interest in these matters and will be familiar with how the HPA has structured itself in Hertfordshire. Could she explain why, in Hertfordshire, which includes her constituency among others, it does neither of those things in being coterminous with neither the strategic health authority nor the county?
§ Miss Johnson
I have already dealt with that question by referring to organisational effectiveness and the historical legacy that the HPA inherited.
I should like to bring Members on to the Health Protection Agency Bill itself, which will complete the second stage of the two-stage process that I mentioned earlier. The current authority is able to perform a role only in England and Wales, whereas the Bill will establish the agency in UK-wide legislation. That acknowledges the fact that threats to public health do not respect boundaries, including boundaries within the UK.
Clause 3 provides for the HPA to carry out all the functions currently discharged by the National Radiological Protection Board. That will happen on a UK-wide basis, as now, which is what responses to the 2002 consultation showed that users of NRPB's services wanted. Clause 3 also preserves and extends some flexibilities in the NRPB legislation, which will allow the appropriate authorities to direct the agency to take on additional functions it that becomes desirable in future.
In future, the Secretary of State and the devolved Administrations will look to the agency to provide the services that are currently provided by the NRPB. At 1103 this point, therefore, I would like to pay tribute to the work and staff of the NRPB. Since it was set up in 1970, the NRPB has served the Government and people of this country with distinction as an authoritative and independent source of scientific advice on radiation issues. It has built up an outstanding national and international reputation that is second to none as a source of expertise on radiological protection issues.
Nevertheless, we believe that the service can be strengthened even further. Transferring the radiation protection functions to the agency will establish a more integrated source of advice to support the delivery of health protection services and it will also enable the agency to exploit the synergies between the various health protection functions. To facilitate that, the chemicals division of the HPA special health authority has been co-located within the NRPB headquarters building at Didcot.
§ Mr. Mark Francois (Rayleigh) (Con)
The Minister will be aware that one of the specialist functions carried out by the NRPB was conducting an analysis of ionising radiation on request from people who had mobile telephone masts located quite near their homes. Understandably, that was a cause of considerable concern, and people could pay the NRPB to set up metering equipment and provide a very detailed analysis of the amount of radiation emanating from the masts and coming on to their properties A charge was made for that service, as I know because I have had constituency casework experience of the problem. Some people found the surveys reassuring, so if the HPA is going to undertake that function in future, would the Government be prepared, as part of the creation of the new agency, to review the charges made to carry out that function? As I said, it can be very reassuring, but it is also rather expensive at present. Are the Government prepared to be flexible about that?
§ Miss Johnson
I am not sure whether the hon. Gentleman is suggesting that we should spend Government money on that—[Interruption.] I am not aware of any changes being envisaged on this point, but it will be a matter for the HPA to consider how best to continue with the functions that it has inherited. I acknowledge the interest in the issue of ionising radiation, which the hon. Gentleman has raised. We expect the services hitherto provided by the NRPB to continue to be provided by the HPA in the future.
Transferring the functions to the agency will not compromise in any way the independent nature of the radiation protection advice that the HPA will provide, or lead to a reduction in its quality The new agency will be an executive non-departmental public body, which is what the NRPB is now. Every effort will be made to ensure that the change process is managed with the minimum amount of disruption to both staff and work. The two bodies are already working closely together and currently share the same chairman.
§ Dr. Andrew Murrison (Westbury) (Con)
The Minister will agree that both radiation and bugs can cross boundaries. Why is it that artificial boundaries will be created by clause 2 in respect of infectious diseases, but not by clause 3 in respect of radiation and the work of the NRPB?
§ Miss Johnson
I am not sure what the hon. Gentleman refers to, precisely. There are several arrangements that cover various aspects of the changes that relate to the devolved Administrations, but—broadly speaking—those will bring provision much more into line across the UK and are likely to lead to a greater consistency of approach, including bringing Scotland into the new arrangements.
As I mentioned, the Bill does not entail any additional public expenditure. Setting up the HPA special health authority has already illustrated the kind of developments that changes to arm's length bodies can achieve. It has shown how, without the need for the Department of Health to seek additional resources from the Treasury, the special health authority has been able to set up an emergency response division virtually from scratch; strengthen the ability to provide chemicals advice so that there is now the capacity to be proactive as well as reactive; and develop local and regional services. I hope that I have made it clear why the Government have introduced this Bill and I therefore commend it to the House.
§ Mr. Andrew Lansley (South Cambridgeshire) (Con)
I am grateful to the Minister for explaining the purpose of the Bill, although many hon. Members will be disappointed that she did nothing to illustrate how incorporating the functions of the PHLS and the NRPB will deliver improved public health or infection control in the future. I do not know how often the House has the chance to debate infection control and substantial threats to public health, but this was a classic opportunity to do so. However, the Minister seemed to have decided that that was not a very good idea. In the course of my remarks, I may illustrate why the Minister thought that.
I join the Minister in paying tribute to the work of the PHLS and the NRPB. She illustrated her tribute with reference to SARS; it is interesting that she did not argue that there was a specific deficiency in past arrangements, but argued merely that the integration of functions was, by its nature, a good thing. The logical conclusion of that argument would be to combine everything into the Department of Health, with nothing done outside it. However, sometimes a specific focus is necessary. It should be noted that although the NRPB now accepts the proposals, just over a year ago it was concerned about the lack of independence and focus on its responsibilities in the arrangements. It will be important to ensure that all the functions of the HPA require a focus on such tasks, so as to maintain the work of the NRPB.
The Bill has a simple structure. It is designed to bring together the functions of the HPA, presently a special health authority, and the NRPB, which is a non-departmental public body. The Minister was not clear about what special health authorities cannot do that non-departmental public bodies can do.
I think that the difference lies in the degree of independence available to those bodies. As a special health authority, the HPA would be directly constrained by ministerial powers and the interpretations of their responsibilities under health legislation; whereas under the Bill, as a non-departmental public body, the HPA 1105 will have its own statutory remit and, if need be, will be able to make its own decisions as to its priorities and how to discharge them. I welcome the fact that the other place made clear in amendments that the HPA can determine for itself what information it should publish and when. That is entirely to the good.
The Minister told us that the chief medical officer's document, "Getting Ahead of the Curve", published in July 2002, stated that the purpose was to bring together in one agency functions necessary to combat the spread of infection and threats to the public from a range of hazards, such as radiation and biological and chemical releases, including deliberate releases. As we made clear in another place, we shall not oppose the Bill, although in the light of what I have just said and, more particularly, of the constructive debate held by my colleagues in another place, I do not understand why the Bill needs a programme motion. I rather regret that. None the less, we wish the HPA success in its objectives. Notwithstanding our concern to maintain a centre of excellence in the agency for the former functions of the NRPB. we want a more co-ordinated and effective response to threats to public health.
Before we discuss those threats, I want to question the Minister about organisation. I said that I was somewhat surprised that the Department is proceeding with the Bill in parallel with the review on arm's length bodies. Thus far in the Bill's proceedings, there has been no reference to the review's impact on the measure. The Minister said that there was an announcement on 20 May, but the original announcement setting up the review of arm's length bodies was in October last year, so the Bill and the review are running in parallel.
My hon. Friends may not have had a chance to look at the review, but the Secretary of State said that he would review 42 bodies. Lost in the small print, however, was the fact that seven of those bodies are already due to be abolished, so there is not much point in reviewing them. Two of them come under the Bill: the Public Health Laboratory Service and the NRPB are due to disappear to establish the HPA. We know precisely why they were included in the review: so that the Secretary of State can keep his number count up. If he is to reduce by half the number of such bodies, he needs as many as possible in the first place.
The Opposition note—as will, I suspect, the wider public—that 20 of the 42 bodies have been established by the Government since 1997. Once again, the Duke of York is marching the civil service and Government organisations up the hill, only to march them some of the way back down.
We know what the Government propose, but we do not know what they currently intend in relation to the review. In May, when the Secretary of State wrote to the bodies concerned, it was made clear that announcements would be made in early July—the Minister will tell me if I am wrong. Early July is not far off and under the programme motion the Bill's Committee stage will finish by 1 July. Lo and behold, there is every possibility that, immediately after the Bill has reported, the Government will say that they are proposing something different. The Minister just will not tell us whether the Government are proposing something different on the powers, structure and 1106 functions of the HPA. Days after the Bill reports, everything may change. It would be an abuse of our current scrutiny of the measure if the responsibilities, or indeed the financing and staffing, of the HPA were to be radically altered by a Government announcement days after the Bill had reported.
§ Miss Melanie Johnson
I reiterate that we do not expect the Bill to be amended in the light of the review. I realise that the hon Gentleman may have written his speech and may want to demonstrate his commendable understanding of the calendar, which is fantastic—we are indeed approaching the beginning of July—but I gave him the assurance that he seeks in my opening remarks.
§ Mr. Lansley
I also understand that the Minister is reading from her brief. At least I wrote my speech.
The Minister says that she does not expect that anything announced will require amendments to the Bill. I was not necessarily talking about amendments to the Bill. If the intention were, for example, to transfer functions relating to infection control to the HPA from the National Patient Safety Agency, it would be perfectly possible to co so without changing the powers in the Bill. If the Government intended to change the HPA's staffing or expenditure, that would be possible without changing the Bill. However, Conservative Members will debate the HPA's objectives and how it can achieve them. Hitherto, we have been conducting that debate on the basis that the HPA will proceed with its current, planned staffing and expenditure. If the Minister says that the HPA's current, planned staffing and expenditure will be maintained when the review's results are announced in July, that is a different assurance from the one that she has already given to me. Perhaps she would like to give us that assurance—no, I did not think so.
If the Minister cannot give us that assurance, it might be interesting to consider whether the Department is doing its job in the review. A number of agencies duplicate functions. It is always difficult to work out precisely what all those agencies are doing, but I suspect that some of the Department's work, particularly in the Government offices for the regions, some of the Health Development Agency's work and perhaps the National Patient Safety Agency's work in relation to infection control and, in particular, hospital or health-care acquired infection and MRSA may well complement but possibly duplicate the HPA's work. That raises questions about whether a further review of the HPA's functions should take place. I have chided the Minister, and it is a pity that she did not tell us that further efforts will be made to try to rationalise the functions of the arm's-length bodies and indeed the Department in that respect. That may be necessary if that is the HPA's purpose.
The Bill will not simplify the relationship between the HPA and the NHS. For example, most of the old PHLS laboratories have transferred to NHS trusts. The Minister will remember the debates that we had last year on the Health and Social Care (Community Health and Standards) Bill. One of the questions asked at that time, to which I do not recall seeing clear answers subsequently, was the extent to which trusts will receive the necessary core funding through primary care trusts 1107 to support surges in capacity for emergencies and the research and development undertaken by microbiologists in those laboratories. That is one of the issues on which it would be helpful if the Minister responded. Last year we were debating the theory. In practice, have PCTs passed to the microbiology laboratories for which they are now responsible the necessary funding for those purposes?
I mentioned last year—I confess that this has particular constituency relevance—that the PHLS laboratory at Addenbrooke's in my constituency would not be transferred to the trust but would remain with what is now the HPA. That raised a question among the biomedical scientists employed there.
As an early implementer of the "Agenda for Change" proposals, Addenbrooke's was introducing—indeed, is introducing—new pay arrangements for its laboratory staff. On the same site, however, the biomedical scientists working for the HPA do not have access to the "Agenda for Change" job evaluations and consequent pay arrangements.
I am sure that the Minister has that in mind. She might be able to tell me whether there will be further delay. "Agenda for Change" is already delayed until December. Last year, the Minister of State, Department of Health, the right hon. Member for Barrow and Furness (Mr. Hutton), made it clear that there was a transitional issue, but that it would be minimised because of the relatively short time before the implementation of "Agenda or Change". The implementation date has moved from October to December, stretching out what might be a difficulty in the relative position of staff on one site.
The relationship with primary care trusts is important. The Minister said that there are memorandums of understanding with every PCT, but that does not quite solve the problems. The problems go deep into whether public health issues are sufficiently resourced, focused on and prioritised in PCTs. Can public health functions be appropriately managed among 303 PCTs across the country? I am not in a position to judge such things; I have to judge them on the basis of what directors of public health and those in PCTs around the country have to told me. They feel that the system is too fragmented and marginalised and that only reactive work can be undertaken. The Minister made it clear that public health objectives, particularly on issues such as infection control must be proactive. I am afraid that, crudely put, ma pagers of PCTs are sacked when they do not meet hospital waiting list targets, but are not sacked for failing to meet any public health objectives. So all the effort and focus goes on the former. That raises the question whether, if it is possible for PCTs to sign a memorandum and not necessarily discharge their functions, and to let the HPA carry on its responsibilities, the public health effort overall will become disconnected.
The Minister waxed eloquently on how things must be integrated, which brings me to an important point. If everything were properly co-ordinated, a strategy for dealing with infectious diseases could be established, implemented and followed through by one body. One would imagine that that is what the Government set out to do. It is curious, therefore, that time and again the chief medical officer in the Department of Health and his teams of people set strategies, but it is the HPA that 1108 is meant to be in the business of implementing infectious disease control and strategies thereby. As the NHS responds to the Department of Health and not to the HPA, the Department must turn the so-called strategies into action plans. What is going on? That is not happening; there is discontinuity between the two. I shall come to that in respect of a number of specific examples.
I want to refer to hospital-acquired infection and MRSA. The MRSA rate has more than doubled since 1997. The Minister will no doubt remind us that mandatory reporting was introduced in April 2001 and say that that shows that there was under-reporting previously. However, even with the previous reporting arrangements, the rate has more than doubled since 1997 and we now know that the level is about 50 per cent. higher than previous reports suggested.
I am sure that the Minister and other hon. Members have met constituents who have suffered from MRSA infection, whether after hospitalisation or otherwise. It is a life-threatening infection, especially among elderly and vulnerable people. The question that we must ask is: is it inevitable?
