Fighting Infection (Science and Technology Committee Report)

HL Deb 08 December 2003 vol 655 cc592-622

5.42 p.m.

Lord Soulsby of Swaffham Prior

rose to move, That this House takes note of the report of the Science and Technology Committee on Fighting Infection (4th Report, Session 2002–03, HL Paper 138).

The noble Lord said: My Lords, it is a pleasure and a privilege to present this report on the topic of fighting infection. All Select Committees deal with important and timely matters, and there can be few more topical and important than the present situation with respect to infectious disease. It is incongruous that, despite the many advances in modern medicine and pharmacy, infectious disease is still a major threat to the health and welfare of the British public.

In 1969 the Surgeon-General of the United States, William Steward, testified before Congress that, It is time to close the book on infectious diseases and to declare the war against pestilence over". This optimism is now widely accepted as not only mistaken but also damaging to the research effort into the control and prevention of infectious disease.

We know that 60 per cent of all ill health is due to infectious disease. The magic bullets of antibiotics have lost their magic; exotic diseases threaten our shores in the forms of HIV, SARS, malaria, Ebola infection and west Nile fever, to mention only a few. The opening paragraph of the Department of Health publication Getting ahead of the curve acknowledges that the post-war optimism that the conquest of infectious diseases was near has proved dramatically unfounded. The document lays out the Government's infectious disease strategy for England. The Science and Technology Committee has put flesh on the outline plans in that document. The establishment of the Health Protection Agency as a co-ordinating body bringing together many facets of healthcare promises to be a very important development. I shall return to that later.

At the outset I wish to thank most warmly the noble Lords on the sub-committee, which included five medically qualified persons, one member who had nursing qualifications, one who was a veterinarian and two others who were scientists, as well as others. Collectively they proved a powerful team of inquiry. Our scientific advisers were Professor Julius Weinberg of City University and Professor George Griffin of St George's Hospital Medical School, both of whom provided valuable input to the committee's deliberations. I pay special acknowledgement to our Clerk, Miss Rebecca Neal, who performed outstandingly in the inquiry.

I also wish to thank the large number of organisations and individuals who gave up significant time to submit evidence in writing and orally. Several institutions and organisations were most helpful in arranging visits, both in this country and overseas. The American institutions in Atlanta, Washington DC and New York, which are listed in the report, were not only welcoming but extraordinarily helpful. They, too, are faced with much the same health problems as we have in the United Kingdom. Similarly, visits to the World Health Organisation, the Institute of Migration and the UNAIDS programme in Geneva provided important information and input to our report.

The report has received a generally positive welcome from all quarters. We appreciate the comments made about it, in particular, the comment from the Health Protection Agency that it is, A welcome, valuable and timely report that re-emphasises the threat of infection". We have made 24 recommendations in our report. I am pleased to observe that, on the whole, the Government response is timely and comprehensive. New structures, such as the new and emerging Infectious Disease Panel, have been or are to be set up to assess the threat from infections, many of which have been identified in our report and many of which are zoonoses or animal-derived. A new inspector of microbiology will promote high quality clinical and public health microbiology. There is the provision of £12 million to tackle hospital associated infection, particularly the alarming growth of MRSA— methicillin resistant staphylococcus aureus—which has come to national media attention. The Science and Technology Sub-Committee on Resistance to Antibiotics warned against this situation in 2001.

With our first recommendation the Government concur that there is still room to improve management and infrastructure and to identify and plug gaps. Mention is made of economies of scale by the integration of expertise and the building of synergies between disciplines through the Health Protection Agency. But it is not clear whether there will be increased resources for this. We hope that additional resources will be made available. It is important that the Health Protection Agency is not compromised in what the Select Committee believed to be an important starting point in its existence.

In our inquiry it was well recognised that each component part of the health service section performed satisfactorily. But one of our early recommendations is that effective communication and collaboration between all organisations involved in infectious disease services should occur, and that an outline of roles and responsibilities should be published to that effect. It is not clear from the Government's reply, however, when or whether they intend to map out those responsibilities. We hope that they will do so.

The committee sees an important role for the Health Protection Agency, which will be set up under the Health Protection Agency Act. That role includes commissioning research, obtaining and analysing data and providing laboratory services. A particular recommendation is that the Health Protection Agency be provided with resources to take on specific and primary responsibility for integrating surveillance relating to human, animal and food-borne infections, in view of the importance of food-borne infections as a cause of ill health. Much ill health is due to that.

The Government's response identifies the various bodies covering the area, including Communicable Diseases Control, the Department for Environment, Food and Rural Affairs (Defra), the Food Standards Agency and the Zoonoses Group. We welcome the promise of close links between the agencies, but we are concerned that, historically, informal links with memoranda of understanding with a large number of committees and groups can lead to problems of inadequate communication. We seek assurance that they will work this time and that the lines of responsibility for effective, integrated surveillance are more clearly drawn than is indicated in the reply.

My colleagues in the inquiry will deal with other areas of the report and the Government's response to it. I wish to comment further on research and development, especially on vaccines. Vaccination is a major and effective approach for the control and prevention of infectious disease. Yet the committee has been concerned that the UK's capabilities for vaccine production have declined over recent years. The Government agree that there is a significant deficit in vaccine capacity. They comment that multiple projects are under way to increase that capacity, to identify the gaps and develop action to bridge them.

The sub-committee is strongly of a mind that vaccine development should be facilitated in the UK and that the Government should maintain clear evidence-based guidelines of vaccine requirements. The sub-committee wishes to see a secure supply of vaccines in the event of a major global epidemic. We point out that overseas suppliers, on which we rely for many of our vaccines, would be under pressure to give priority to their own country's needs. The Centre for Applied Microbiology and Research—previously known as CAMR and now HPA Porton—could well serve that purpose. It is hoped that the Government will consider favourably an application from CAMR for that purpose. The HPA comments that it would be imprudent not to have the HPA Porton capability. We share that opinion and the view that it should be properly funded.

Since the publication of our report various vaccine production groups have represented that they have provided, or can provide, important vaccine development—for example, for the prevention of pneumococcal bacterial meningitis and pneumonia of children. It is said that the development at Speke can handle a pandemic of influenza, although I understand that the production of a tuberculosis vaccine at that site is to be discontinued.

At the National Institutes of Health in America, we were told of the small business initiative for small companies willing to take the financial risks inherent in the development of a vaccine. If the vaccine was patented, the company was obliged to make every effort to bring it to market. In the United Kingdom that is approached by a tax credit system to help small, innovative biotech companies in the development of novel vaccines and others. It remains to be seen whether that will be more effective than the NIH scheme; however, there is no doubt that small biotech companies should be encouraged to take up vaccine development.

The inquiry anticipates a clear, outstanding role for the Health Protection Agency to set standards and clarify lines of accountability. We have made a series of recommendations for action by the HPA, including one to develop collaborative relationships with organisations concerned with tackling infection, including the devolved administrations, environmental health departments and the Food Standards Agency. While they agree with that recommendation, the Government consider it ambitious to expect a proposal on the issue to be published by April 2004. Our reply is, if not by that date, when? We expect it to be fairly soon.

Similarly, we are aware of the importance of international collaboration and the availability of personnel for secondment. We trust that, not only the HPA, but the Department of Health in general, can be involved in international infectious disease control. The HPA points out that resilience needs to be built into its staffing to respond to such demands, and we agree. The HPA's corporate plan, which has just been published, proposes a bold and ambitious programme. Clearly, there is much to be done in drawing together the expertise of a wide range of health, scientific and related staff so that it can respond swiftly and in a co-ordinated manner to new and existing threats from infectious disease. We wish it well. But to do well it must be given the resources to develop into the kind of structure that we need, and of which we will be proud.

Moved, That this House takes note of the report of the Science and Technology Committee on Fighting Infection (4th Report, Session 2002-03, HL Paper 138).—(Lord Soulsby of Swaffham Prior.)

5.58 p.m.

Lord Haskel

My Lords, I am delighted to speak in this debate, for two reasons. The first is to express my congratulations and thanks to the noble Lord, Lord Soulsby, who was chair of our sub-committee, and my gratitude to my colleagues both inside and outside your Lordships' House, with whom it was a pleasure to work on this report. I add my thanks to Rebecca Neal, our Clerk, who looked after us with tact and efficiency.

The second reason that I am pleased to speak is that I agree with the noble Lord, Lord Soulsby, that the Government can be congratulated on listening to our report and responding to it in a generally positive way. That shows that they are taking seriously the fight against infection. Their response contained several promises to deal with matters raised in our report. Indeed, one of the promises was implemented last Friday with the announcement that health trusts will appoint directors of infection control. The directors will apply the strict rules of hygiene to help establish the culture of prevention about which we spoke in our report.

The need for these simple rules of hygiene was clearly demonstrated when we visited Birmingham City Hospital. We were shown how taking steps to ensure that wards were cleaner, equipment was looked after for cleanliness, gloves were worn and hands were washed helped to stop the spread of hospital-acquired infections. We were told that about 100,000 people a year pick up infections in hospitals in Britain. Simple procedures helped to prevent the spread of yet more sophisticated infectious agents. We were also told that simple procedures were sometimes left undone because of the pressures of work and time. Making somebody responsible for ensuring that those procedures are carried out can only be helpful, and I hope that that person will also have authority. For my part, since that visit to Birmingham, I wash my hands a lot more frequently.

The other thing that impressed me about our visit was our meeting with an environmental health officer. We met him in a group together with a number of other people involved in infection control, such as senior doctors and administrators. However, it was obvious that he was bottom of the pecking order, despite being right in the front line of the fight against infection. My noble friend on the Front Bench does not need me to remind him that the message from every general since Alexander the Great is that the effectiveness of the best battle plan depends crucially on the training, equipment, morale, skills and the numbers of frontline troops. We were concerned about virtually all of those aspects regarding environmental health officers. The Health Protection Agency, in its response, also shares our concerns, speaking about "staffing becoming desperate". I agree.

From the Government's response, they obviously think that entry to the profession should be of degree standard. Why? It will enable environmental health officers to bring more analytical skills to the job, be better trained in science and will raise the status of their work. They will have parity of esteem with other professions that have degree entry and it would deal with training needs. However, what about recruitment? Will the increased status mean more pay? All new entrants will do a degree course from 2004 and bursaries will be available, but what will happen to recruitment between now and when the students of 2004 graduate? Perhaps the Minister will consider some of the more successful schemes in industry in which employers are compensated for giving staff time off for training. Perhaps that would help to fill the gap.

This problem is a difficult one. Although environmental health officers are employed by local authorities, their work impacts on the Department of Health, the environment, law enforcement, the Home Office and the Food Standards Agency. Perhaps the lines of responsibility should be clearer. The Government are offering placements in all those various departments and agencies, but we need to recruit people in the first place. That is where the Government will have to do better.

The noble Lord, Lord Soulsby, reminded us of the committee's visit to the United States. One experience that impressed me was our visit to the TB control centre at Harlem Hospital in New York. There was an item in a paper recently about the relatively high incidence of TB among immigrants in Britain, both legal and illegal. The item implied that the matter was thought to be too sensitive to deal with openly, and hinted that the rise in the incidence of TB was due to immigration.

It is a sensitive and controversial issue, but I was impressed with the robust and open way in which the health commissioner in New York dealt with it. He impressed us all with his vision and vigour, and we were all impressed by his comparative youth—he seemed to be younger than my own children. The health commissioner let it be known through official and unofficial channels that free testing and treatment for TB were available to all and that they were entirely confidential. The names and addresses of immigrants—legal and illegal—would not be disclosed to the police, the Internal Revenue Service or the immigration authorities, before, during or after treatment. All that was said quite openly, because otherwise people would not come forward for treatment.

I learned that the treatment is difficult and unpleasant and takes the best part of the year, and that continuity is essential. Patients had to come to the hospital so that staff could watch them take their tablets. Those who did not or could not come to hospital had their tablets taken to them by couriers, who watched them take their medicine. The couriers obviously did that at great personal risk, because there could be no police protection. We met a courier and some of the nurses involved in that work. It appeared that what motivated them was that they, too, had been TB sufferers and the cure had changed their lives. They were anxious that others should also benefit. The health commissioner told us that the exercise had had a major influence on reducing the incidence of TB in the city. We all came away pretty impressed.

What happens if the newspaper report is correct and there is a high incidence of TB among immigrants in Britain? Obviously, illegal immigrants cannot go to the NHS and they are a danger to the rest of the population. Do we ensure that patients take their medicine by watching them, as they do in New York? This is an important part of fighting infection and we should be rather more open about it. Indeed, we referred to the whole matter of openness in our report. We recommend that the Health Protection Agency creates a post of infectious disease specialist to act as spokesperson to communicate with the public and create increasing awareness of infectious diseases. I agree with the Health Protection Agency that this problem cannot be restricted to one person—that is not practical. However, the Government's response says that the Health Protection Agency will develop its own communications strategy to raise the understanding of health protection by the public.

Raising understanding usually means trying to influence or control the media so that the desired message gets across. However, we have learnt that, although it may get the correct message across, it erodes trust in the message. We do not want that to happen in the fight against infectious diseases, because it could have disastrous results. We have all learnt in recent years that winning the argument in matters of public health is not enough. We have to win hearts and minds as well, and we cannot do that just by raising understanding.

The Health Protection Agency will have to make hard decisions about fighting infection—medical and social decisions. Indeed, that will be put to the test next week when a play will be broadcast on television about the MMR vaccine. I understand that the play is based on real events, but that the truth will not be allowed to get in the way of a good and powerful drama. The screening of the programme will be an opportunity for the Health Protection Agency to show its strength and commitment to winning hearts and minds and fighting infection. The Government should get on with establishing the Health Protection Agency as a completely independent body like the Food Standards Agency. It can then get on with the difficult business of informing the public about the risks of infection and winning the trust of the public that the information is independent and the best available.

Another reason for getting on with the Health Protection Agency Bill, is that it should enable the agency to be more commercial and less bureaucratic in its relationship with the biotechnology industry. The noble Lord, Lord Soulsby, touched on that issue. The Health Protection Agency's paper in response to our report deals very satisfactorily with its relations with other public bodies, but it ignores its relationship with business.

The biotechnology industry is less confident and less proactive than it was two or three years ago and the tone of the Government's response seems to reflect that time instead of now. Firms seem to be anxious about where a new class of antibiotic will come from as germs become more resistant to the old ones, as the noble Lord, Lord Soulsby, reminded us. The Health Protection Agency will have to be more proactive in persuading industry to work with it. Indeed, it should become an instrument of innovation, as is likely to be described in the report of the DTI later this month. I hope that the Minister will look at that report. It is relevant, because it deals, I think, with the role of public purchasing and innovation.

In a way, this is my swansong as, by rotation, I have now left your Lordships' Science and Technology Committee. Even though the membership may change, it is important for the committee to return to its recommendations from time to time to see whether they have been implemented—or not, as the case may be—not only in matters of fighting infection and the associated topic of antibiotic-resistant bacteria, but also on the many other matters that your Lordships' committee has studied. Returning to those issues will ensure that they are taken seriously. Keeping witnesses informed of progress so that they will remain interested is also important, because they will then see that their time and effort have not been wasted. That will ensure that their vital evidence continues to flow. I know that the noble Lord, Lord Oxburgh, is committed to the issue, so I am sure that the committee is in good hands under his chairmanship.