Methicillin-resistant Staphylococcus aureus accounts for only 1 per cent. of Staphylococcus aureus incidents in Dutch and Danish hospitals, whereas the proportion in England is more than 40 per cent. As for variation within the UK, the incidence can be seven times worse in Yorkshire than in Cambridgeshire. I am sorry to plug my constituency again, but the Minister and I visited Papworth hospital on Friday to join the celebration of 25 years of heart transplant surgery at the hospital. I recall on a previous visit talking with the medical microbiologist who is responsible for infection control at Papworth—the necessity of minimising infection among immuno-suppressed transplant patients is obvious, and the measures taken at Papworth are stringent. The hospital is not new—anything but. Staff at Papworth often work in difficult and cramped conditions in rather aged buildings, but they achieve extremely low rates of hospital-acquired infection, and I suspect that that is part of the reason why Cambridgeshire has such a good overall result.
There is no inevitability about the rate of hospital-acquired infections—it could be far lower. Just a few weeks ago, I visited Redditch hospital—I had expressed an interest in visiting the stroke services and the ward for stroke patients, but we had an interesting visit to the orthopaedic ward. The nurse in charge of the orthopaedic ward told me that that no one with an infection was coming on to her ward. If someone was to be referred to her ward, she would know whether they had an infection, and if they had, they would, in effect, be kept in isolation and barrier nursing would be used. She was adamant: no one was going to acquire an infection while they were on her ward. The reason we were unable to visit the stroke ward next door was that there was infection in that ward.
That tells us that what is needed is the ability to manage wards properly. There must be the power to ensure that risks are not taken, that infection is kept out, and that standards of hygiene and measures such as hand-washing are enforced.
§ Dr. Julian Lewis (New Forest, East) (Con)
I, too, am concerned about the number of deaths occurring in 1109 quite major hospitals near my constituency. What role does my hon. Friend see for the HPA in raising standards of cleanliness and in ensuring that barriers to infection are instituted in hospital wards, so that there is better protection?
§ Mr. Lansley
I am grateful to my hon. Friend for asking that interesting question. The HPA's role is important, but it is essentially about surveillance—discovering the extent to which there is infection and the extent to which it is acquired in hospital, and reporting on the circumstances. However, there is discontinuity between that role and setting out the action plan—what is to be done about the problem. It was the chief medical officer who followed up previous documentation by publishing in December "Winning Ways", his action plan for dealing with MRSA and hospital-acquired infection. It is not the HPA's responsibility to set out how the NHS goes about preventing hospital-acquired infections. I shall not go through everything that the chief medical officer said about spending additional money on research and development, having directors of infection control in each hospital, minimising the use of invasive procedures and reinforcing guidance.
Disappointingly, the Government have not understood that this is fundamentally about good practice and giving patients a basis on which they can make judgments about hospitals and about where they are referred for treatment. People rarely know the infection rates, including those for MRSA, of local hospitals to which they may be referred. Unfortunately, there has to be a scandal before people begin to learn about conditions in their local hospital. It should not be like that. Patients should know such things, which would enable them to exercise choice. We will make such information available, which is a powerful illustration of the way in which the NHS will be incentivised and required to respond to patients' priorities. Hospital-acquired infection rates, particularly those for MRSA, should be routinely published to facilitate patients' decisions about where they wish to have their elective treatment. As a result, hospital management, instead of ticking performance indicator boxes to say that they have a process in place and have appointed a director of infection control, will bring down infection rates.
At the moment, the Government fool themselves and the public by publishing cleanliness standards. In 2003, according to the Government, there were no hospitals with poor cleanliness standards; 78 per cent. had good standards, up from 22 per cent. in 2000. However, 15 of the 20 hospitals with the worst MRSA rates were given a good cleanliness record, so there is no relationship in the Government's mind between cleanliness and the levels of hospital-acquired infection, particularly for MRSA. However, for the public, a high incidence of MRSA is critical to their judgment about whether or not a hospital is clean.
§ Dr. Julian Lewis
Surely, if my hon. Friend is right and the HPA's main function is surveillance, he is making a strong case that it has a lot more to do in its new form than it ever had to do in its old form if it is to carry out that function effectively.
§ Mr. Lansley
Yes, I am making that point, and that work has to be done in a way that ensures that the agency's responsibilities and those of the Department of Health are meshed together. However, it is not just about the agency's or Department's functions but about managers' response. More research and development is needed so that new technologies can be introduced to support effective infection control. Like many Members, I have been to see people who are working on new technologies, some of which have been piloted in hospitals across the country. Their introduction is urgently needed, and the agency could certainly help with that. We need to make progress on dealing with the problem, because we cannot necessarily resist not only MRSA but VRSA—vancomycin-resistant Staphylococcus aureus.
§ Mr. Lansley
As my hon. Friend can substantiate from his medical knowledge, VRSA is very serious. MRSA is a dangerous infection, but at least we have an antibiotic to respond to that threat. However, that antibiotic is not effective against VRSA, so people suffering from it would have serious problems.
Certain things need to be achieved to close the gap between the role of the Department and that of the HPA. On Second Reading, immediately after the Minister in another place, Lord Warner, had spoken, my noble Friend Lord Fowler made a speech about HIV/AIDS and sexual health—there is no one better qualified to make a speech on the subject than him—and he regretted that the Minister had not spoken about the issue, particularly HIV.
Neither did the Minister responsible for public health say anything about sexual health or HIV/AIDS when she introduced the Bill to this House this afternoon.
§ Mr. Lansley
I beg the Minister's pardon. She referred to HIV/AIDS, but she did not tell us what the Government were proposing to achieve additionally in relation to it, or about any specific functions that were planned for the HPA in that regard.
In the 1980s, as Secretary of State, my noble Friend Lord Fowler led a powerful, hard-hitting public health campaign. It was about not only HIV but safe sex, and it was intended to be communicated to the wider population and to create peer pressure among young people who might otherwise engage in unprotected sex. It was effective, and it was one of the reasons why, until recently, the rates of HIV infection acquired in the United Kingdom were substantially below those of other countries. From memory, I believe that the numbers in this country were a quarter of those in France.
More recently, however, the incidence of HIV has risen. Indeed, the incidence of acquired infections has risen pretty much across the board. The levels of chlamydia and gonorrhoea infection have more than doubled, and the level of syphilis infection has increased by a staggering nine times the previously recorded infection rate. The HPA's latest update report states that, over the preceding year, there had been a 20 per 1111 cent. increase in the number of those living with HIV in the UK, and that there had been an increase in heterosexual acquired HIV as well as an increase in the number of people entering the UK from sub-Saharan Africa who were infected with the Virus.
The HPA has had things to say in that regard, but will the Government act? The question is whether they will go beyond a national strategy and set out standards to which the NHS has to respond. In terms of the Government's structuring of such matters, that would involve a national service framework for sexual health. In the absence of such a framework, the money that the Government say that they are investing will not necessarily get through to, for example, the genitourinary clinics and will not help to bring down the time that people have to wait for treatment.
I accept that there are exceptions regarding waiting times. I was at St. Mary's hospital in Paddington today, which continues to see patients virtually immediately—certainly on a same-day basis. However, that is the exception rather than the rule. The average waiting time for treatment across the country has lengthened; it is now between 10 and 12 days, and in some places it is as long as six weeks. That service simply does not meet people's needs. To combat sexual health problems, we must not only provide an immediate service for patients—for whom these are sensitive issues—but minimise the risk of onward transmission and infection. Over the course of weeks, there could be a multiplication of such risks for the population generally. Have the Government proposed such a national service framework? No, they have not, and it will fall to us to do so if they do not.
Tuberculosis—especially multi-drug-resistant TB—is a serious global problem that is rapidly also becoming our problem.
§ Mr. Francois
I apologise to my hon. Friend for interrupting his flow, but I shall have to depart in a moment to go up to European Standing Committee A, which overlaps with this debate, and I want to put one suggestion on the record before I go. My hon. Friend will be aware that an element of the Bill deals with homeland security, and that the HPA has a potential role in that regard. The paragraph of schedule 1 that deals with staff states:The Agency may appoint such staff and on such conditions of service as it thinks fit.May I suggest, through my hon. Friend, that it might be useful if the HPA were to appoint liaison officers to serve with both the regular regiment responsible for chemical, biological, radiological and nuclear issues in homeland defence and the contingency reaction forces that would need to react to a CBRN incident, so that, in such a dreadful eventuality, HPA liaison staff would be there on the ground with the appropriate military units and would be able to make an initial response that could be communicated back to the agency? We know from experience in other countries that the early identification of a threat is critical to saving lives.
§ Mr. Lansley
I am grateful to my hon. Friend, whose expertise on the subject of response to such emergencies is greater than mine. Clause 5 sets out a general duty to co-operate, which is presumably intended to embrace 1112 local authorities, the Ministry of Defence and everyone concerned with response to civil emergencies, but the Bill tells us nothing about how that duty will be exercised. I hope that in the course of questions from the Opposition and debate in Committee, the Government will flesh out how they intend that co-operation to work. They were tested on the matter in another place and had little to say. We will return to it in due course.
The chief medical officer's strategy document, "Getting ahead of the Curve", identified TB as a "massive international health problem" and showed that the illness, which had dramatically declined in the UK until the late 1980s, was making a comeback. The CMO report listed reduction strategies that had worked in the past, including immunisation and treating those in the very early stages of infection. It suggested that the Department of Health put in place a TB action plan by "early 2003".
In March this year the World Health Organisation confirmed that drug-resistant strains of TB common in eastern Europe and central Asia pose a major threat to the European Union. Perhaps the Minister can tell us whether there has been any incidence of multi-drug-resistant TB in the UK. I am aware from my visit to St. Mary's, Paddington that for reasons of civil emergency and in relation to TB, the number of cases of which is rising sharply, isolation rooms and arrangements have been put in place, so the hospital could deal with multi-drug-resistant TB, should it encounter the disease.
However, the TB action plan has still not appeared. The Minister's predecessor in 2002 promised itby the end of the year"—[Official Report, 4 November 2002; Vol. 392, c. 137W.]When my hon. Friend the Member for Westbury (Dr. Murrison) asked in March 2004 where the action plan had got to, it was promisedin the next few months",—[Official Report, 25 March 2004; Vol. 419, c. 1051W.]but there is still no indication from the Department when it will be published, let alone implemented.
According to the British Thoracic Society, up to half of patients attending accident and emergency departments with TB are "slipping through the net". The BTS considers, and I think it is a fair concern, that the homeless, refugees and asylum seekers are particularly at risk, and points out, along with others, that the incidence of TB in some London boroughs is at third-world levels. In Brent there are 116 cases per 100,000 population, and in China 113 cases per 100,000 population—broadly equivalent. TB in Britain rose by 20 per cent. in the past decade, but in London by 80 per cent.
Why is there no action plan? Why are Ministers avoiding the sensitive issues of screening for disease or identifying the groups at risk? We have examined the issues. We do not believe that compulsory screening is the way forward, but Ministers have access to the HPA and their own surveillance resources, and their appraisal may be different. This would be a good time for the Government to tell us when they propose to publish the long-overdue TB action plan.
On hepatitis C, the Minister corrected my hon. Friend the Member for Mid-Worcestershire (Mr. Luff). The Government estimate that there are 200,000 people with 1113 hepatitis C, but there may be significantly more. The majority are undiagnosed. Effective treatments are available. "Getting ahead of the Curve", the report produced by the chief medical officer, stated thatgood surveillance is the cornerstone of a system to control infectious diseases".However, we do not have surveillance; we have an awareness campaign, which does not appear to be working.
In a report in December 2003. the HPA found that transmission among those who inject had increased. The action plan—a familiar refrain, Madam Deputy Speaker—was first promised in 2002, and by May 2003, it was promisedin the next few months".The Under-Secretary of State for Health, the hon. Member for Welwyn Hatfield (Miss Johnson), now says:The plan will be forthcoming over the summer and into the autumn".—[Official Report, 8 June 2004; Vol. 422, c. 142.]Delay may be costly.
In 2002, the CMO said:Whilst costs of not treating are low initially, as the disease progresses, many more people move to decompensated cirrhosis where the treatment costs, which may include liver transplantation, increase dramatically".The disease is undiagnosed in 90 per cent. of cases, and up to 85 per cent. of people with it will develop chronic disease if it remains untreated—many such people would suffer the severe consequences arising from advanced liver disease. Surveillance now will forestall those costs later.
Finally, has a national pandemic strategy on flu been agreed between the Department of Health and the HPA? Do the Government intend to stockpile antiviral drugs such as Relenza and Tamiflu? Avian flu was only a precursor to the threat that we may face—we do not know when the threat will occur, and it may take some time. The spread of severe acute respiratory syndrome shows the speed with which a new virus to which we do not have immunity can travel around the world. As Ministers know, developing a vaccine when a virus is introduced into this country can take months. The availability of antiviral drugs is important to offset the risks associated with the outbreak of such an infection. I do not know whether this judgment is correct, but it has been put to the Government that stockpiling antiviral drugs would enable us to respond to such a threat. Is stockpiling happening, is it intended to happen and is a strategy in place?
In this debate, we have heard two different speeches, one about public health and one about organisational matters inside the arm's length bodies of the Department of Health. As far as the public are concerned, public health matters: a sexual health and sexually transmitted infections crisis is occurring; TB is rising and we do not have an action plan; perhaps 200,000 people with hepatitis C could be identified and treated, but such plans do not, as yet, exist; and while the incidence of HIV increases, the response is uncertain.
The Government have failed to live up to their responsibilities on infection control. More than any other aspect of health care, public health is the 1114 Department's concern. We are currently debating obesity, which has increased contrary to the Government's so-called public health objectives. Binge drinking has increased, and while smoking has reduced among men, it has not significantly decreased among women. The Secretary of State for Health helps no one by treating smoking as one of life's few remaining pleasures.
§ Mr. Lansley
If my hon. Friend will allow me, I shall not go down that path.
Right across the board, the Government have not delivered a public health strategy. They have not delivered specific strategies for the particular infectious diseases hat are the subject of this afternoon's discussions and that are the responsibility of the HPA. It is a travesty to say that those infectious diseases will be better combated by the creation of the HPA, when the responsibility still lies with the Department, which, even in response to the CMO's recommendations, has failed to ensure the deployment throughout the NHS of the resources and standards of care to deliver the action plan.