6.15 p.m.

Baroness Finlay of Llandaff

My Lords, I add my thanks to those already expressed by my noble friend Lord Haskel for having been able to serve on the committee, which I joined shortly after joining the Select Committee on Science and Technology. The noble Lord, Lord Soulsby, guided the committee through some complex waters and Rebecca Neal's support, always offered with good humour, was welcomed by all members.

The report is just the beginning. I reiterate the assertion of my noble friend Lord Haskel that the topic will need to be revisited in five or 10 years and kept under constant review, because the infections and the problems that they pose will probably become greater.

I was fortunate to be able to visit the headquarters of the World Health Organisation in Geneva as part of the committee's inquiry. I became starkly aware there of the importance of the links between the clinical and epidemiological services here in the UK and those operating at a world-wide level. I hope that the Government will ensure that those international links survive the reorganisation in services, because levels of expertise are fast-tracked through them.

A lot has been said about antibiotic resistance. To underline my plea to revisit the issue possibly in 10 years, I shall highlight some of the data on methicillin resistance. In 1992, about 3 per cent of staphylococcus aureus infections were resistant, but ten years later, that proportion had risen to 43 per cent. That is an alarming increase in antibiotic resistance. As has been emphasised in the report, training at all levels for those who work in health is crucial. I shall return to training in a moment.

The Chief Medical Officer, Sir Liam Donaldson, is to be commended for the amount of work that he has done in looking at problems of hospital-acquired infections that were highlighted in recent reports and for the initiative following the Select Committee's report. The two groups of hospital-acquired infections are hard to distinguish; namely, those that have occurred simply because patients have been in a particular environment and would otherwise have been fine, and those where the person has been so ill and susceptible in hospital that he would either have become infected with his own organisms or be at a very high risk of cross-infection. The difficulty is that a lot of those infections result in death and we do not have any good national data on the number of deaths through hospital-acquired infections. In fact, to ascertain that data is incredibly difficult. A large, complex, case-controlled study that looks at all the risk factors may be required to separate those cases where infections are genuinely hospital-acquired from those where the infection is a contributory factor and therefore associated with the death.

The report, Winning Ways, shows that some participating hospitals have been improving their reporting procedure, but that many are unfortunately unchanged and show worsening data. Clinicians on their own are not very good at differentiating bacteraemia— that is, blood-borne infection—from other local infections. Clinical microbiologists have a crucial role to play in making such differential diagnoses.

That point was highlighted by a general practitioner, Dr Arthur, who, following the death of his wife from MRSA, had launched a campaign that coincided with, but was unknown to, our inquiry on hygiene in hospitals. From looking at anecdotal reports of coroners, he suggested that current estimates of deaths from hospital-acquired infections may be only a quarter of the true figure, although his study also included anecdotes from people who were going to report a death. He has suggested that a tick-box be required on a death certificate, but it may be that such measures will vastly oversimplify the complex data that need to be collected.

However, the report emphasised the need to collect data and to do so in ways that are compatible with all parts of the service. The Government have responded to that with their initiative on the electronic capture of data. I emphasise that it is important that data entry is simple for the end user or the data collection that the Government are rightly striving to undertake will be incomplete.

Cleanliness in hospital environments has been emphasised. In the Government's response to the report, the importance of that, particularly in relation to respiratory syncitial virus, was highlighted. That virus can last up to six hours on hard surfaces and causes severe infections in children and babies. Often, those children need to be ventilated for a time.

I have already alluded to the publicity generated by MRSA. That may survive for variable amounts of time and seems to be killed off by sunlight. Another infection has not featured in the headlines: clostridium difficile, which causes devastating diarrhoea and debilitates patients. Unfortunately, that can persist indefinitely on surfaces and needs to be washed away.

The importance of hand-washing has been emphasised by everyone and the Government have responded strongly to the need to improve it. The size of the job to be done should not be underestimated. Alarming data from the USA suggest that half of healthcare professionals do not adequately wash their hands after visiting the toilet. I have not found any such data from our own hospitals, but perhaps that is an issue that needs to be investigated.

Patient-to-patient transfer of infection has highlighted the need for hand-washing, but the increased use of electronic equipment such as syringe drivers, infusion pumps and electronic temperature and blood pressure devices, which go from one bed to another, must be monitored as a source of transferred infection, particularly when spores such as clostridium difficile can last indefinitely in the crevices, creases and screw tops of such equipment. So, one of the highest priorities must be hygienic hospitals.

The report addressed the issue of training at undergraduate level and made a plea for the incorporation of adequate training in infections into curricula. Sadly, curricula throughout the UK have a long way to go. In my medical school, we are fortunate to have academic microbiologists who have taken a lead in ensuring that microbiology remains on the curriculum, but I know of medical schools in which it has faded from the curriculum. I believe that that has also happened in the teaching of other healthcare disciplines. The Government's action to influence universities will have to be forceful, if we are to make sure that the criteria for infection re-enter the curriculum.

Yesterday, I asked one of our students whether she felt that she had been adequately educated in hand washing. She was able to recount to me the practical session using a UV light to show who was not washing their hands adequately. She said that, on clinical placement, she saw staff moving from one patient to another on the wards without adequately washing their hands. As a student who had just had her hand washing training, she did not feel able to stop staff and tell them that they ought to wash their hands in between. She had noticed that, on many wards, there were no adequate sinks between beds to encourage hand washing. She commended Llandough Hospital, in which alcohol hand-cleaning devices were available everywhere. She noted that positive move, but it is sad that she did not notice it in every hospital in which she had been on placement.

There is remarkably little training in infection issues on most postgraduate courses. At the moment, infection control does not form part of ordinary clinical appraisal. Every clinician in the service at every level needs feedback on rates of infection on their ward and among their clinical team, so that there is ownership at every level in the individual team. The initiative launched in the past week in England will, I hope, ensure that that discipline comes through the service. In Wales, the strategy has been slightly different. They have gone for a bottom-up approach, feeding data back. I hope that, with one system or another, we will see some improvement.

Training the next generation of microbiologists poses huge challenges to the Government. There are only 39 whole-time equivalent consultants in infectious diseases and tropical medicine in England. Half of those are academics. New posts require substantive funding, if they are to continue. Serious consideration may need to be given to the creation of academic posts with long-term funding, to ensure that there is an attractive career path for the next generation of clinical microbiologists. The research and development that we will need will depend on the academics, as well as on the clinicians.

There has been a shortfall in the number of funded specialist registrar training posts. Unfortunately, the devolution settlement between England and Wales has meant that funding for two and a half posts has been lost from Wales. There are consultant posts in clinical microbiology that have been vacant not just for months but for years. Adequate training of the next generation of consultants is crucial.

I have a concern that, when the funding for microbiology laboratories in trusts is no longer ring-fenced but is handed over to PCTs, there may be a tendency to provide funding that will merely maintain laboratories rather than encourage them to flourish. I hope that that concern is misplaced, but I urge the Government to watch the development of laboratories carefully. The Health Protection Agency Bill is before us, and the Health Protection Agency must work in harmony with the National Health Service in Wales to deliver public health outputs at local delivery and at a high level.

The need for research was highlighted in the report and recognised in the Government's response. The Government plan to enhance funding for research into communicable diseases. That was stated in their response. However, there is a need for people with academic training and with sufficient remit to get the high calibre research that is needed. The quality of the proposals competing for funding for research is relatively poor. Some of the projects seem relatively simple, so they do not get funding in open competition.

The issues relating to consent in the Human Tissue Bill may also make some areas of research more difficult. For instance, in work using collections of sera, it would be difficult to obtain specific consent for the sera to be used as part of a research programme.