We are content not to oppose the Bill, but its contents are no substitute for a Government who can give the necessary lead on public health and provide the public health strategies and the ways in which to deliver them that are needed in the light of the current Government's failures on public health. We therefore criticise the Government but not the Health Protection Agency. We want it to deliver its functions more effectively in future.
§ Liz Blackman (Erewash) (Lab)
I shall be brief and use my time to ask a few practical questions about the nuts and bolts of the Health Protection Agency. It is generally agreed that the Bill is timely. It creates a more responsive body to deal with a climate of increasing threats and risks, which include: the escalation of known diseases such as TB, HIV/AIDS and sexually transmitted infections; the appearance of new diseases such as severe acute respiratory syndrome; and the threat of the release of pathogens—small pox, anthrax and chemical and radioactive agents.
A weighty responsibility to provide specialist support for health protection o the NHS and local authorities is placed on the body but a more co-ordinated response was needed to find a way forward. The Government's two-stage approach has been logical. They created a special health authority in England and Wales and subsequently moved to the UK-wide body that we are considering, thereby acknowledging the risks that the whole UK faces.
There is a rationale for the creation of such a body, which will provide wide expertise in a single framework and, most important, a single reference point. It should create a co-operative ethos. There will be cross-fertilisation of good ideas, scope for high standards across the board, the spread of best practice and an enhancement of the UK's international contribution through initiatives and surveillance.
1115 It is encouraging that work is already well under way through the special health authority, which focuses on improving skills, widening research, co-ordinating several training exercises, setting up nine regional and 36 local health protection teams, creating memorandums of understanding with the local primary care trusts and, as my hon. Friend the Under-Secretary said when she opened the debate, playing a vital part in combating the SARS epidemic. The modelling work that it contributed was especially valuable and the World Health Organisation complimented it on that.
The Bill creates a body that has a legislative basis for exercising health protection functions in every part of the UK. Working practices already reflect that, for example, in the unified HIV/AIDS surveillance programme throughout the UK. It also improves the body's flexibility to respond to future threats by allowing the agency to be directed to take on other powers, enabling future flexibility and allowing devolved Administrations to shape the use of the agency to fit their needs.
I read the Hansard report of the debate in the other place. I was surprised that the Opposition did not mention it because it was a lively debate on the way in which the agency will publish and be allowed to publish information and advice. Indeed, the hon. Member for South Cambridgeshire (Mr. Lansley) was right that the measure confers strong powers on the Health Protection Agency. That is encouraging and gives the agency a great deal of freedom and opportunity to publish what it likes when it likes. However, there is obviously a proviso that it does not contravene the Data Protection Act 1998 or publish information that is not in the public interest. It also has to publish an annual report, which, I hope, will be debated in the House.
What will make the agency maximise its effectiveness is not only sensible structures, but a high degree of cooperation from people, as well as their preparedness.
There was also a lively debate about primary care trusts, to which the hon. Member for South Cambridgeshire referred. It has to be said that there are concerns that PCTs receive 75 per cent. of the NHS budget and have an enormous range of responsibilities, but I do not go down the hon. Gentleman's road of saying, "Well, so they can't cope."
We know already that there are differently performing PCTs, and the key to ensuring that this measure works and that PCTs play their full part in relation to the agency is giving them support, but also ensuring that mechanisms are in place to support their capacity to respond to what the agency requires of them. Where will the facilities to monitor their performance and any necessary additional support be located? Will the Minister say something about that? Similarly, local authorities have an enormous role to play. How will their performance in this regard be monitored and their quality assured across the board?
Clause 5 says:In the exercise of its functions the Agency must co-operate with other bodies which exercise functions relating to health or any other matter in relation to which the Agency also exercises functions.I accept that it is not sensible to name the bodies in the Bill if that has never been practised, but it would be interesting to know the range of other bodies that we are 1116 thinking about that may have a relationship with the agency and how they are to be prepared to work with it as effectively as they can.
I want to flag up the issue of information exchange, which is vital if the agency is to work to its maximum. What protocols will be put in place to ensure that that goes smoothly? This was flagged up in another place by Earl Howe:If a local authority, in pursuit of its duty of co-operation, receives sensitive personal data of a medical nature, who in the authority, and indeed outside, should be entitled to read that information? How should it be stored? Suppose after a while there is no strict need to continue holding the data, because the matter has been dealt with, what should be done with the files? Should the local authority retain the data just in case, or should they be destroyed? All these questions arise as a matter of practice."—[Official Report, House of Lords, 29 April 2004; Vol. 660, c. 941.]So, it is important as we progress that these issues are clearly dealt with.
The other issue involving information exchange is information technology infrastructure. Will the Minister say a few words about where we are with that infrastructure, which will allow the speedy and accurate exchange of information between the agency and the various bodies that it will work with?
That is not meant as a criticism of the Bill, which I welcome. It is extremely encouraging that the special health authorities are making such progress already. I consider this an extremely positive move, but I would like the Minister to comment on the issues I have raised.
§ Mr. Paul Burstow (Sutton and Cheam) (LD)
I rise to give some support to the Bill, which should make progress through the House. It certainly has the support of the Liberal Democrats, just as it had in the other place, but with a number of caveats.
I wish to pose some questions.
It would be a mistake to see this Bill as simply a legal formality. It is more than that: as other Members have said, it is an opportunity to examine a key part of the nation's public health machinery, which should safeguard us not just from the microbiological, chemical and radiological threats that nature throws at us but from those that can be engineered by man, both for benign and malign purposes. As we have heard, the new agency has been up and running as a special health authority for a little more than a year—it has celebrated its first anniversary, which is something to be celebrated, given that some of the bodies that have been introduced by this Government do not reach a second year before they are abolished.
I want to pick up on several issues. First, on the arm's length review, about which there has been quite an exchange across the Dispatch Box, I think that I am clear on the Government's current position. On the potential effect of clause 2(1)(a), to which we can return in Committee, reference is made toprotection of the community (or any part of the community) against infectious disease and other dangers to health".1117 That is a broad remit. It could open up the agency to taking on functions to address other public health issues, perhaps in relation to lifestyle and preventable causes of disease. We might explore whether it was in the mind of the parliamentary draftsmen, who advise the Government on these matters, to give it that degree of flexibility for future innovation and development. From what we have heard from the Minister, however, it appears that that is not on the agenda at this stage. Having said that, given that we have heard that the public health White Paper will be delayed until the autumn, and given the publication in February of Derek Wanless's report identifying a number of gaps in the public health machinery in this country, especially in respect of health promotion, education and the essential capacity to evaluate public health measures, is the HPA likely to celebrate its second anniversary completely unchanged, with the status quo that it currently enjoys, or will the opportunity be taken—which, I think, should be taken—to give it a wider role in driving forward and developing a public health agenda in this country?
The hon. Member for South Cambridgeshire (Mr. Lansley) made an important point about the success in the 1980s of some of the public health promotion campaigns in relation to HIV/AIDS. To some extent, that capacity has been lost. Derek Wanless, in his report, identified the fact that in the process of combining and reorganising a number of public health functions, the health promotion and health education function seemed not to be assigned either to the HPA and its predecessor bodies or to the Health Development Agency. That is a great pity and a great gap in the Government's capacity to be able to move forward on a public health agenda. For that reason, I hope that the Minister can say whether that gap will be closed, first, by the declaration in the White Paper and, more importantly, by ministerial action to put in place the necessary organisations.
Mention was also made of the need to pick up on concerns about the explosion in sexually transmitted infections in this country. The hon. Member for South Cambridgeshire went through the litany of appalling statistics, which make shocking reading. Undoubtedly, the HPA, in its surveillance role, enables us to get a clear picture of the scale of the task that faces the country, the Government and us all. I have no doubt that there is a need for a national service framework in respect of sexual health, not just to deal with treatment issues—the deficits have been well rehearsed in the Health Committee's inquiry—but, more importantly, in terms of health promotion and the capacity to diagnose. That is an important part of the wider public health debate that we need.
My second concern is the need to ensure that the UK has a robust system of microbiological surveillance, capable of reacting quickly to and dealing with threats that might be perceived. I remain unconvinced of the wisdom of transferring most of the Public Health Laboratory Service's microbiological laboratories to NHS trusts, not least because of the formal submission of the PHLS board during the consultation phase last year, in which it expressed concern that the fragmentation of the service would lead to a loss of an efficient co-ordinated response to the detection and 1118 control of infectious diseases. Many around the world saw the PHLS network as setting a standard to which others aspired. The Centre for Disease Control and Prevention in the USA must rely on the fragmented network that we are now in the process of creating. It does not have a federal structure, with federal laboratories and capacity. It looked covetously at the arrangement that we had in this country, and, I understand, is seeking to emulate the structure from which we seem to be moving. It would be useful to examine in Committee whether we can be confident that the fragmentation of the system will give us the robust surveillance that we need.
From written answers, and from exchanges today, I understand that this place and the other place have been reassured that all this will be dealt with through a memorandum of understanding between the HPA, NHS trusts and so on. With primary care trusts and NHS Trusts confronted with so many "must dos" from Whitehall, where exactly does a memorandum of understanding fit into the hierarchy of standards, targets and tick boxes? It is not clear. Is it not just a gentleman's agreement between those organisations, which in reality has few teeth and little ability to gain traction when it comes to PCTs' commissioning decisions and the allocation of their limited resources? If the HPA does have cause for concern that a laboratory lacks sufficient staff or financial resources to be a satisfactory part of the surveillance network, what is the mechanism to call that in, examine it, and scrutinise it? I hope that the Minister will be able to rehearse precisely what would be done in that situation to safeguard the public interest and to make sure that we have a satisfactory surveillance system in place.
I understand that a possible part of the answer will be that the Healthcare Commission will take on the role of inspecting Microbiological laboratories and that a new inspector will be appointed for this purpose. Why do we need an inspector of a system that was once part of an organisation, but for which responsibility is now dished out among NHS trusts? Is that not just a regulatory solution to a problem caused by the Government's changes in this area? Would it not be better to have a unified surveillance network?
The concern is about not just fragmentation of surveillance but overstretch of public health professionals working in PCTs. Many of those staff, particularly directors of public health, are acting up to that position because there are vacancies. In some cases, they are doubling up, because there are not enough directors of public health medicine around the country to do the job. There are shortages, and there are vacancies to be filled. At the moment, many of those directors find themselves being deployed in crisis management mode, not in terms of fighting infection but in terms of helping PCTs to deliver the Government's must-do agenda. As a consequence, there is little time to engage with the HPA on such issues as surveillance, diagnosis and management and control of outbreaks of infection.
As has been mentioned, how will the duty to co-operate contained in the Bill work in practice? Who will initiate that duty? Who will co-ordinate it? Local authorities, for example, have emergency planning roles. Under the clauses dealing with a duty to co-operate, will they have a right and an ability to call in the 1119 expertise of other agencies to enable them to discharge their responsibilities? How will that fit together? The hon. Member for Erewash (Liz Blackman) mentioned data and information sharing, which also fits in. Just having a duty to co-operate, without adequate explanation from Ministers as to how it will operate in practice, seems an insufficient safeguard for the public at local level.
As has been said, the Bill has already been considered in the other place, and I am grateful to my noble Friend Lord Clement-Jones for his hard work on it.
That brings me to the third concern, which my noble Friend raised in the other place: the HPA's role in respect of zoonotic infections. During exchanges, the Minister, Lord Warner, confirmed that the HPA has the lead role on zoonosis in humans and has contributed to work across the world on things such as combating avian flu. However, the question that was not addressed at each stage of the Bill in the Lords—I hope that it will be tonight—is precisely where responsibility lies, and what role the HPA plays when an outbreak occurs in the animal population and there is a clear and perceived risk of transfer to humans. Who has overall responsibility? Is it the Department for Environment, Food and Rural Affairs, the HPA, or the Department of Health? Can it be made clear who has the lead responsibility in those circumstances? Perhaps the Minister will answer that question.
The HPA has the key job not just of surveillance but of controlling infections. I am thinking in particular of the vexed question of hospital or, as we are now required to call them, health-care acquired infections. It is interesting that we now call them health-care acquired infections, because the current surveillance enables us to know only about infections in the context of the hospital setting. We still have little information about the extent to which infections are picked up in ether care settings. I hope that Ministers can give us some information about what is intended further to strengthen the monitoring and surveillance systems to deal wish that.
Just last week, there were reports that deaths from MRSA—methicillin-resistant Staphylococcus aureus—infection could double within the next five years because the bacteria is becoming increasingly resistant to the antibiotic vancomycin. That resistance has been noticed in the United States of America and in Japan, but so far it has not been found to be prevalent in this country. However, scientists at the university of Bath, university of Bristol and Southmead hospital say that all five major types of MRSA, including those seen in the UK, are now beginning to show signs of resistance to vancomycin. At this point, there are treatments that still work, but the concern is that time will be lost because of a trial-and-error process to find the right combination of antibiotics. At this stage, the HPA tells us that it has not found a VRSA problem in this country, but clearly it is becoming an issue for us.
Clearly, efforts to instil and to reinforce a culture of zero tolerance of poor hygiene practice need to be redoubled. MRSA and other infections are not a fact of life with which we should attempt to reach an accommodation. To reach an accommodation with those infections is to accept that we will not be able to defeat them.
1120 When I asked the Under-Secretary of State for Health, the hon. Member for South Thanet (Dr. Ladyman), a question about research to develop new antibiotics to enable us to deal with concerns about the greater resistance to antibiotics of a number of infections, he said:I am not aware of any, but the problem is of great concern to the Government and to the pharmaceutical industry. As someone who used to work in the pharmaceutical industry and whose pension is in part in its hands, I can assure him that I, more than anyone, would like to see new classes emerging. However, as far as I am aware, they do not exist and that is an issue for us to address."—[Official Report, Westminster Hall, 13 January 2004; Vol. 416, c. 237WH.]That was a perfectly legitimate response. It was helpful. The question is: how are the Government addressing that? I raise that in the context of the recent publicity surrounding the HPA's proposals to develop a vaccine development facility at Porton Down. I ask the Government whether they could outline tonight what they plan to do. Do they plan to have partnership arrangements with the pharmaceutical industry, to implore that industry to act, or to take direct action themselves of one sort or another—to ensure that there is a pipeline of antibiotics, so that we do not eventually reach a day when no antibiotic can stop those infections?
One tool in the fight against infections is the use of isolation rooms. The Government will tell us that there is already guidance about the provision of such rooms. When I asked Ministers written questions about that to find out how the Government are satisfying themselves that that guidance is being followed through in practice, I was told that they had no plans to monitor compliance with the guidance.
That is a cause for concern of itself but, when one asks whether guidance more generally to do with hygiene practice in hospitals is being monitored and audited systematically, we are told that it will be part of the work load of the Commission for Health Improvement but that there will not be a published national audit of the work that is done to ensure that there is compliance with those standards. Surely the public deserve to be able to satisfy themselves that their local hospital complies fully with those guidelines. How can Ministers satisfy themselves that those guidelines are being properly and sensibly adhered to locally? At the moment, there is no mechanism to enable them to do that.
When I undertook a survey of health trusts just a couple of years ago, the Department of Health sent an e-mail suggesting that it would be far better not to answer my questionnaire but to direct me to the guidelines that were issued by the Department, rather than tell me what it was doing on the ground. It is a cause for concern that the Department did not seem to think that it would be a good idea for a Member of Parliament to find out whether guidelines were being followed and whether infection-control measures were being taken. Indeed, I was told in written answers that it would be disproportionately costly for the Department to collect that information.
It seems that the Government's answer on isolation rooms is, "They will arrive by happenstance. They will arrive as a consequence of modernisation programmes in individual hospitals and new-build programmes but there will not be a concerted effort to ensure that they 1121 happen systematically." We heard just last week that, in a new hospital in Norfolk, the necessary air conditioning arrangements to ensure that the isolation rooms did not contaminate the rest of the hospital were not made. As a consequence, the rooms were allowing infection to spread around the hospital.
§ The Parliamentary Under-Secretary of State for Health (Dr. Stephen Ladyman)
May I put the record straight, because there has been misinformation on that subject? Those positive pressure rooms were never used for the purpose intended. The problem was discovered before they were ever used. There was never any risk and there was never any infection spread through the hospital.
§ Mr. Burstow
That is a good answer to a point but it raises concerns that those rooms were not used for their intended purpose because they were never fit for that purpose. The NHS is still not systematically providing the isolation rooms that are needed. What we hear in the Minister's reply is that we have a hospital that has purpose-built rooms that are not fit for the purpose and therefore cannot be used. I am grateful for the clarification but it does not come as a complete comfort.
In 2000, in response to a National Audit Office report, the Government decided rightly to introduce a mandatory reporting system for MRSA. That was a welcome step. It revealed how big a problem it is. Since then, Ministers have rightly said that they intend to expand that surveillance system to capture information about other types of organism that cause illness and problems in hospitals. Again, it is unclear from all the written answers I have seen and from other exchanges on the matter in the past year what the timetable is for the roll-out of those other infection-surveillance systems. It would be helpful if that could be set out in detail today, in Committee or, more probably, in answer to a written question, so that we are clear.
The hon. Member for South Cambridgeshire mentioned the patient environment action teams and the traffic light system that is used to give the public what I would call false comfort when it comes to issues of cleanliness in our hospitals. The truth is that the whole initiative should be prosecuted under the Trade Descriptions Act 1972. It does not address the key concerns about hygiene in our hospitals, yet it gives people the impression that it does. Even today, there are still occasions when it is cited as a measure in the Government's fight against infection in our hospitals. It is nothing of the sort. It is a useful programme in what it does, but it is not part of the fight against infection.
The Bill puts in place the agency. It defines its powers and its relationship with the Department of Health, but some public health experts and academics have expressed the view that the laws governing public health need to be updated to deal with issues such as SARS.
It would be useful if the Minister could give us some indication of the Government's thinking about whether there will be such a fundamental review in legislation, and if so, when we can expect to see that legislation.
IT has been mentioned already, and I want to seek further clarification. The NHS has embarked on a massive IT procurement programme spanning several 1122 years. Good IT and communications will be important in making the surveillance network work effectively, but it is not at all clear Precisely where the HPA fits into the NHS procurement timetable. Can the Minister tell us?
The Bill will put in place an important part of the public health infrastructure, but it deals only with the control of infectious disease, which is a significant part of the public health agenda but by no means the whole picture. That agenda also needs to address preventable disease, which often results from lifestyle in terms of sexual health issues smoking, obesity and so on.
The Wanless report earlier this year painted the sorry picture of a history of stop-start—boom and bust, we could call it—in public health: reports were commissioned, but then gathered dust for years; reports were published and targets were set, but were never achieved. Under both the present Government and previous Governments, public health has been poorly served. The Bill is a useful measure, but a lot more will be needed in the White Paper if there is to be real progress in public health and a real improvement in the health of the nation
§ Mr. Adrian Bailey (West Bromwich, West) (Lab/Co-op)
I welcome the Bill. I realise that as the attention of the nation is focused on events in Portugal, or perhaps on Wimbledon, it may not loom large on the public's radar, but although it is small it is important, and could have a profound effect on everybody in the country.
The Bill is a logical progression in the organisation of the special health authority, and builds on the good work of that body over the past year. It is part of our civil contingencies strategy. In introducing the Bill, the Minister outlined the different bodies that will comprise the Health Protection Agency, and I shall not repeat all their names, but the essential thing is that they are all highly respected for their work over the years. They have expertise and they have carried out research, but they have all developed independently. Combining them into a single body will enable them to share good ideas and best practice.
The need for that to be done was highlighted by what the Minister said about potential terrorist attacks. When such an incident occurs, it may not be immediately obvious which body is best equipped to respond. Perhaps more than one body should be involved—perhaps all of them. It is therefore logical to combine them in one Health Protection Agency, not only to speed the response, but to develop over time a culture of partnership working to maximise their effectiveness.
I welcome the Bill because it also goes far beyond emergency response The agency will be an essential element in the strategic planning of health care. The specialist support for the rest of the NHS in terms of health protection will be better delivered by one body than by fragmented sources.
The NHS is delivering an excellent and improving service to millions, day in, day out. None the less, its role is essentially reactive and patient-driven. In responding to the health needs of millions, it is acquiring information and data that could be immeasurably useful in identifying health trends and shaping public 1123 health policy. By collecting those data, analysing and interpreting them, the HPA will be able to identify gaps in health provision and shortfalls in capacity.
As a national non-departmental organisation, the HPA will be able to assist the development of public health policy. It will be able to inform the debate on lifestyle choices, improving health and other areas of Government policy, so that others too, can play their part in promoting public health. The agency will have the opportunity to develop authority on health policy, which Governments will ignore at their peril. Previous speakers have mentioned the debate in the other place about the independence of the reporting, and I welcome that too.
When Governments make recommendations on lifestyle and health policy, they are sometimes publicly vilified as promoting a nanny state. I believe that the work of the agency and its recommendations will provide an authority that will re Rice the chance of future Government health policy being depicted in such a negative way. The agency will have independence and authority, and therefore credibility. which will assist the Government in promoting health policies that will benefit everybody.
In the essential successful working of the HPA, I regard partnership as the key theme. The quality and expertise of the agency is unquestioned, but it is not a big organisation, and it cannot transform public health policy on its own. The way in which it works with Government and with other local and international health agencies will determine how successful it is.
I welcome the setting up of the nine regional and 36 local health protection teams, but in the other place Lord Warner commented that there had beenearlier difficulties with some PCTs"—[Official Report, House of Lords, 5 January 2004; Vol. 656, c. 15.]I hope that the memorandum of understanding that governs the relationship between the HPA and the primary care trusts will resolve those difficulties. My hon. Friend the Member for Erewash (Liz Blackman) defined the issues that need to be clarified, and effective working between the HPA and the PCTs is essential if the agency is to realise its full potential.
The public health challenges that face the Government, such as hospital-acquired infections, TB, and above all, sexually transmitted diseases, have already been mentioned. I shall not repeat the statistics that have been cited in the Chamber already, but it is important that the HPA, in its surveillance role, should be able to provide backing for the other Government organisations, designed to construct a strategy to combat and eliminate those problems.
There are issues yet to be resolved about precisely what the role of the HPA, as opposed to that of the local health organisations, will be. I am concerned that if we do not achieve early success in that regard, that role may be questioned, as a result not of tie agency's problems or incompetence, but of failure in other areas of policy delivery.
That would be regrettable, and I ask the Government to look at those problems and ensure that the HPA's work is effectively translated into action on the ground to deal with them.
1124 Little has been said on partnership working internationally, so I shall touch on that. The report by the chief medical officer Sir Liam Donaldson, "Getting Ahead of the Curve", highlighted different threats to world health. It would seem that as soon as we eliminate one health hazard, another potentially more deadly one appears. Among the reasons that have been cited for that are global trade, migration, animal diseases and environmental changes. Those are in addition to the man-made risks, whether industrial risks or terrorist activity.
Even Sir Liam Donaldson cannot have realised when he made his report in January 2002 how prophetic his utterances were to be. In a short time, we had the outbreak of the SARS epidemic, a truly international health threat arising from the very factors that he had outlined. My understanding is that the HPA played a vital role in the World Health Organisation's work to combat SARS, and it has subsequently signed a memorandum of understanding with a new health protection agency in Hong Kong specifically targeted at research, training and emergency planning relating to diseases originating in the far east. I see that as a most important development, and a potential health prototype that should be introduced in other areas. Will the Minister consider the possibility of setting up similar organisations to cover other parts of the world? The most obvious is Africa, where a range of infectious diseases run rife, to the detriment of the health of millions of people on that continent and with serious potential implications for people on other continents.
Britain has huge expertise in the bodies that comprise the HPA. By bringing those bodies together, the Bill will improve communication, assist policy development and enable collective expertise to be targeted more effectively. It provides a model that could be developed by and with other countries, which could have a profound impact on public health throughout the world. I therefore welcome the Bill and support its Second Reading.
§ Mr. Peter Lilley (Hitchin and Harpenden) (Con)
I had intended to follow the excellent example of my hon. Friend the Member for South Cambridgeshire (Mr. Lansley) and focus exclusively on the health policy aspects that the Bill raises, rather than on the bureaucratic reshuffle on which the Under-Secretary of State for Health, the hon. Member for Welwyn Hatfield (Miss Johnson) focused and on which the hon. Member for Erewash (Liz Blackman), who has temporarily left the Chamber, made a thoughtful contribution. However, in view of the Minister's failure to answer my question on the powers that this body is being given, I feel it necessary to return to that issue.
The Bill gives as the main functions of the new bodythe protection of the community… against infectious diseaseandthe prevention of the spread of infectious disease".1125 That is fine; we all support those objectives. However, the Bill goes on to give the agency apparently unlimited powers to achieve those objectives. It says:The Agency may do anything which it thinks is—I find that surprisingly open-ended. The Minister, who appeared to be rather unfamiliar with that provision, said that it was intended to enable the body to be independent of the Government, but as my hon. Friend the Member for Buckingham (Mr. Bercow) said, a body does not have to be omnipotent in order to be independent. Clearly, that provision has nothing to do with restraining interference from Ministers.
the exercise of its functions.
- (a) appropriate for facilitating, or
- (b) incidental or conducive to,
I would therefore like the Under-Secretary of State for Health, the hon. Member for South Thanet (Dr. Ladyman), when he winds up, to tell the House what powers the agency will actually have. Will it, in its attempts to fulfil its function of preventing the spread of disease, have the power to detain people suspected of being infected? Will it have the power to distrain property thought to be carrying infection? Will it have the power to levy charges or impose fines on those who interfere with its attempts to restrict the spread of infection? Those are important issues. There could be arguments for giving a body such powers, but it would be unusual for the House to give them away without any restraint at all. without specifying in the Bill the circumstances in which they could be used and without any recognition by Ministers that such draconian powers were being conferred on a Government agency, albeit one acting at arm's length from the Government.
§ Dr. Julian Lewis
My right hon. Friend has been in the House much longer than I have. In his long experience, has he ever come across a Bill that has given such an open-ended mandate to an agency in that fashion?
§ Mr. Lilley
My hon. Friend makes a good point. I have cast my mind back to see if I can remember such a case, but I cannot. That might be—I have some sympathy with the Minister on this—because when one is dealing with a long Bill, one often approaches the Dispatch Box with some trepidation that one might be asked the meaning of one of the obscure and complicated clauses. One therefore tries to focus on what those clauses mean and perhaps misses the more obvious clauses at the beginning, so I may have missed such clauses in other Bills. However, I am not aware of this Bill having any precedent. I hope that the Minister will tell the House why this provision is included in such an unrestrained and draconian fashion.
I really want to focus on the main issue raised by the Bill, which is the prevention of the spread of infections and in particular, the control of hospital-acquired infections—an issue of growing importance to the public, although the Under-Secretary did not mention it in her speech, nor does the publicity material on the Bill issued by the Government. That is a hugely important issue, so it is extraordinary that the relationship between this body and that problem was not discussed at the Dispatch Box.
1126 We know that nearly one in 10 patients who enter hospital acquire an infection there that they did not have beforehand. We know from the National Audit Office that an estimated 5,000 people at least die every year from superbug infections acquired in hospitals and that up to 20,000 may lose their lives through some involvement of superbugs in complicating other factors. We know from the European Union that the problem is more prevalent in British hospitals than in those of anywhere else in the European Union with the possible exception of Greece We know, too, that the problem is getting worse more rapidly in this country than anywhere else in Europe. We should like to know what role the Health Protection Agency will play in tackling that important problem.
That is an important aspect of health to which the Government's main approach does not appear to be relevant. The Government's main approach is that all health problems can be solved by having billions of pounds rolled at them in the hope that they will eventually be tackled. However, if we succeeded in tackling the problem of hospital-acquired infections, far from needing extra resources, we would save many lives, and release vast resources for the treatment of other illnesses or to save the Exchequer money.