Looking forward, we need to consider other forms of infection control, and there is a huge gap in knowledge. The design of effective interventions to reduce the prevalence of hospital-acquired infections and to limit the development of antibiotic resistance seems like an obvious area of research, but it is not undertaken to an adequate degree because there is inadequate funding for such research. Areas such as the way in which microbes communicate with each other and quorum sensing may become important, but the development, through the pharmaceutical industry of yet more antibiotics will probably lead simply to increasing complacency that antibiotics will ultimately do the job and that new ones will be found and will breed out further resistance.

The last area of education that I shall address is public education. The need for a public education campaign is huge. There is public complacency and a misguided belief that antibiotics can cure infections, hence the tremendous shock when patients die of infections. Infections always have been and will remain life-threatening.

A study of primary school children in Leeds revealed poor hand washing. Children who had episodes of diarrhoea and infection had worse hand-washing practices than children with lower instances of gastro-intestinal infection. Perhaps the public education campaign should be at that level. Could people such as soap opera stars be used to influence public behaviour in hygiene? Some good public education materials are being developed, particularly in e-learning, but we must ask whether they will reach the public.

Our report highlighted a huge job for the Government to do. In their response, the Government have taken all the areas seriously, giving a commitment to work on them. I ask the Government to consider keeping the matter under scrutiny in the long term. Unless it remains under long-term scrutiny, it may drop from public consciousness, and we will have a whole set of new infections.

6.28 p.m.

Baroness Masham of Ilton

My Lords, it is a pleasure to thank the noble Lord, Lord Soulsby of Swaffham Prior, for his continued hard work in sharing this latest inquiry into fighting infection.

The noble Lord also chaired a sub-committee on resistance to antibiotics and other antimicrobial agents. The report came out on 17th March 1998. I had the honour of serving on that committee. That report stated, at page 42, that MRSA posed one of the biggest challenges to infection control. Dr Mayon-White called for a national MRSA strategy and pointed out that MRSA was, a marker for cross-infection generally". Therefore, a strategy to control MRSA would bear down on other infections as well.

The time has come to be more forceful. I like the cover of this report. I congratulate the person who suggested it and designed it. But Box 14 on page 38 should be much stronger. It states: Handwashing is a key intervention to reduce spread of infection and yet it is known that many health care workers do not wash their hands when moving between patients. Research could inform those who organise services how better to design wards and run services so as to minimise the barriers to handwashing". Surely, with around 5,000 lives being lost every year from MRSA, the word "could" ought to be replaced with "should" or "must".

The rise in highly resistant MRSA and other serious infections is put down to poor hygiene, more advanced surgery techniques and the over-prescribing of antibiotics. At long last the Government have got the message: the complacency that has existed in many healthcare establishments cannot continue. Would it not be wise to screen staff as well as patients for MRSA when they come into hospital? The committee were concerned to find that, given the significant demands placed on NHS trusts to fulfil their clinical roles, there were as yet no plans to provide any material incentive for NHS laboratories to rise to the public health challenge.

The committee noted that the recent House of Commons Health Select Committee report on sexual health expressed concern about the impact of recent changes in management of laboratories conducting surveillance of sexually transmitted infections. The rise in HIV and other sexually transmitted infections is very worrying. The British Medical Association has called for an end to waiting times for sexual health treatment. It stated: We have now reached crisis point in genitor-urinary medicine with many clinics having waiting times of anything up to eight weeks. We need to return to a position where they can see patients within 48 hours". I hope that we can hear some hopeful words from the Minister so that GUM clinics will be able to cope with the increasing demands.

The report puts great importance on the need for good surveillance. It is worrying to note that the sub-committee found that information is not shared between all those responsible for surveillance. On page 20 of the report, the committee recommends that, given that there is little vaccine production capability in the United Kingdom, by April 2004 the Government should develop and publish a strategy to ensure secure access to supplies of vaccine in the face of national outbreaks of infectious disease.

There have been some tragic cases of children dying of Fujian flu lately. Are vaccines to be made available to protect children and other vulnerable groups against that dangerous strain of flu? The report recommends that the Government should fund enhanced surveillance of the impact of vaccine programmes on the incidence of disease, particularly when new vaccines are introduced. It also recommends that the Health Protection Agency be provided with resources to take on specific and primary responsibility for integrating surveillance related to human, animal and food-borne infection at national, regional and local levels in order to bridge the gaps that currently exist between those areas of specialty.

The report states that GPs receive inadequate training about best practice in identifying and treating infections. One problem area seems to be when and when not to use antibiotics. In some cases, antibiotics are vital to life. Near where I live in north Yorkshire, a man 41 years old, married with two young children, lived on a farm and undertook relief milking. Some months ago he died of leptospirosis, or Weils disease. The organism leptospira icterohaemorrhagiae is harboured and excreted by rats and enters the body through a bite or skin abrasion and infected water. I am told that in New Zealand at-risk farmers and people working with water would be vaccinated. Should that happen here?

SARS alerted many people to the fact that one never knows what infection will come next. With many drug-resistant infections emerging, that is a serious matter. I am glad that the Government are responding. I look forward to the Minister's reply. Only last week, at lunch, a guest told me that his sister-in-law had been infected by MRSA in a private hospital in Yorkshire. Worse still, the next person to use the room also caught MRSA.

Infections have no boundaries. I hope that the Health Protection Agency will also cover private hospitals and nursing homes and medical and nursing staff as well as patients who use and work in both private and National Health Service hospitals. I hope that there will be no discrimination. Fighting infection must mean that everyone works together for a safer society.

6.37 p.m.

Baroness Emerton

My Lords, I, too, welcome the opportunity to contribute to the debate. I am grateful for the privilege of serving as a member of the committee led so ably by the noble Lord, Lord Soulsby. As well as my noble friend Lady Finlay and the noble Lord, Lord Haskins, I too pay tribute to Rebecca Neal who was the Clerk who facilitated not only the work of the committee in an efficient manner, but also gave me personal support in my introduction to the work of the sub-committee of the Select Committee.

I, too, welcome the Government's response to the committee's report. I shall focus on the Government's announcement last week of the appointment of a director of infection control to all NHS trusts. I was particularly taken with the words of the Secretary of State, the right honourable John Reid, when he commented that, old fashioned hygienic methods were needed. There really is no magic solution. It is about hard work and old fashioned methods". Having trained as a nurse 50 years ago, I truly can claim to have been brought up in old-fashioned methods of cleanliness and aseptic techniques. The ward and theatre sister was the person who controlled the environment and was responsible for cleanliness. When dressings had to be applied, damp dusting was carried out two hours before any wound was exposed.

I admit that there have been many advances in the past 50 years with regard to sterilisation and wound management. However, as has already been said today, I am very aware that the discipline of basic procedures—for example, hand washing—has slipped in many instances. Recently, I witnessed a surgeon removing sutures, not having washed his hands either before or after the procedure.

As a chairman of an NHS trust, I was very aware of the convoluted lines of management control to rectify dirty lavatories, bathrooms and patient areas.

I realise that the contracts with commercial firms contain quality standards, but someone from management is not always available to deal with a problem. One has first to go to an NHS manager who then contacts the commercial firm, and by then, time has passed. I therefore endorse the Secretary of State's statement—there is a lot to be done which requires hard work.

Will the director of infection control be an executive member of the board or a non-executive member in an advisory capacity? The lines of communication and organisation of management control within the health service are very complex. We know that they have to cross lines of organisational management to get things done.

I wonder whether the director of infection control might meet the same problem that I met when I requested that toilets in the hospitals were inspected on an hourly basis, as they are in motorway services, supermarkets and public areas. My request had to be considered first by the chief executive of the trust and the facilities manager. A discussion then took place with the commercial contractor. The costs and staffing implications had to be assessed, which resulted in a three-month delay before any action could be taken. The results of this investigation showed that the cost was outside the budget, so there was a further delay in implementing the regular checking of toilets and bathrooms.