It is extraordinary how little attention has been paid to that issue until recently. When I compare the uproar at the five people killed in the railway accident at Hatfield near my constituency—every one of whose loss of life was a personal tragedy—to the reaction to the fact that an estimated 5,000 people a year die as I have described in our hospitals, I cannot help but think that the treatment given to the matter by Government, politicians and, until recently, the media, has been disproportionate.
When one thinks of the disparity between the Government's pursuit of what turned out to be illusory threats of biological warfare in the middle east and the actual biological warfare being fought and, it would seem, lost in our hospital wards through dirty and unwashed hands, one cannot help feeling that there is a disproportionate failure to recognise the seriousness of the problem.
§ Dr. Julian Lewis
My right hon. Friend is most generous in giving way. One is tempted to comment on the paradox that he just raised by recalling the statement once made about a small number of deaths being a tragedy and a large cumber of deaths being a statistic. My right hon. Friend rightly points to basic failures such as not washing hands as being responsible for some deadly infections. Why, then, should we need a Health Protection Agency to put something right, when we all know what is wrong?
§ Mr. Lilley
My hon. Friend makes another very good point. I hope that we do all know what is wrong, and I intend to investigate further the causes of this problem.
I became interested in the subject partly as a result of cases that I encountered in my own "surgery", as we tend to call our advice bureaux in our constituencies. Over the years, I have met people who lost relatives as a result of infections acquired in the course of hospital operations or who themselves had acquired the infection and been maimed permanently by it. I was subconsciously aware that there was an issue there.
1127 Some years ago, I wrote a paper about the health service entitled "Patient Power". While I was working on it, I discovered the National Audit Office estimates of the scale of the problem. I campaigned for the publication of information authority-by-authority, hospital-by-hospital, on these sorts of problems, so that patients would have the power to take informed decisions on the basis of that information. It was as a result of the subsequent publication of such information that I learned that the trusts in my own constituency had very poor records at that time and were near the bottom of the national league table. Indeed, one was virtually at the bottom. I am happy to say that both those trusts now take this issue seriously and that both have improved their ranking markedly—they are now close to the national average.
A little while ago, I had a meeting with the infection control directorate at the East and North Hertfordshire NHS trust, and a lengthy briefing from the clinical standards officer at the West Hertfordshire trust. I am glad that this issue is now being given priority locally: I would like to see it given an even higher priority at the national level and I hope that the HPA will play its role in that.
We have to ask ourselves why, given the manifest dedication of most people who work in the NHS, to whom I pay tribute, does this problem exist, and why have we as a nation been so slow to face up to it? Part of the answer to the latter question lies in the fact that, as a former health Minister said, the NHS has become part of our national religion. As a result, we are reluctant to think that anything can go wrong within it. We do not want to accept or face up to the fact that it can be a place where illnesses are caused and acquired as well as cured and treated, but we must accept it. Moreover, the Government must face up to it. I am afraid that some people in government are still in denial about the problem and believe that it can simply be spun away or ignored, but it cannot and it must not.
I shall not develop at great length—at least, not at this stage—the disgraceful episode that occurred last autumn. The Government issued a statement to try to pretend that they were doing something about the problem, but when asked to bring the statement before the House, they admitted that they were doing nothing new at all. That was symptomatic of the their attempts to deny the problem. The Minister's failure even to mention it today in the context of the Bill suggests that some in government are still in denial about the seriousness of the problem.
§ Dr. Lewis
Does my right hon. Friend feel that one of the reasons why less attention is given to MRSA infection in hospitals than it should is that the people most affected by it are elderly patients? If it carried off larger numbers of younger people, perhaps there would be a stronger lobby. Is it not a disgrace that our elderly people are coming to think of host hospitals as places where, if they enter, they may not come out alive?
§ Mr. Lilley
My hon. Friend's critique is valid. It is true that less attention is paid to the problem than would be paid to it if the majority of the victims were not elderly. However, let us not conceal the fact that people in the prime of life are affected, too, including an increasing number of children. All ages will be at risk if we do not tackle the problem vigorously.
1128 Why is the position getting worse—and getting worse faster—in this country than in most of our continental neighbours' countries? A number of explanations have been put forward. When I last spoke about the problem, Government Members suggested that it was due to the privatisation of the cleaning services in hospitals. On this issue, none of us should take refuge in defensive or doctrinal attitudes about what happened in the past. We should not be making partisan points. If the problem did result from the privatisation of the cleaning services, it should be changed. I would fully support that. I want to save lives, not impose a particular doctrinal arrangement on the organisation of the health service. Let us be clear: is this a serious charge? If it is, why have the Government done nothing to alter those arrangements and to bring back the cleaning services in house? Clearly, the Government do not believe that that is the cause of the problem.
§ David Taylor (North-West Leicestershire) (Lab/Coop)
The right hon. Gentleman may be indirectly referring to me, as I sometimes raise that very issue—though not in the arbitrary terms that he suggests. Does he accept that the outsourcing of hospital cleaning can contribute to or worsen problems that already exist on the wards, even though the root cause of the problem may be a lack of adequate hand washing in the wards and elsewhere?
§ Mr. Lilley
If I accepted that, I would want to do something about it and change it. I am sure that the hon. Gentleman, who is sincere and dedicated, would want to, too. Sometimes, however, I believe that others make the point for purely partisan political purposes. If the Government believed that analysis, they would surely want to change it. They do not believe it. Why not? I suspect that it is because it is not true.
Some colleagues went with the BBC to Germany to investigate the same problem in German hospitals, which were pristine and sparkling clean, as one would expect, and run with Teutonic efficiency. The BBC journalist said that he imagined the Germans had such clean hospitals because they did not privatise their cleaning services, but the German doctors responded by saying, "Of course we do". They wanted expert, specialist people to clean their hospitals; they did not want the job to be left to people such as themselves who were not experts in the matter. The BBC journalist told the German doctors that it was a problem in our country and had led to poor standards, but they responded by saying that if the cleaning companies did not get it right, why did we not change the supplier or the cleaner? One thing that our present system does allow is changing the cleaner to secure a better one. Would it not be best to do that, rather than change the system?
I visited a BUPA hospital and asked the same question. That hospital was also sparkling clean and infection free. I asked how that had been achieved and whether the hospital did all its cleaning in house. I was told that outside cleaners were used, but that the contract was managed properly. The hospital authorities insisted that the contractors had named cleaners responsible for each ward and the responsibilities were more than just for cleaning. They included changing the light bulbs, ensuring the supply of loo paper and so forth. That brought pride of ownership.
1129 It may be that the structure of the NHS does not allow NHS managers to manage their contracts properly. We should consider whether medical staff should have a greater say in handling such contracts and ensuring that contractors meet the highest possible standards of cleanliness.
The NHS may be too centralised. Indeed, I asked the BUPA manager why he could do what NHS managers seemed unable to do. He said that he had been an NHS manager and the problem was that the NHS was so centralised that all initiative was stifled and it was difficult to introduce the sort of changes that he had made in his smaller hospital. The NHS may have problems that we should tackle, but we should not do so on a partisan, doctrinal or point-scoring basis. We need to get it right and save lives.
Lack of ward cleanliness is not the prime cause of hospital-acquired infections or superbugs. It is essential that wards should be clean, although the impact on infection is probably secondary. However, standards of cleanliness influence the whole climate of a hospital. If one works in a clean, sparkling, bright and fresh environment, where every part of the hospital is clean—the loos and the entrances, as well as the wards; under the beds as well as beside them—one is more likely to be meticulous about observing the protocols for cleaning one's hands.
The failure to wash hands between contacts with patients is the main way in which infections are transmitted in hospitals. The National Patient Safety Agency says that the hand-cleaning protocols are observed only 40 per cent. of the time in hospitals. That is a serious matter. Why should it happen? One explanation, which first appeared in a newspaper article and was republished in a pamphlet, is that the hospital authorities—matrons and other staff—do not have the power to discipline and insist that staff adhere to the protocols. The author, Harriet Sergeant, carried out research in hospitals and described one occasion in particular. She wrote that the matron
had shown me the apron and glove dispenser at the entrance of a side room containing an MRSA patient. Every nurse, she said, had to don a disposable apron and gloves before touching the patient, then remove them before leaving.As we chatted, I noticed a nurse walk in, see to the patient, then depart. She had not touched the dispenser. This was done in front of the matron and the infection control manager. Neither appeared to notice. In astonishment, I interrupted the two women. Had I misunderstood? It appeared not.The article goes on to say that the matrontut-tutted. 'You've got to have eyes in the back of your head with these girls,' she said. The infection control manager nodded sympathetically—'Doctors are far worse'," she added. There was clearly no question of a reprimand for the nurse.The high levels of hospital-acquired infection are an indictment of NHS management, who have failed at every level to exert authority and pull together the groups involved for the benefit of the patient.I do not suggest that that story is typical, but it was told by someone who spent much time researching the issue. Ministers should say whether they are satisfied that matrons and others in authority in hospitals have the power to insist that staff follow protocols properly. If Ministers are not satisfied, they should produce proposals to reinforce and enhance the authority of those in charge.
1130 We should have every sympathy with the nursing and other medical staff involved, because the protocols put considerable demands on them. According to the NPSA, if nurses washed their hands with soap and water, they would have to spend 56 minutes—nearly an hour—of every eight-hour shift washing their hands to meet the requirements of the NICE protocols. If they use alcohol-based rubs, the time is drastically reduced to 18 minutes, but that is still quite a long time. A nurse may have to wash her hands up to 40 times in an hour.
Considerable demands are made on nursing staff and we should investigate, whether that could be improved by introducing new Products. Since taking an interest in this subject, I have been contacted by several companies that claim to have new products that would disinfect hands better, without chapping them or requiring such frequent application. They say that their products are wonderful and would meet all requirements. I am not here to act on behalf of any pharmaceutical company, but they claim that because the protocols are laid down centrally by NICE, new products, such as those that do not contain alcohol—the protocols specify that hand cleansing must be done either with soap and water or with products that include alcohol—are precluded from consideration, even though they might be gentler on hands and not require such frequent application. The agency should investigate those alternatives and encourage the development of new procedures and innovatory products. That could make it easier for staff to meet the requirements and prevent the transmission of disease from one patient to another.
Since I took up this issue, people email me and share their expertise. A former consultant microbiologist in an NHS hospital sent me an article he had written for the British Medical Journal. It said:We have managed to keep MRSA out of our rehabilitation unit by a combination of pre-screening, rigorous hygiene and vigorous treatment. Any patients referred from the acute hospital wards require two clear sets of swabs—and if we find (for they are all swabbed on arrival) that they are MRSA positive then they are isolated and treated until clear.The email also states thatwe have been put under pressure to relax our criteria because they delay transfers. It has been argued that our policy is out of step with the rest of the hospital; but then so is our infection rate. One patient of ours appeared to acquire the organism on the unit twice, each time after the visit of a surgical team.My correspondent also says:With the imposition of targets, for instance the target to move people out of casualty departments within a set time, infected patients may get moved from ward to ward, thus exposing new staff and patients to the organism.That is a third explanation: targets are getting in the way of the application of the protocols and causing patients to be put at risk and shuffled around hospitals, which—as the Government's chief medical officer admits—is one of the causes of the spread of the disease in hospitals.
Someone else wrote to me claiming that lack of research is the problem. He pointed out that in many other countries, research has been done and use made of bacteriophages, which eat viruses. He said that there is scope for research in that area, which might develop methods of tackling the problem that do not involve the use of antibiotics. Again, the agency could—and in my view should—do work in that area.
1131 It is also open to question whether we use antibiotics correctly. I do not just mean whether we use them too profusely, which is often suggested to be the problem. The Academy for Infection Management has been arguing that the delayed use of antibiotics, while waiting for laboratory tests on a particular infection, allows infections to take hold and spread; and that it would be better to use early after the discovery of an infection a broad spectrum antibiotic against the likely range of causative pathogens, especially the sort of agents that do not seem to give rise to resistance to those problems. The seven-year study known as MYSTIC—meropenem yearly susceptibility test information collection—suggests that drugs based on meropenem can do that and that, if used, would cut down the spread of those diseases and vastly reduce the need for people to go into intensive care units.
Thus there are things that could be done. It is sad that, in the context of the Bill, the Government do not mention the problem that I have of outlined. It is sad that they seem reluctant to look creatively at what can be done and that, when faced with the problem, they simply regurgitate existing measures, pretending that they are new but admitting on subsequent questioning that they are not. It is sad that they are still in denial about the scale and seriousness of the problem.
My overall conclusion is that if we are to tackle the problem, we must bring the Florence Nightingale culture back to our hospital wards, so that at every level people realise the importance of preventing such infections from taking hold and spreading. We must use every kind of imaginative development to ensure that the process is made easier for the medical staff who, in other respects, serve us so well in our hospitals.
§ David Taylor (North-West Leicestershire) (Lab/Co-op)
Like previous speakers, I welcome the Bill, which will clarify and codify the responsibilities of the HPA, with immense benefit for the population of our country.
The contribution of the right hon. Member for Hitchin and Harpenden (Mr. Lilley) was very interesting, although I do not intend to speak at such length. First, I want to focus briefly on the specific duties of the agency in connection with radiological protection. I want to cite a constituency case that has been going on for some years, and I hope that the Under-Secretary of State for Health, my hon. Friend the Member for South Thanet (Dr. Ladyman), can give me some good news about that problem. Secondly, I want to examine the bodies with which the HPA must co-operate and from which it must accept direction. One such Government agency—the Environment Agency—appears to be delinquent and tardy in its response to a radiological problem.
The Bill makes it clear that the HPA will absorb the National Radiological Protection Board and its prime functions, which, as set out in the helpful research paper, arethe acquisition of knowledge about the protection of mankind from radiation hazards… to provide it formation and advice to persons (including Government departments)it is to that point that I direct the Minister's attention—in relation to protection from radiation hazards either of the community as a whole or of particular sections of the community".1132 The latter point relates to my constituency case. Will the Minister expand a little on how the agency will carry out that role, which was previously the responsibility of the NRPB?