I believe this is where decisive action needs to be taken. The director of infection control will need to have the accountability and authority to take executive action. This therefore needs to be clearly spelt out in the new director's job description. The same goes for food hygiene, catering and the wearing of uniforms.

We all accept the old adage, "prevention is better than cure", but, as has already been said, we need to reduce the number of hospital-acquired infections. This is urgent, given the need not only for reduction in suffering and mortality but also to reduce costs and increase efficiency. It is estimated that the stay of a patient contracting a hospital-related infection is extended by 11 days and often more in the case of MRSA.

I welcome the Government's commitment to enhancing the education programmes. Health professionals and all staff working in the environment of healthcare need to have basic training— indeed, health professionals need to have more in-depth training.

I have concerns that the primary care trusts need to be involved in considering the ways in which control of infection will be effective. They, too, may need a director of infection control.

I believe that as well as hard work and old-fashioned methods, there needs to be an additional word— "discipline". It is not a popular word in this day and age, but historically, from Florence Nightingale onwards, it has been proved that a disciplined approach to the control of infection is effective.

I also agree with my noble friend Lady Finlay that the Government should be encouraged to have a regular review of the control of infection.

6.44 p.m.

Lord Oxburgh

My Lords, the Science and Technology Committee tries hard to choose subjects for study that are timely and relevant. Rarely in its history can it have hit the mark so squarely as it did this time—hardly had it begun to take evidence than the SARS outbreak began its march across the world.

I, too, wish to acknowledge the contribution of the Academy of Medical Sciences which, some months earlier, drew the committee's attention to this area as one in urgent need of review. I also wish to acknowledge the excellent work of our two special advisers and our hardworking Clerk.

Having settled on this topic, the committee also had the wisdom to invite the noble Lord, Lord Soulsby, to chair the inquiry. This he did with consummate skill and patience, and I think your Lordships will agree that the report which was produced under his guidance is a worthy successor to that of the earlier inquiry he chaired on antibiotic resistance, which has had considerable influence on both sides of the Atlantic.

As has been pointed out by others, infectious disease accounts for a great deal of illness in the UK and world wide. Around 13 million people die from infections each year, and about half of those are children under the age of five. Unfortunately, as other noble Lords have pointed out, in this country we have come to regard infections as something we do not need to bother about. In the last century, the combination of good hygiene, clean water, good sanitation and, in the latter half of the century, antibiotics, virtually eliminated most of the serious infections from the developed world. For this reason, when it comes to training nurses and doctors, infection has a rather low priority in the curriculum.

Our report made the point that the situation was changing rapidly and urgent action was needed if we were to avoid serious outbreaks. I, too, pay tribute to the way in which the Government have responded to the challenge of infections, even though the solutions they have chosen may in some ways differ from those that we favoured. The most important thing is that the problem has been recognised and action has been taken.

The subject is enormously broad. For that reason, I will speak on just three aspects of infection and its management—the role played by animals or organisms in the emergence and transmission of infection, the need for effective means of surveillance, and education.

The problems we face are partly new and partly old problems better understood. It has been known for many years that while some micro-organisms that cause human disease pass directly from person to person, there are many others for which the transmission pathways are more complex and involve other micro-organisms, insects or higher animals. The role of mosquitoes in the spread of malaria and that of rodents and fleas in the spread of plague are relatively well documented. However, a host of other pathogens are spread by complex vector paths that are very poorly known.

One such pathogen that may be coming our way is the West Nile virus. It may be of particular interest to the House because it appears to be one from which elderly men are especially at risk. The virus has been spreading from north Africa for some years and is now affecting both coasts of the United States. It can affect horses and some birds, such as crows, although the final vector, as far as human beings are concerned, seems to be the mosquito. Intriguingly, and with the wisdom of hindsight, the first indication of the arrival of the virus on the eastern seaboard of the US was the unexplained discovery of dead crows in the fields.

I have given just a few examples, but the picture I wish to paint is of an immensely large and complicated web of life in which, numerically at least, human beings and higher animals are a rather insignificant part. Within that web there is an enormous range of relationships—different food chains, different relationships that may be competitive, symbiotic or parasitic. None of the elements of the web are static; they are continuously evolving in response to the pressures of their immediate environments, albeit at different rates. We become particularly aware of that when a newly evolving species happens to be a pathogen in human beings or animals, such as when a new strain of flu emerges from south-east Asia.

Noble Lords may reasonably ask what is new, given that this situation has always been with us and we have learned to live with it. The answer is that this complex web of interdependent organisms, which we still understand only dimly, is being affected by at least three important factors: first, the very rapid global movement of people and goods, particularly foods; secondly, the rapid—at any rate by historical standards—displacement of the world's climatic belts, for whatever reasons; and, finally, the rapid increase in the world's population and a consequent increase of both urbanisation and deforestation.

Modern communications allow us to travel readily to almost any part of the world or to eat crops that were harvested only a few days earlier in another continent. That allows other passengers to travel as well, particularly insects, bacteria and other micro-organisms. They arrive into an environment in which many will not survive; but others will, and a few may flourish and possibly wreak havoc on the local ecosystem. When that part of the ecosystem happens to be ourselves, we recognise the arrival of a new infectious disease. What happened with the introduction of rabbits into Australia can happen with microbes as well. TB is on the increase in parts of this country and the United States.

Organisms are not necessarily dependent on hitching a free ride on people or goods; shifts in the world's climatic belts mean that the distributions of fauna and flora migrate with them. The human population therefore has to become used to living with a range of new pathogens that arrive as the climate changes.

Finally, the doubling of the world's population over the last 50 years has been concentrated in the less developed regions. It has proved difficult for people to continue to make a living on the land and they have migrated to the cities, which often did not have the sanitation or other facilities appropriate to receive them. When those people brought with them their pigs and their birds, it was an ideal environment in which microbes that caused no great harm in animals could jump the species barrier and develop into a virulent human pathogen. Indeed, as the CJD/BSE/scrapie story unfolds, it may turn out that species jumps can occur in much less extreme circumstances.

The conclusion is that, with infectious disease, we are rapidly entering new and largely uncharted waters. We are almost certain to see new and unwelcome additions to the range of pathogens to which we are exposed. Some will simply be new to us, while others will be new to the world. Our greatest danger will be the complacency that has come upon the general population in the western world, through the combined effects of antibiotics, clean water and sanitation. As the report showed, there is a new and growing danger.

What is to be done? It is clear that, although the medical profession and drug companies have an important role, probably the most important task, as various noble Lords have pointed out, lies with us in our everyday lives— in our personal hygiene, in the proper maintenance of our water and sanitation facilities, and in the way that food is managed in our shops and restaurants. We have seen the decline of traditional, labour-intensive, but effective means of infection control, such as scrubbing and cleaning, using soap and bleach. Soap and detergent are particularly effective against many bacteria because they can break down the jelly-like outer protective coating of the bacterium. That is a matter of education in school and elsewhere, and the message must be got through that although we may have got away with it in the past, this is a new situation and is potentially dangerous.

Finally, on surveillance, it goes without saying that if the arrival or outbreak of a new infection is recognised early, there is a reasonable chance of managing and containing it. GPs must be able to report suspected new outbreaks with no more inconvenience than a mouse click on the consulting room computer. The information must be properly managed centrally and, if appropriate, matched with patterns that emerge from calls to NHS Direct. GPs must know rapidly that a new infection is about and, if necessary, be reminded of the symptoms. That must be a priority within the new IT system that is being planned for the NHS. If appropriate the information must be passed on to neighbouring countries—and in that connection we must continue to play a full part in the World Health Organisation. Surveillance must involve not only the medical profession, but the veterinary profession, biologists and microbiologists as well.

If we are not to return to the misery of earlier centuries, these challenges demand the concerted and co-ordinated efforts of the Department of Health, the HPA, Defra, DfES and the DTI. Is the Minister satisfied that the processes of co-ordination and collaboration between the disparate groups that are in place or planned for the immediate future are sufficient and robust? If they are not, the future is bleak.

6.56 p.m.

Lord Addington

My Lords, I must make one small apology. I was not a Member of the committee; thus, when I read through these documents, I first had the feeling that the matter was comparatively straightforward. After more reading, I decided that it might not be so straightforward. As I went through the Government's responses, I had the fortunate feeling that the Government have something in place that responds to many of the concerns that were raised— primarily the point about co-ordination, which is dealt with, at least in part, by the Health Protection Agency, or HPA. As I was reading, I kept trying to remember exactly what HPA was, and came up with an amazing variety of combinations.

I hope that the Health Protection Agency is something that does what it says on the tin. because something that co-ordinates the services available would meet many of the concerns raised in the report. The primary problem is that they do not guarantee, do not claim to guarantee or cannot guarantee that there is enough spare capacity to handle the unexpected. The Government may say that they have something there. However, in terms of public capacity and testing and analysis in public laboratories, what capacity do they regard as enough to handle any new outbreak? Exactly what do the Government have there? I may have missed it in their response, but if they could answer that question, we might come back to the subject later with an idea of the Government's thinking on spare capacity. I refer to spare capacity for situations that are not run-of-the-mill or normal. In the light of that information, we might then have a chance to see what we can go on to do.

Of the many other considerations that were raised in the report, the one that really struck me was that most of what we are talking about is very old science. Taking into account the idea that most of the diseases that we deal with in future will be known, we are talking about diseases that will strike at the most vulnerable, as has traditionally happened.

An unfortunate fact is that our public health seems to be declining in terms of nutrition, vitamins and the protein balance. Illnesses such as rickets have re-emerged in our society. As many noble Lords have said, new immigrants are entering the country who may bring in new infections. The health standards in their countries of origin tend to be lower than ours. I refer to certain other underprivileged groups, for example, those in prison. Educational failure, health failure and offending records tend to go together. What is the Government's thinking regarding those vulnerable groups?

Will the new structure address those vulnerable groups, and what will it do to improve their treatment? The noble Lord, Lord Haskel, referred to TB cases being treated in the Harlem Hospital in New York. We need programmes that offer treatment to immigrants, whether illegal or not. We should do immigrants a good turn in that respect for the simple reason that it would avoid TB being spread in our society and infecting more people. By saving those people we would save ourselves. Will such an approach be encouraged in our society? Asylum seekers and new immigrants have had a very bad press. A series of nasty, snide digs have been levelled at them as people who bring infection with them. Unless we introduce a scheme along the lines of that mentioned by the noble Lord, Lord Haskel, we shall encourage a series of social ills as well as physical ones. Do the Government have any plans to introduce such a scheme involving joined-up government thinking between the Health Protection Agency, immigration services and the Prison Service? If such a scheme is not introduced, those vulnerable groups will miss out on treatment.

As regards children's health, I encourage the Government to consider not just infection itself but to ask themselves why infections are taking hold. The Government should further examine the ways in which family benefits are most effective in encouraging families to eat nutritious food and thus ensure that the fertile ground for infection is cut away. The Government should consider whether education on nutrition should be given with benefits. Of late we have heard a great deal in this House about obesity. People may be eating the wrong things. Will the Government address the issue of healthy eating as well as just giving out benefits? The spiral of economic deprivation leads to bad nutrition. If we can interrupt that spiral, I hope that we shall make some progress.

Unless the Government are prepared to return to very old-fashioned values, for example, regarding the regular scrubbing of hospitals—as I believe was pointed out by the noble Baroness, Lady Emerton— much trouble will arise. Unless they also address the fact that we just do not know what will happen next in this context and build in enough spare capacity to deal with the worst case scenario that we can imagine, we shall experience further problems. That will happen irrespective of how well we deal with the infections of which we are aware. SARS was the most recent of a variety of infections. I draw the Minister's attention to a passage in the report referring to the common cold. Everyone I know has a cold at the moment, myself included. I attribute that to the presence of a small toddler in my house. Such infections are easily spread and we are always playing catch-up in trying to tackle them. I hope that the Government have some idea of how they are prepared to tackle such infections.

7.5 p.m.

Lord Skelmersdale

My Lords, the House will be grateful to my noble friend Lord Soulsby and his committee for their exhaustive work on this subject. I should like to add my congratulations to the Clerk, Rebecca Neal, who had the unenviable task of summarising 395 pages of evidence into the 36 pages of the report itself—a major piece of precis that anyone should be proud of.

Public health, which is what we are basically talking about here, has been defined as, the science and art of promoting health, preventing disease, and prolonging life through"— and I emphasise this— the organized efforts of society". Society, though, can do a certain amount for itself. I shall discuss that in a minute. Preventing disease brings me straight into a major criticism of the report. "Arrangements for formal collaboration", says the executive summary, are poor, and lines of accountability are unclear. Collaboration is difficult: many organizations and health professionals are involved in fighting infection". You can say that again! Centrally we have the Department of Health. Under this we have the Public Health Laboratory Service, soon to be devolved to the Health Protection Agency. Then there are the nine departmental regions; under them are the strategic health authorities; and under them the primary care trusts. Five bodies are backed up by pathology departments, microbiology and PHLS labs. At the sharp end are the hospital physicians and the general practitioners. All need training; a point well made by the noble Baroness, Lady Masham. I reserve judgment on whether the HPA will be able to cut this particular Gordian knot.

Consider a wedding. The guests are likely to come from all parts of the country. They drink and, more importantly, they eat. It takes only a tiny bit of mayonnaise or undercooked meat for a salmonella outbreak to occur. All unbeknown to the guests, they carry it around and some will inevitably spread it to their families and neighbours. It may be quite quick and easy to establish the epicentre of the outbreak, but how is the information to be transmitted around the country? Is it, as has happened in the past, to go up through this long bureaucratic chain of command, resulting in a '"Dear Doctor" letter from the CMO, and taking weeks if not months to get the information to where it is really needed—the hospital departments and GP surgeries? Would it not be far better for the local laboratories to report immediately to their PCTs, and the PCTs to talk to each other? In these days of the much vaunted e-government, it should be very easy to compose an e-mail and copy it to all PCTs. This is dealt with in Sir William Stewart's evidence on page 316 of Volume 2. As the noble Lord, Lord Oxburgh, said, speed is of the essence.

Salmonella is a comparatively local problem, but what about an international one such as SARS? In preparing for this debate, I was told that this disease was originally to be called simply, Acute Respiratory Syndrome. The tautological word "severe" was added to avoid the acronym, ARS! That is far worse than the inelegantly named CHAI—the Turkish word for tea— that I referred to not long ago. After that little aside, let us look at SARS. According to the WHO, during the outbreak in the Far East, a total of 8,098 people became sick, of whom 774 died. The terrifying thing about SARS is the speed at which it gets around, inevitably, I am afraid, with the world shrinking faster and faster due to cheap travel and bad air circulation and scrubbing of air in aeroplanes.

The first case was reported on 16th November last year as an unknown acute respiratory syndrome in Guangdong Province, South China. A small paragraph on 14th February 2003 in the Weekly Epidemiological Record reported 305 cases and five deaths from an unknown acute respiratory syndrome. The Chinese Ministry of Health informed the WHO the same day. In passing, as the news had already broken, the Chinese lost no face in that. However, looked at from this distance, the speed of more general notification was slow. We now know that a medical doctor from the province checked into the ninth floor of the Metropole Hotel in Hong Kong with atypical pneumonia. He infected at least 12 other guests and visitors to that floor.