Clause 3 (4) states:If a Health and Safety body asks the Agency to enter into an agreement with the body for the Agency to carry out any of the body's functions relating to radiation… on the body's behalf, the appropriate authority may direct the Agency to do so.Can the Minister tell me whether, in certain circumstances, the Environment Agency is considered a health and safety body? Can the Bill, when an Act, be used by my constituent to try to encourage the Environment Agency to act more effectively than it has been able to do so far?
Clause 5(1) states:In the exercise of its functions the Agency must co-operate with other bodies which exercise functions relating to health or any otherrelated matter. Subsection (2) notes that a bodyother than the Agency mentionedhas a duty to co-operate with the agency. There is a mutual duty to co-operate, so can the Minister tell me whether the Environment Agency would be classified as a relevant body for the purposes of that clause?
I shall give a little detail about the case I mentioned. It relates to the disposal of radium sources and comes under the Radioactive Substances Act 1993. I shall not go through the whole nine years of the case so far, but will highlight the problems for my constituent's firm, although the firm itself is not in North-West Leicestershire. My constituent states that, in 1995,what is now the Environment Agencyissued an edict requiringall Lightning Protection systems incorporating devices containing radioactive materials to have the devices removed, dismantled and disposed of by the year 2000".That was mostly complied with, but many devices were removed only after the deadline and some remain. Will the HPA have an advisory role about those residual lightning protection systems, especially when installed in locations such as school premises?
In good faith, my constituent's firm continued to strip out those devices containing radioactive materials for some time but found that it was unable to dispose of the material satisfactorily. With the encouragement of the Environment Agency, the firm had taken into storage radium foils from premises and from competitor companies in the expectation and belief that there would be an ongoing route for disposal. However, four years after the deadline, the Environment Agency has not been able to provide my constituent's firm with such a disposal route, so it is storing radiological waste at its south Nottinghamshire headquarters that at some stage may prove a hazard to the people who currently work in the building, to future occupants of the building or even to people who may break into it—there have been thefts of equipment from the offices.
The firm asks:What are we supposed to do with this waste? What happens if our small company gets into difficulty leading to closure or… our offices are broken into? It strikes us that someone needs to take responsibility for sorting this out and not leave just our waste but presumably other radium source waste stored in small relatively unsecured pockets around the UK.1133 When the HPA takes over the duties of the NRPB, will it have that responsibility?
The firm notes:Currently we hold many hundred sources of Radium 226 totalling an equivalent of 976 Mega bequerels.
I conclude by summarising my questions for the Minister. Is the Environment Agency a health and safety body for the purposes of the Bill? Does it have a mutual duty of co-operating with the HPA and would it, therefore, have an interest in the case that I briefly set out? I should have liked to set it out at greater length in an Adjournment debate, but although I have been trying for several weeks I have been unable to obtain one. What advice can the Minister give me to pass on to my constituent and his firm? As the years roll by, they are getting extremely concerned about the possible health hazards of the material that they stored in good faith, at the behest of the Environment Agency, which has neglected its duty to offer the means for the safe and satisfactory disposal of those materials. I shall listen very carefully indeed to the Minister's reply.
§ 7 pm
§ Dr. Julian Lewis (New Forest, East) (Con)
The House owes a debt of gratitude to all those hon. Members who have spoken following the initial brittle, unfleshed skeleton that the Minister outlined at the outset, for trying to add some substance to the debate. When one looks at the Bill's fine print, one sometimes forms an impression that it is designed largely to try to get round some of the self-inflicted problems brought about by the way in which devolution impedes the carrying out of the functions of the existing agencies, rather than introducing any major or substantive change to the way that the problems that the agencies are supposed to address will be addressed.
It was a pleasure to listen to my right hon. Friend the Member for Hitchin and Harpenden (Mr. Lilley) renewing his gallant campaign on behalf of the victims of MRSA. I find it quite incredible that, in the 21st century, it is necessary for a politician of his seniority to have to plead with those who work in the health services to adopt the measures of basic hygiene, basic cleanliness and basic common sense that Florence Nightingale pioneered more than 150 years ago. It is quite deplorable that so many hon. Members find that our constituents tell us terrible tales of relatives—often elderly folk, as I said in an intervention—who go into hospital for one ailment and then contract an infection that, all too often, proves fatal.
My hon. Friend the shadow Secretary of State for Health outlined the case for considering topics such as MRSA, HIV, TB and hepatitis C in the context of the Bill. He was right to do so, but the dimension that I wish to address is that which concerns the defence aspect, for which I have some responsibility on the Conservative Front Bench. The Bill has been portrayed as establishing an agency that will fulfil a valuable role if this country is subjected to chemical, biological or radiological assault. That needs further clarification because the sort of measures that are necessary to deal with those types of threat are very different.
A chemical attack, if carried out, has a very quick effect. That was well seen in the sarin attack on the Japanese subway. A biological attack, by contrast, if 1134 carried out against animals, may make itself apparent somewhat more slowly, and if carried out against humans, much more slowly still. A radiological attack can be very slow indeed in making its effects apparent. So entirely different types of plan must be ready to deal with those emergencies if they come to pass. The threat and the attack need to be contained. If the attack involves one of the longer-lasting or slower agents to act, it needs to be traced and then treated. The Bill does not make it clear who will actually do that work.
The research paper on the Bill prepared by the Library points out that the existing agency had already been involved in some exercises. I quote from the briefing material:Two exercises based on the release of smallpox have already been conducted to assess the effectiveness of the major incident plans. More recently a field exercise based on the deliberate release of sarin, involving more than 200 volunteer casualties, was conducted in Newcastle. The exercise also included a desktop training exercise, where members of the health and emergency services planned a response to additional major emergency incidents.It quotes Dr. Nigel Lightfoot, director of the emergency response division at the Health Protection Agency, as saying:We are very pleased with the way in which the day has gone. The procedures involved in the field exercise went so well that we finished an hour ahead of schedule.I felt on reading those words that there was something terribly British about all this and something terribly amateurish. I am concerned that, in focusing on the structures of the agencies to the extent that the Government have, they are taking their eye off the central question of how the agencies will relate to the people on the ground who must cater with a disaster if one were to occur.
When the issue was raised in Committee in the other place on 3 March, Earl Howe said:The first question that we must ask is how the provisions of the Civil Contingencies Bill interrelate with those in this Bill. The Health Protection Agency will have a major role to play in many types of civil emergency, yet the most that is hinted at in the Bill is that it will be obliged to,'co-operate with other bodies… which exercise functions relating to health or any other matter in relation to which the Agency also exercises functions'."—[Official Report, House of Lords, 3 March 2004; Vol. 658, c. GC 287.]But what are those bodies with which co-operation must take place?
My hon. Friend the Member for Newark (Patrick Mercer) was involved in his responsibilities of shadow Minister for homeland defence—even though we do not have a Minister for homeland defence, despite the fact that we should—in taking the Civil Contingencies Bill through Committee. In doing so, on 29 January, he made a point about the civil contingencies reaction force—the volunteers on whom so much will depend if an attack is mounted and to whom my hon. Friend the Member for Rayleigh (Mr. Francois) alluded in an intervention. My hon Friend the Member for Newark said:It is no coincidence that the CCRF has found itself extremely stretched in terms of declaring itself operationally ready. Just before the Bill's Second Reading—strange to relate—the Government said that the force was ready. However, the facts are rather less than the theory."—[Official Report, Standing Committee F, 29 January 2004; c. 89.]1135 My hon. Friend went on to point out that, of the 7,000 CCRF volunteers who are supposed to be under arms, only 5,000 are physically accredited as part of the organisation. He then went on to make an extremely important point that further cuts that total: the sort of people who volunteer to undertake such dangerous duties are all too often the same people who already have a reserve liability with the armed forces and who, in the present climate and intensity of military operations, are already on call for dispatch to active service outside the United Kingdom's boundaries. So we do not have anything like that total of volunteers readily available, but the same applies, a fortiori, to the regular armed forces.
The regular armed forces, with the normal emergency services, would be in the front line of tackling any of those catastrophic attacks if they were to occur. We know perfectly well the strain under which they are already labouring. Their morale is not improved by constant reports of imminent announcements from the Secretary of State for Defence—which have yet to happen but which we are pretty sure will happen—of major cuts in front-line forces. So we must ask ourselves how the new agency will be able to deliver what it is supposed to deliver.
It is not even clear where the borderline will lie between what the agency is supposed to do and what the emergency services, armed forces and reserve civil contingency forces are supposed to do. When one looks at the Bill and in particular at clause 3, one sees under the heading "Radiation protection functions" thatThe Agency has the following functions in relation to risks connected with radiation (whether ionising or not)"—and it gives two:(a) the advancement of the acquisition of knowledge about protection from such risks;(b) the provision of information and advice in relation to the protection of the community (or any part of the community) from such risks.On reading that subsection, one is inclined to agree with the interpretation of my hon. Friend the shadow Secretary of State, who said in response to one of my interventions that, as far as he could see, much of the role of the Health Protection Agency is one of surveillance—as well as, perhaps, tendering advice. One wonders, given the agency's independence, what sort of advice and guidelines it will be given on how it should try to prepare the public for what might be a devastating attack by chemical, biological or radiological means.
If I may be forgiven, I shall cast my mind back to the most recent occasion that I can think of when the problem of how much sensitive and worrying advice to give to the public was last aired. The year in which I remember that being a particular issue was way back in 1980, when there was beginning to be the stirrings of concern about the involvement of the United Kingdom both in a new generation of its own nuclear weapons and the basing here of certain American nuclear weapons. The anti-nuclear campaign pressed very hard for the Home Office advice to the public to be published, and under that pressure, it was published in the form of the "Protect and Survive" booklet. When it was published, the very people who had pressed for its publication proceeded to mock it, to rubbish it and to say how useless it was. I would not be surprised if the Health 1136 Protection Agency found itself faced with a dilemma when it considers that precedent, which I am sure will be brought to its attention.
After all, we experienced an incident in this Chamber, after which it was said that not even the people present at the time had been given the correct advice on what to do in the event of the possibility that something of a chemical or biological nature had been thrown into the Chamber. Yet, when the security services came forward with advice on what they think we ought to do, straight away people were saying, "You are alarming the public; you are being unnecessarily alarmist. You are cutting off the House of Commons from the people." These issues are not easy ones to deal with. I hope that the Minister in his reply will make it clear to what extent it will fall to the new Health Protection Agency to decide what sort of information should be made public to educate the British people on how best to protect themselves in advance of such a terrible incident, and to what extent it will do so under Government authority.
§ David Taylor
The hon. Gentleman describes the dilemma that the Government face, but the present Opposition face such a dilemma too. The Government are either over-zealous, nanny-stateist and alarmist, or they are neglectful of their duties, derelict in their duties and ought to be doing more. The Opposition have made a living out of that for the past three months or more.
§ Dr. Lewis
That would be a fair point if the hon. Gentleman could show that the Opposition have made any remark about the nanny state or over-zealousness in the context of the serious issues that we are debating. I have been present for the entire debate and have not heard one such point made from the Opposition Benches. It obviously depends on the subject under consideration. When the Labour Government inflict their opinions on the public about ways in which they should conduct their lives that fall far short of the implications for serious security or life and death of the issues that we are discussing, it is quite right for us to describe them as over-fussy. When dealing with matters of gravity, such as those before us, the hon. Gentleman will not hear comments of that sort from the Opposition Benches.
§ Mr. Lansley
I am interested in what my hon. Friend has to say, which he is setting out very well. Does he agree that the criticism that we might be trying to have it both ways is able to be made only when the Government have failed to tell us how they propose to deal with these matters? There is a problem with discussing the Bill in that clause 5, by its structure, effectively says nothing more than that the Health Protection Agency will co-operate with other bodies, unspecified, and that other bodies, unspecified, will co-operate with the Health Protection Agency. The argument about a list of such bodies is secondary. We need some idea of the manner in which the co-operation is to be carried out, by whom and in what structure.
§ Dr. Lewis
My hon. Friend is absolutely right. In particular, we need to know the chain of command. What does the co-operation involve? Let us suppose that the Health Protection Agency decides that certain steps must be taken instantly in the case of a quick- 1137 acting chemical attack, a slow-acting biological attack or a very slow-acting radiological attack. Let us suppose that the Health Protection Agency comes up with the idea, "We'll need troops to do this and emergency services for that", but the troops and emergency services say, "That's all well and good but we haven't got the forces available", or "We've worked out rather different ways to tackle the problems." It sounds as if the people who will be theorising and conducting the surveillance—the people who are affected by the Bill—are not properly connected to those who will have to do the real work on the ground in such dire circumstances.
§ David Taylor
To set the hon. Gentleman's point in context, the right hon. Member for Hitchin and Harpenden (Mr. Lilley) rightly focused on MRSA conditions and the worsening of that problem. All the increases in morbidity and mortality associated with MRSA pale into insignificance when compared with that linked to obesity and smoking—passive or otherwise. So, on the one hand, we have the overzealous nanny state, and on the other we are told that the Government are washing their hands of responsibility for MRSA—pun intended.
§ Mr. Deputy Speaker (Sir Alan Haselhurst)
Order. Before the hon. Gentleman is tempted too far down that line, he might recognise—as I hope will the hon. Member for North-West Leicestershire (David Taylor)—that that point is taking us a little far away from the subject of the Bill.
§ Dr. Lewis
I do, Mr. Deputy Speaker. With your indulgence, I shall respond with a single sentence. There is all the difference in the world between people who choose to overeat or to smoke and people who go into hospital because they are ill and who then fall victim to a hospital-acquired infection, without having exercised any choice.
In line with your stricture, Mr. Deputy Speaker, I return to the Bill. I am concerned about the lack of clarity about connections between those who will be governed by the operation of the new agency and of the legislation and the emergency services, the armed forces and the civil contingencies reaction force. I was impressed by the point made by my right hon. Friend the Member for Hitchin and Harpenden, who referred to clause 4(2), which states:The Agency may do anything which it thinks is—What does that mean—the agency may do anything? Ought implies can, according to the basic moral philosophy lectures that I recall from all too many years ago, but we do not know what the agency's powers will be. I suppose it means that, provided that the agency has the power to do certain things, it will have the discretion to do them—but in what areas will it be able to exercise its authority? We do not even know whether the agency will have the power to require the emergency services, 1138 the armed forces or the reserve civil contingency forces to co-operate with its schemes. The subsection means both everything and nothing. It is all rather mystifying.
the exercise of its functions.