So far, the outbreak is confined to China, but on 7th March—not very long afterwards—new reports come in from not only Hong Kong, but Vietnam. Approximately 20 hospital staff become sick with similar symptoms. Three days later, the problem in Hong Kong has escalated. Within hours of reporting being ill, 18 healthcare workers are diagnosed. On 14th March, a flight attendant reports with SARS in Singapore. Contact tracing, a vital weapon in public health, will subsequently link her illness to more than 100 SARS cases in Singapore. To cut a long story short, the following day 15th March—SARS is reported in Canada. On 15th May, it is reported in the UK. On 22nd May, a second outbreak occurs in Toronto. By 6th June, there were 82 cases in that second outbreak.

From then, we know that through proper quarantine regulations the epidemic was controlled. However, it is not only how quickly, but how dramatically SARS affected the far east, Canada and several other countries that is so worrying, as many of those are not developing nations with inadequate healthcare provisions or vaccination programmes, but developed countries with a healthcare infrastructure and economy remarkably similar to our own.

Closer to home, in spite of the recent scare stories, hyped naturally by the media, I remain proud of my part in the introduction of the MMR vaccine. It was introduced primarily because, although we had a working vaccination programme for the individual diseases, we were not targeting the right people. Men, who were not vaccinated against it as babies, were carriers of rubella, with all its dreadful effects on pregnant women and their babies. The average number of birth defects as a result of rubella infection has fallen from 250 a year before 1970 to an average of four— yes, four—between 1991 and 1995. If that is not success, I do not know what is.

The only issue in the case of the MMR vaccine is the media attention surrounding possible side effects. I will go to my grave believing that the fact that autism and Crohn's disease present themselves at around the time that the MMR vaccination is given is coincidental and not causal. After all, do not babies learn to run around the age of two?

Only 84 per cent of babies received the MMR vaccine in 2001–02, 8 per cent lower than the peak coverage achieved in 1995–96. Over 90 per cent is required for proper control, so even with single vaccines, the courses of which are often not completed, we face an upsurge in not only rubella but measles and mumps as well. I agree with my noble friend Lord Soulsby about the rundown of vaccine production in this country, but that is not exactly the point that I have just made. Why do we vaccinate human beings but Defra sets its face against the same thing in animals, something we have learned over the BSE crisis? Perhaps the Minister will be able to answer.

Friday's report, Winning Ways, by the Chief Medical Officer was well reported in the papers that I read, concentrating as it does on diseases in hospitals. However, it is only a partial response to the committee's report. Hospitals are well known to be dangerous places health-wise. I once came round from an elective operation complaining to the surgeon of a sore throat. "Nothing to worry about", he said, "it's probably the anaesthetic". A little later the anaesthetist came round. "Oh dear", he said, "your throat's very red", and gave me some soothing medicine. Soon after I started to sweat. The following day a rash appeared, getting progressively worse.

It was not until the day after that that a friend came to visit me. It so happened that he had just retired as the head of the local public health service laboratory. He looked at me and said, "If it weren't impossible, I'd say you had scarlet fever". A physician was summoned, my temperature of 105 degrees was taken, and the condition was—surprise, surprise— confirmed. I was pumped full of antibiotics and recovered. That occasion was not the hospital's fault; I had been in contact with an undiagnosed scarlatina case, and the operation had exacerbated the problem.

That just goes to show how things happen. Is it any wonder that flu, legionnaires' disease or MRSA spread like wildfire in a hospital, where not only is the temperature warm, but the patients' resistance is inevitably at a low ebb? The very fact, too. that methicillin resistant staphylococcus aureus, to give it its full name, has a toehold in a hospital makes it inevitable that it will spread. Indeed, the latest figures show that the number of people recorded as dying of it is rising, as the noble Baroness, Lady Finlay, said.

I spoke earlier of the organised efforts of society, but society could do a certain amount for itself. The noble Lord, Lord Haskel, spoke about this. How often have we been in a public toilet in a restaurant and seen people not washing their hands? How often have we seen unfinished courses of antibiotics returned to the pharmacist, or worse, thrown in the bin? I am no pharmacologist, but is it surprising that diseases become resistant to antibiotics when that happens? The CMO's report makes the point highlighted by the noble Lord, Lord Addington, about nurses and doctors washing their hands after touching patients. A new pair of surgical gloves each time on originally clean hands might be a bit more practical, but who am I to argue?

Interestingly, a recent article about Ebola from the Congo makes the same point. Health officials there are apparently trying to stop the habit of friends and relatives touching the bodies of dead people. Not sterilising and reusing catheters and drips but throwing them away is another suggestion in the report. That is a matter for negotiation, I suspect, because there is cost involved, although I have no idea how much it is. However, it is something that the National Health Service will have to sort out. Surely it is wise advice.

I question the role of what will surely come to be known as the super de-bugger, an upgrading of an existing management post referred to by the noble Baroness, Lady Emerton. In days of yore when we had proper matrons, that would have been one of her roles. Surely it should be again, and cleaners should come under her.

On a slightly different subject, I remember Her Royal Highness Princess Anne making the keynote speech at an early AIDS conference, and describing HIV/AIDS as an evil monstrosity perpetrated by mankind upon itself, or words to that effect. That is true not only of HIV/AIDS, but of all sexually transmitted diseases and many others besides.

Most of us were brought up with the slogan, "You've got to eat a peck of dirt before you die". I did a little research. The noble Lord, Lord Warner, loves to rush to the dictionary, and I did exactly the same thing. There are two gallons in a peck, and I reckon that that is a heck of a lot of antibodies. I doubt that a child born today will eat more than half a pint. No wonder minor sicknesses abound; it is my view that the health police are often doing more harm than good.

Finally, I was struck by Professor Weinberg's comment on page 378 of volume two that the role of surveillance was to provide early warnings of an increase—he might have added the word incidence—of infection. All well and good, but unless the warning is passed on quickly, we will be putting Pelion on Ossa. The written evidence of the Infection Control Nurses Association makes the similar point that the collection of data is not standardised, and may even be false. It takes time to check the accuracy. So it may, but I doubt whether it is that damaging or that long.

That returns me to my central point, for which I shall quote the PHLS written evidence on page 134 of volume two. The most telling definition of "surveillance" is that, surveillance is the delivery of information for action". On this matter, we cannot have action without the wide spread of information, arriving quickly at the point of delivery of that action.

There is so much in the report that I have inevitably only scratched the surface, despite speaking too long. I trust that the Department of Health will build on Sir Liam's report and continue taking action on this section of public health, which is so vital to every man, woman and child. The committee's report should help them to do that, and I trust that the department will accept it lock, stock and barrel as a valuable aid in the war on infection.

7.20 p.m.

The Parliamentary Under-Secretary of State, Department of Health (Lord Warner)

My Lords, I am grateful to the committee for the work it has done on this important issue and the chance that this debate provides to discuss the committee's work and the Government's response. I also pay tribute to the work of the noble Lord, Lord Soulsby, and of my noble friend Lord Haskel who will now leave the Science and Technology Committee.

The Government's response focused on the strategy described by the Chief Medical Officer in his report Getting Ahead of the Curve, which was published in January 2002. I shall use this debate also to outline the further work the Government will be doing as a result of the document Winning Ways published last Friday on action to reduce healthcare associated infections. Despite the temptation offered by the noble Lord, Lord Skelmersdale, I shall not venture into the areas of MMR or BSE.

The CMO's strategy observes that, this country is internationally respected for its work on infectious disease surveillance", and that we have, traditionally had a much stronger public health system than many other countries"; but that at the same time, the present system falls short of what is necessary fully to protect the public health". That is the position from where we start. For the first time ever the Department of Health now has in place a strategy for tackling infectious disease. The strategy brings together a great deal of information about infections and sets out a number of actions, which in total provide a systematic approach to preventing and controlling infectious disease. Some noble Lords have drawn attention to the importance of co-ordination, with which I agree. We have tried to bring the threads together in what was a rather disparate area in that strategy.