- (a) appropriate for facilitating, or
- (b) incidental or conducive to,
Having touched on the information that the organisation may issue, the relationships that it might have, and the command structure that it needs but that is not clearly set out in the Bill, I am concerned that we are being asked to sign a blank cheque. If the Bill was about the ordinary business of life, we could say, well, sometimes we just have to leave discretion to people in high places to use their judgment as best they may; but the Bill deals with exceptional and grave situations. Whenever an attack occurs, be it a conventional military attack or an unconventional terrorist attack, the odds are that it will not have been predicted. All history indicates that that will be the case. We therefore have to work on the assumption that something will happen at some stage, and that when it happens it will be unexpected. For that reason, we need to have confidence that the structures ate in place to mitigate the impact of such an attack when it occurs—it will be too late to plan when the attack is under way.
We are being asked to sign up to a template with few features, a plan with few details, a strategy with few conditions or explanations attached. As the Bill progresses, we will need a great deal more reassurance from the Government that they know what they are doing and that the agency will be something more than a purely bureaucratic and administrative reshuffling of the deckchairs on the deck of the Titanic.
§ Mr. Mark Francois (Rayleigh) (Con)
It is, as ever, a pleasure to follow my hon. Friend the Member for New Forest, East (Dr. Lewis), who speaks with great authority, especially in relation to homeland security and defence. I cannot outdo his great knowledge of the subject, which was evident in his speech, but I should like to make a brief contribution from a certain perspective. I served in the Territorial Army for some seven years during the cold war. Part of my role was to serve as what was then called a nuclear, biological and chemical, or NBC, instructor. It was my job to train those in my unit to prepare for an attack using such weapons. The nomenclature has changed: in the 21st century, we speak of chemical, biological, radiological or nuclear—CBRN. The acronym has changed but the principles remain the same, and although I might be slightly rusty, points from the training that I did are relevant to the debate and, in particular, to the homeland security aspects of the Bill.
Like other hon. Members, I am concerned about clause 5, which relates to co-operation. It is a brief clause, which lacks detail. Subsection (1) states:In the exercise of its functions the Agency must co-operate with other bodies which exercise functions relating to health or any other matter in relation to which the Agency also exercises functions.That is extremely loose wording. In parallel legislation, the Civil Contingencies Bill lays out in detail the responsibilities of the various agencies that would be involved were such a nightmarish scenario ever to transpire in the United Kingdom. Part of the feedback from the emergency planning community is that hitherto—under Governments of different colours; my 1139 point is not partisan—the arrangements for dealing with such threats have been unclear. During the cold war and while we were threatened by attack from the Soviet Union, clear arrangements were in place governing what people should do in the event of such an attack. However, in the 1990s, those arrangements were run down to save money. The incoming Labour Government continued that process of running down, to the point where who would do what in a crisis became very unclear. All experience shows that in situations in which, for obvious reasons but particularly given the type of media that we have today, the civilian population might panic, it is vital that when time is short and people are under tremendous pressure, those with responsibility know precisely who has to do to what. Unfortunately, the Bill does little to help in that respect.
Let me illustrate my point. Five or six weeks ago, a chilling "Panorama" programme envisaged a co-ordinated terrorist attack on London, with several bombs placed at major stations on the underground going off in swift succession during the morning rush hour, followed later in the morning by the explosion in the financial district of the City of London of a chemical tanker containing chlorine. Experts were invited to work through how they, sitting as a Cabinet Committee or its advisers, would respond to the attack. One of the participants pointed out that, whereas in the 1980s, every household had a "Protect and Survive" booklet to tell them what to do in the event of an attack, no such guidance is currently issued. People are advised to stay indoors and to turn on their radio, but families do not have information to hand that they can study and use to prepare themselves. I admit that not everyone would want to discuss such a gruesome subject over Sunday lunch, but if people had such material at home, they could read it. I wonder whether the Health Protection Agency could have a role in providing such information—in giving people non-alarmist, factual guidance on what to do in the event of an attack.
§ Dr. Murrison
One particular problem is the distribution of iodine in naval ports, where a great deal of confusion has grabbed the headlines. Does my hon. Friend agree that in such cases the HPA could make an early intervention to clarify the position for people living in the area?
§ Mr. Francois
That practical paint helps to amplify the argument that I am seeking to make. We cannot afford grey areas in such cases, and we must be clear about who is responsible and what they are responsible for. The HPA may play a role in clearing up those anomalies, providing a valuable service for the public, who need non-alarmist, clear, simple advice about what to do in terrible situations.
Before concluding, I should like briefly to amplify the point about liaison that I made in an intervention. Evidence from unfortunate events around the world, including the sarin attack on the Tokyo underground network, show that it is critical to identify the agent used as early as possible. In the event, it was a non-persistent nerve agent, which can cause death, but dissipates relatively quickly. It is important in such scenarios that experts reach the scene urgently, analyse exactly what the agent is and report that information to a higher command so that appropriate counter-measures can be 1140 deployed in what emergency planning specialists call "the golden hour". The resources available in that first hour can have an exponential effect on the number of lives saved, so I suggest that there is merit in having liaison officers from the HPA attached to police units, fire and rescue service units—in many cases they would be the first to respond to such incidents—the regular Army battalion trained for a CBRN role, and the regional civil contingency reaction forces, comprising regular, but mainly Territorial, reservists deployed around the country, who would seek to respond within a matter of hours.
HPA specialists should be attached in peacetime to those units, exercise with them and get to know their senior commanders so that if the grisly day ever came and we had to conduct such an exercise for real—please God that we never do, but we cannot discount the possibility—they would be embedded in those units, and could liaise with them, with the result that everyone would be likely to respond much more quickly and efficiently. The HPA would learn quickly exactly which agents were used, helping it to plan countermeasures that might subsequently save a large number of innocent lives. I hope that the Under-Secretary of State for Health, the hon. Member for South Thanet (Dr. Ladyman), is prepared to consider that practical suggestion.
This is an important subject, and it is worrying that the Bill is vague about it. The Bill will go into Committee next week, and I hope that in our detailed scrutiny of it we can examine those questions in greater depth. In a non-partisan way, we put the Minister on notice that we intend to raise the matter. We would like him to do some homework and liaise with other Departments so that in Committee he can provide us and the people whom we represent with adequate reassurances.
§ Dr. Andrew Murrison (Westbury) (Con)
We have had a good debate, although I am a little disappointed. I arrived thinking that I would learn how the Health Protection Agency would help us to provide better public health for the population. Our constituents clearly want such provision, but there have been serious shortcomings over the past few years. However, at the close of our debate, I am none the wiser.
We want to know, as a number of Members have said, precisely how the HPA, under its new constitution, will make a difference to public health. We have been gravely disappointed, as has been said in our debate, by the Government's record on a number of issues. We accept, of course, that the reconstitution of the agency is a step in the right direction, and accept entirely the Government's good intentions. However, in Committee we need to know chapter and verse why they think that the new agency will help.
As with any Government intervention, it is not beyond the realms of possibility that it may do some harm. The National Radiological Protection Board is concerned about that, and a few red flags have been raised in our debate, particularly by Conservative Members. The NRPB is intimately involved in plans to deal with disasters involving nuclear plants, and I share its concern that it is possible that some of its expertise and esprit de corps will be watered down in the new 1141 arrangements. I am not saying for a moment that that will happen, but we have to be alive to the possibility that it might. We should not assume that those changes are necessarily all for the good, although I accept on balance that most of them are. I hope that in Committee Ministers can give us examples of the way in which public health will improve as a result of the changes that they envisage.
I do not intend to rehearse the public health issues that are to the fore and where things have not been done terribly well. They are a matter of public record, and hon. Members have mentioned tuberculosis, sexually transmitted disease, teenage pregnancy, and—a minor issue, but an important one for those affected—the debacle over disposable instruments for tonsillectomy. In its new guise, the HPA may wish to look at that ongoing issue, as I have found it difficult to get any agency to assume responsibility for the problem. Other recent issues that we have heard about include MRSA and the scandal of hospital-acquired infections.
"Getting Ahead of the Curve" says that the agency was initially to be called the national infection control and health protection agency. Of course, we do not want to be long-winded, but it would he interesting to know the thinking behind the deletion of the first part of that descriptor and whether it has any significance other than a laudable desire to be brief. We have rightly heard a great deal about the need for cross-cutting, interdepartmental solutions. We remain confused about exactly how the HPA will work. Will its role be advisory or investigative? Will it conduct surveillance, or will it have to do the job of protecting public health itself? I suspect that the latter does not apply, because to get the job done it would need the co-operation of a large number of agencies. Who will have responsibility for turning recommendations into action, and how will that work? I wonder, perhaps mischievously, whether the Minister has examined the Public Health Act 1848, which established the General Board of Health. That model was recently dug up and commended by the Nuffield Trust as a way of getting to grips with public health. The board took charge of public health and achieved improvements. It did not just study things, but delivered results. Our constituents want action on the various things that I mentioned, including TB, hospital-acquired infection, MRSA, teenage pregnancy and so on.
I am not entirely certain about the direction that Ministers intend the HPA to take. Will it deal chiefly with crisis events such as the terrorist threats that we face in the 21st century and novel threats arising from infections, or it will be more of an elective body? Under the powers that Ministers might give to it, will the HPA look at factors that affect the health of the population in a more elective way? I am thinking particularly of the challenges of obesity, for example. In what way do Ministers see the HPA developing in the years ahead?
We need to look at public health in the round. We cannot simply consider the HPA in a debate such as this, because everything links together. The hon. Member for Sutton and Cheam (Mr. Burstow) was worried about fragmentation in public health, and he is right to be, although I am a little unclear as to his party's intentions in that regard. My understanding was that the Liberal 1142 Democrats were keen to alloy public health to local government, but it is difficult to determine whether he would rusticate parts of public health in that way. How would he avoid the charge of fragmenting the public health function? No doubt that will be explained in due course, but he is right to worry about the possibility of fragmentation.
I must point out, however, that we now have things called clinical networks, which are a far more sophisticated way of linking expertise within health institutions. Perhaps that is a model that needs to be commended. We should not imagine that health professionals act in isolation; clearly they do not. They talk to each other. Indeed, they probably talk to each other far more than they talk to their managers, for example. That is how these things tend to work. So let us not assume that, just because there is not a wiring diagram somewhere, people do not talk to each other. Of course they do.
Ministers need to decide where the public health function should lie. Should it lie at primary care trust level, or is that too low? Is a small PCT serving a population of 100,000 the right place to invest our public health resources? Arguably not. It is arguable that this should be done at a more strategic level. All these matters need to be considered by Ministers if we are to improve public health delivery, because delivery, rather than structures is the important thing at the end of the day.
I have to mention tuberculosis: we need an action plan for TB. I hope that the Minister will give us a clue—an updated clue, perhaps, because I first asked for one in March—as to where the action plan is. Without one, it is difficult to know what to do with this escalating problem. A number of professionals have written to me about TB; it is clearly a matter that taxes the profession as well as the poor people who are affected by the condition. In a letter published in The Sunday Times on 30 May this year, Dr. Peter Davies, a consultant respiratory physician, wrote:Dr. Reid is selective in his letter on NHS improvements. In the past decade tuberculosis cases have increased by 40 per cent. across the UK and have doubled in London yet the government has still not published its action plan on tuberculosis and, as a result, no extra resources are available.That is deeply worrying. This is not for want of asking on our part, and I hope that the Minister will give us an updated idea of when we can get the TB action plan. Presumably, the HPA will be looking out for that plan just as much as we are.
We would also like to know, please, when the action plan on hepatitis C will see the light of day. We have rightly heard a great deal about the disease; in many ways, it is a covert disease, and a condition that many of us know very little about. We need an action plan to address this problem as well.
Several right hon. and hon. Members have mentioned hospital-acquired infections. My right hon. Friend the Member for Hitchin and Harpenden (Mr. Lilley) made an eloquent exposition on the subject, and I was also interested to hear his thoughts on iatrogenic illnesses—those conditions that people acquire as a result of being treated. He was right to point out that most of us do not want to think about the possibility that our doctors and nurses might actually co us harm. Sadly, though, that is 1143 sometimes the case, and we need to address that issue as a matter of urgency. I hope that the HPA will take an early view on that.
Most of this is not rocket science. We have heard about directors of infection control and a new working group being introduced as the Government's response to this crisis, but really it is to do with basic practices such as hand washing. Thinking back to my time as a medical student and a doctor, I remember wandering round in a white coat that was rarely changed from one month to the next, and I know that I was not unique in that, although I hear the Minister tut-tutting from a sedentary position. I was also probably as guilty as anyone else of wearing a tie which, tad it been swabbed microbiologically, would have shown some remarkable results. We have seen a lot of material in the recent published literature about such issues.
Perhaps the HPA will consider advising doctors not to wear ties, or to wear bow ties. Perhaps the more outrageous of them might wish to adopt the wearing of a cravat. The problem of hospital-acquired infection has clearly been identified, and some of the clothes that doctors wear are a possible source. One solution would be to change doctors' habits, yet we have not seen a concerted effort to do that. So we need action on that, and I hope that the HPA will provide at least some of it.
I was interested in hon. Members' descriptions of hand washing. I recently served in Iraq as a regimental medical officer, and I became accustomed to washing my hands all the time using alcohol washes of some kind. My right hon. Friend the Member for Hitchin and Harpenden expressed concern about the risks involved in the repeated use of alcohol rubs, but the modern ones do not cause too much of a problem in that respect, and it becomes second nature to use them. If I can be persuaded constantly to wash my hands in that way, I am sure that most health professionals can. It really is not that difficult. Of course, in Iraq, it is absolutely imperative. There, even more than in this country, hygiene is essential in preventing cross-infection.
Probably the most damning remark that I have heard in this regard came from Professor Hugh Pennington of Aberdeen university, who is on record as saying that he has investigated slaughterhouses that have been cleaner than some hospitals. That is rather graphic, but sometimes graphic is what is needed. If we are to address this problem, perhaps more words like that are needed, and if respected physicians such as Dr. Pennington are making such remarks, we certainly need to listen.
I am uncertain about the remit of the HPA, and I am concerned as to where Ministers might be leading it. Indeed, I think that they might h the only a vague idea of where they would like it to go I am mystified as to whether it will do crisis management, focusing more or less exclusively on infectious disease, or whether it will look at broader health-related problems, such as obesity and smoking. Perhaps the Minister will give us some idea about that when he responds to the debate. If he is unable to do so in the limited time available, perhaps we can flush that information out of him in Committee.
I was interested to hear hon. Members' remarks about the National Radiological Protection Board, and I have written on my notes: "Wax lyrical about the NRPB". Unfortunately, time will not allow me to do that, so I 1144 must abbreviate my comments. I was going to wax lyrical about the board because, in a previous incarnation, I worked fairly closely with it and developed a healthy respect for the organisation. It is worried about its access to Ministers. I know that it treasures that access, and feels that direct access to Ministers by a body of that sort is necessary. I hope that the Minister will be able to say that his door will always be open to the director of the NRPB, or whoever heads up the board.
The advice that the NRPB gave in the aftermath of Chernobyl is an example of how well it is regarded internationally, and it would be a great pity if that regard were to be watered down. It would be a particular pity if the ethos of the NRPB were to be diluted in any way, or if its personnel were to find their morale or expertise being degraded as a result of any of these changes.
I am sure the Minister would join me and say that he would want to do nothing that might jeopardise the high reputation that the NRPB rightly enjoys.
I am worried about co-operation with other bodies. Several hon. Members mentioned that today, including my hon. Friend the Member for New Forest, East (Dr. Lewis) and the hon. Members for West Bromwich, West (Mr. Bailey) and for North-West Leicestershire (David Taylor). All of them, in one way or another, touched on concerns that stem from clause 5. The chief problem is that the Bill is vague almost to the point of being meaningless on the interaction of the HPA with other bodies. We do not know which they are or what form the interaction will take. The Bill is also opaque as regards their duty to interact with the HPA.
That is cause for particular concern in the context of civil contingencies. We need clarification of lines of responsibility in the event of the disasters that my hon. Friends the Members for New Forest, East and for Rayleigh (Mr. Francois) mentioned. That is lacking from the Bill, and I hope that in Committee it will be clarified to our satisfaction.
The reference made by my hon. Friend the Member for Rayleigh to liaison with military units is crucial. Again, I have some experience of that. Although there will always be interaction on an individual level—arguably that is the most profitable way in which organisations interact—nevertheless that needs to be formalised. I should have thought that the Bill was exactly the place for that to be set out, but sadly that seems not to be the case.
Clause 7, which deals with the publication of information, exercised noble Lords in another place. We shall have to bring Ministers back to the matter in Committee. The clause uses the rather sinister phrase,not in the public interestas a reason for non-disclosure of information. That is a worrying turn of phrase. My noble Friend Lord Fowler said that the alarm bells started ringing whenever he heard that kind of language used. Many of us see red when we read it in the Bill. We need to know what will be in the public interest. Ministers should tell us the circumstances they envisage when publication of information will not be in the public interest. Obviously, 1145 they cannot specify each eventuality, but a description of the sort of situations that would make Ministers consider the publication of information not to be in the public interest would be extremely useful.
It is important that we focus on the national programme for IT in the NHS in the context of information gathering. We heard nothing today about how the national programme for IT in the NHS might fit into the plans laid out in the Bill. We hear stories that the programme is behind schedule. If it is, we clearly have cause for concern. I hope the Minister will tell us that that is not the case. The Prime Minister has said that he thinks an attack on this country by somebody with ill intent is almost inevitable. The HPA will be heavily involved if that occurs. If there is an attack using biological weapons, IT will be essential in providing an early warning. I hope any plans for IT in the NHS will give priority to the HPA.
We have not dealt a great deal with devolution and how it impacts on the Bill. Clause 3 contains plans for the National Radiological Protection Board, which appears to be a UK-wide body under the new arrangements, yet clause 2 dealing with infectious diseases seems to set up barriers between the nations of the United Kingdom. It is not entirely clear why that should be. I intervened on the Minister to try to get an answer to that. Perhaps the Under-Secretary of State for Health, the hon. Member for South Thanet (Dr. Ladyman), will give us some idea why there is that difference between clauses 2 and 3. The hon. Member for Erewash (Liz Blackman) mentioned the HPA in the context of devolution. My memory is a little hazy about the exact point that she was trying to make, but no doubt she would appreciate an answer as well.
I am slightly concerned about the cost of the HPA, who will pay and where the money will come from. That is dealt with briefly in paragraph 19 of schedule 1, where we learn that the devolved Parliament and Assemblies will contribute, or chip in, at a level that they will determine. That is confusing, especially as regards giving the HPA tasks that it considers appropriate and which are agreed with the Secretary of State in England. I am worried about the devolved bodies chipping in, as that is not prescriptive. I am also worried about the projections for future earnings by the HPA, which will earn quite a lot of money, particularly as the Centre for Applied Microbiology and Research develops its virus facility in Porton Down.
We need to know how much money the HPA will be operating with. There appear to be two unknowns: first, how much the devolved Assemblies will contribute, and secondly, how much will be earned by the HPA from outside bodies. It is important, because we need to know from year to year how much the HPA will have. We also need to be reassured that there will not be a ratcheting effect, whereby the more the HPA earns, the less the Government are prepared to commit on a yearly basis to its important work. We all know, especially in view of the kind of work that the HPA will be doing, that outside earnings can be unpredictable. The agency needs to be able to predict fairly closely how much money it will have for its functions.
§ Mr. Geoffrey Clifton-Brown (Cotswold) (Con)
My hon. Friend has read the Bill carefully and will know 1146 that paragraph 20 of schedule 1 states that the devolved authorities may make loans to the agency—that is, the HPA. Sub-paragraph (3) goes on to say:A loan may be made on such terms (including terms as to repayment and interest) as the person making the loan decides.Would my hon. Friend like to take out a loan from his bank manager on those terms, without any negotiations taking place?
§ Dr. Murrison
I am grateful to my hon. Friend. I would certainly like to take out a loan from my bank manager if I were able to dictate the terms. That ties in with the issue of the devolved Assemblies deciding what they will contribute to the budget of the HPA. That needs to be more clearly laid out.
We have had a far-ranging debate, Mr. Deputy Speaker, and you have been extremely patient in allowing a broad debate on public health issues. It is a shame that in her remarks the Minister did not touch on the public health concerns of our constituents. I hope that the Minister might deal with subjects such as tuberculosis, hospital-acquired infection, teenage pregnancy and chlamydia. We want to know not just about the structure of delivery of public health, but precisely how Ministers plan to address the important public health issues that face us.
§ The Parliamentary Under-Secretary of State for Health (Dr. Stephen Ladyman)
I join the hon. Member for Westbury (Dr. Murrison) in his paean of praise for the National Radiological Protection Board. In a previous incarnation I, too, worked closely with the NRPB. I worked in the building next door. When the building that the NRPB occupied was used for filming an episode of "Dr. Who". it was one of the few occasions that I can recollect when one could see a cyber man eating his sandwiches on the lawn in the sunshine. The standard of science in the NRPB was always of the highest quality, and I congratulate the board on the work it has done in the past.
As the Under-Secretary of State for Health, my hon. Friend the Member for Welwyn Hatfield (Miss Johnson) said when she opened today's debate, the establishment of the HPA was first proposed in "Getting Ahead of the Curve", the chief medical officer's strategy for infectious disease and other aspects of health protection. She also explained why it was decided to create the agency through a two-stage process, and that the Bill is the second stage of that process.
The HPA special health authority came into existence on 1 April 2003, and the Bill will complete that process by establishing the agency in UK-wide legislation as a non-departmental public body and by giving it the full range of functions that were envisaged for it in "Getting Ahead of the Curve" which highlighted the diversity and constantly changing nature of the threats to public health that we face.
The rationale for creating the agency was the recognition that the existing structure for health protection in this country needed strengthening in order to manage those threats. In particular, the specialist support for health protection on which the NHS and local authorities rely was fragmented among a number of different bodies and individuals. Those included the 1147 Public Health Laboratory Service, the national focus for chemical incidents, regional service providers, the National Radiological Protection Board, the Centre for Applied Microbiology and Research, as well as local consultants in communicable disease control and regional health emergency planning advisers.
That fragmentation was a concern, and the Government concluded that the delivery of health protection services at both local and national levels could be improved by combining the functions of those bodies and individuals in a single organisation. That will allow the agency to function as a one-stop shop, capable of providing the expertise for dealing with any scenario. It should also enable a greater degree of cross-fertilisation of good ideas and good practice between the different fields of health protection
As the Under-Secretary of State for Health, my hon. Friend the Member for Welwyn Hatfield and I have already said, the agency was first created as a special health authority and already provides the UK Government with stronger and more integrated arrangements for health protection. The HPA has also strengthened our ability to respond to threats from chemical and biological terrorism. In particular, it has co-ordinated a number of training exercises and has recently issued a set of clinical action cards for GPs that contain advice on identifying and treating victims of chemical or biological attack.
I shall deal with some of the points raised by hon. Members in the debate. The hon. Member for South Cambridgeshire (Mr. Lansley) was somewhat churlish in his comments about the Government's review of arm's length bodies. He might have mentioned that one of that review's objectives is to save £500 million by 2007–08, but that seemed to slip his memory.
My hon. Friend the Member for Erewash (Liz Blackman) pointed out that the agency will have the scope to raise standards. It will have the powers and the independence to publish what it likes, when it likes. [Interruption.] I realise that the hon. Member for South Cambridgeshire spoke for a very long time, but he did not say an awful lot that is worth responding to, although I shall return to one or two of his points.
My hon. Friend the Member for Erewash asked about the types of bodies that must co-operate under the Bill. It would not be practical to list all such bodies in the Bill, but we do not envisage that they will find it difficult to recognise themselves. Such bodies will include NHS bodies, local health authorities, the national public health service for Wales, the Scottish centre for infection and environmental health and international bodies such as the World Health Organisation. We regard co-operation between such bodies as essential.
§ Dr. Ladyman
No. The hon. Gentleman spoke for a very long time. Although well-paid hon. Members are present tonight, I am sure that less well-paid members of Palace staff want to get away to do other things this evening, and we should have shown them a little more respect.
The hon. Member for Sutton and Cheam (Mr. Burstow) pointed out that the Bill should be about more than administration. Creating the agency is about 1148 more than administration, and its work will be much more important than just administration. However, the Bill itself is about the creation of a new body and the relevant structures; it is not about the public health agenda in its wider aspects. The Bill is a Bill; it is not an action plan or the public health plan that Conservative Members have gone on about all day. It is only the generosity of the Deputy Speakers during the day that has allowed them to wax lyrical on many pet subjects, some of which are important, but are not necessarily pertinent to the Bill.
My hon. Friend the Member for West Bromwich, West (Mr. Bailey) rightly pointed out that the agency will have a strategic planning role for national health. He pointed out that by its nature the NHS is reactive, and that the HPA can have a proactive role. He also highlighted the important principle of partnership working.
The right hon. Member for Hitchin and Harpenden (Mr. Lilley), the hon. Member for South Cambridgeshire and others raised the subject of methicillin-resistant Staphylococcus aureus. The right hon. Member for Hitchin and Harpenden has discussed MRSA on previous occasions. I know that he takes a great deal of interest in that subject, and I congratulate him on that, and on the thoughtful way in which he put his points. However, he also made a lot of party political points, before saying that we should not make party political points and going into the thoughtful section of his speech.
The right hon. Member for Hitchin and Harpenden and the hon. Member for South Cambridgeshire highlighted the success of countries such as the Netherlands and Denmark and asked why they do not have the same problem with MRSA as us. One reason is that those countries did not suffer the misfortune of 18 years of Tory Government, and as a consequence they did not lose the culture that is necessary to ensure cleanliness and action against infection, and the building fabric of their health services did not fail.
Dealing with MRSA is not only a matter of cleanliness, although that is clearly part of the equation. The matter also concerns the built environment and the availability of single rooms. We must create hospitals where such infections can be resisted and a culture of behaviour to prevent the spread of infection. None of those things happen overnight. We have implemented measures on all of them, and I am confident that we will see great improvements in the control of MRSA as a consequence of those changes.
My hon. Friend the Member for North-West Leicestershire (David Taylor) raised a constituency case. I encourage him to write to me with more details and I shall ensure that it is examined. He asked whether the Environment Agency was a health and safety body under the Bill. The answer is no. Health and safety bodies under the Bill are defined in clause 3(7). My hon. Friend also asked whether the agency could co-operate with the Environment Agency under clause 5 and the answer to that is yes. We shall look into the matter that he raised.
The hon. Members for New Forest, East (Dr. Lewis) and for Rayleigh Mr. Francois) raised defence issues that are important and fascinating but, for the most part, frankly irrelevant to today's debate.
1149 We live in a dangerous world where we are at war with terrorists. That war has gone on for many years and will continue for many years. Tragically, in this country, we know the consequences of terrorist attacks and we can expect terrorists to try—and they may succeed—to acquire biological, chemical and radiological weapons in the future. That is why it is essential to have a health protection agency that is capable of building up a body of expertise and helping us to manage the potential threats.
We hope that such attacks will never come to pass—we must hope for the best and prepare for the worst. That is what the agency will do. We should not forget that mother nature can bowl the odd googly, as we have seen with recent outbreaks of SARS and the tragedy of HIV. We need an agency that is capable of focusing expertise and giving us genuine independent advice. The Bill creates exactly that in the new Health Protection Agency. I commend it to the House.
Question put and agreed to.
Bill accordingly read a Second time.