Recent events have made us all much more aware of the risks from infections as well as chemical and radiological threats. Those aspects were explained persuasively by the noble Lord, Lord Oxburgh, who drew our attention to the role of animals and birds as carriers and some of the problems arising from easier international transport, which has increased the risk from imported infections carried by people or foodstuffs. We are also seeing a greater number of patients with immuno-deficiencies that make them more susceptible to infection. We now have the spectre of deliberate release of pathogenic organisms. All those factors plus the emergence of SARS earlier this year—mentioned by the noble Lords, Lord Skelmersdale and Lord Oxburgh—have led us to look afresh at how we can best protect the health of our population from infectious diseases. Such issues and others have been well recognised by the committee's wide-ranging report.

First, I shall describe some of the progress that the department has made since Getting Ahead of the Curve was published before responding to some of the specific recommendations in Fighting Infection.

The new and emerging infections panel mentioned in Sir Liam's report has been set up. The function of the panel is to identify key areas for action and to advise on priorities. The panel reports to the Chief Medical Officer and held its first meeting in November 2003. It is expected to meet every six months. The CMO has also announced two new actions to help NHS staff combat infections. One was new funding of nearly £12 million to help NHS hospital pharmacists monitor and control more carefully the use of antibiotics. The other was the extension of mandatory national surveillance of healthcare associated infections which include blood stream infections and serious adverse incidents associated with infections, such as ward closures due to gastro-enteritis.

I shall say more later about the new action plan on healthcare associated infections. Alongside, we have action plans for tuberculosis and hepatitis C which will be published soon. The action plan for TB will have clear objectives, but the issues surrounding them are complex. That is why we are taking time to ensure that they are thoroughly thought-through. I remind my noble friend Lord Haskel that we have TB testing capacity at Heathrow and Dover, for example, for people coming into this country. An action plan will be published early next year to support implementation of the department's Hepatitis C Strategy for England following consultation last year.

We have implemented the proposal in Getting Ahead of the Curve to transfer to NHS trusts those laboratories in the Public Health Laboratory Service that carried out routine clinical diagnostic microbiology activity, and are transferring to the Health Protection Agency those that carry out specialist and reference microbiology. The transfer of laboratories to the NHS took place on or by 31st March 2003.

The Health Protection Agency now has, or commissions, a public health laboratory in every region. Steps have been taken to ensure that all the laboratories transferred to NHS trusts are appropriately resourced and motivated to continue to meet their public health responsibilities. We intend that standard national operating procedures will be put in place throughout the NHS microbiological pathology service so as to improve quality and ensure consistency of reporting arrangements.

The department's programme for modernising pathology services includes a requirement for all NHS pathology laboratories to be enrolled for accreditation by an appropriate accrediting body. The HPA is in the process of agreeing service level agreements with relevant NHS trusts which will define their health protection outputs, including reporting infectious diseases and submitting samples and isolates for further analysis. I hope that that gives the noble Lord, Lord Addington, some reassurance on the action we are taking on capacity.

A new inspector of microbiology post has been created to champion and promote the delivery of high quality clinical and public health microbiology services. We expect to have the inspector in place next month. He will initially be located within the Department of Health and the post will transfer to the Commission for Healthcare Audit and Inspection in late 2005 or early 2006.

I am well aware of the doubts that have been expressed by noble Lords and others about the rationalisation of microbiology laboratories and what has been perceived as a break-up of an effective public health network. But my information is that the laboratory transitions have all been carried out smoothly and the public health business has not been disrupted, as some feared.

As the Fighting Infection report described, the role of vaccines is key to protecting our population from infections. A programme of research to inform key policy decisions relevant to the future use of vaccines in the UK is currently being undertaken. This programme covers a number of topics, including evaluating new and potential vaccines for use in the UK childhood programme and in adults. Undertaking this programme of research will allow the introduction of vaccines at the earliest opportunity and in the most cost-effective manner. I will come shortly to the committee's recommendations concerning a strategic vaccine facility.

A number of noble Lords mentioned the Biosciences Innovation and Growth Team report. In response to that report, I have established a high-level working group, the Research for Patents' Benefit Working Party, chaired by the department's director of research and development, Sir John Pattison. This will look at how we can take practical steps to implement some of the ideas and issues recommended in that report. It will report to me and to my right honourable friend the Secretary of State within about six months.

The Chief Medical Officer's strategy also describes our progress in developing clear and comprehensive contingency plans to reduce the impact of any future terrorist attack. This is a vital part of our ability to fight infections. However, as these measures will be dealt with in the Government's response to a different Select Committee in another place, I do not propose to go into such detail here.

I turn now to the subject of the new Health Protection Agency. The Chief Medical Officer's strategy proposed the creation of that agency. It was established as a special health authority on 1st April 2003, and in this Chamber we shall shortly be debating the Bill to make the agency a non-departmental public body. The Health Protection Agency integrates into one organisation expertise which was previously dispersed throughout a number of different bodies. I shall not go into that detail. It also works in partnership with the National Radiological Protection Board, whose functions will be transferred to it under the new legislation. Therefore, there has been a considerable move to integrate and co-ordinate much expertise dispersed around a number of organisations.

We believe that the Health Protection Agency is the first of its kind in the world. Its creation is an essential, ground-breaking, development for the protection of health in this country. For the first time, we have an integrated, coherent organisation which spans the major areas of health protection and brings together local, regional and national responses to emerging threats. In response to the concern raised by the noble Lord, Lord Addington, who asked whether we were planning for the unexpected, the emergency division of the HPA carries out regular exercises to test our ability to respond to a number of scenarios and it continually models projections for different diseases.

The HPA published its first corporate plan setting out 12 strategic goals, the first of which is to prevent and reduce the impact and consequences of infectious diseases. The department will be working closely with the agency to develop its plans and targets for future years. The HPA is providing its own response to the committee's report.

I now turn to the Government's response to the recommendations made by the Select Committee. We have considered the recommendations very carefully and I hope that that shows in our published response. We welcome the great majority of the committee's recommendations and will be working with the HPA and with other stakeholders in the NHS and local and central government to put them into effect. In some areas, of course, we do not see exactly eye to eye with the committee. Where that is the case, we have made it clear in our response.

We noted the committee's recommendation for a central strategic vaccine facility. We have not been convinced by the evidence that we have seen so far, and we have yet to see a clear and persuasive business case that describes exactly what such a centre would provide. The development and production of a vaccine is not a rapid response to an emerging infection, and we need to be very clear about the purpose before we commit the substantial funding which it would require.

We are also not sure about the committee's recommendation that we should produce a definitive publication of all the roles and responsibilities of those involved in responding to infections. We believe that the staff across the country who are involved in this area know very well what they have to do and that they would not necessarily be helped by the publication of such a description. The establishment of the HPA makes the position far clearer, as I believe many noble Lords recognise.

My noble friend Lord Haskel raised the issue of the recruitment of environmental health officers. We are working with the Chartered Institute of Environmental Health, and I am sure that colleagues in the Office of the Deputy Prime Minister will study very carefully my noble friend's concerns.

Finally, I turn to the issue of reducing healthcare-associated infection and the report, Winning Ways: Working together to reduce Healthcare Associated Infection in England, launched last Friday by my right honourable friend the Secretary of State and the Chief Medical Officer. The noble Baronesses, Lady Finlay and Lady Masham, spoke eloquently on those issues, as did other noble Lords. The report represents an important action plan for tackling such infections. It recognises that the problem of infection in hospitals and other healthcare settings is a challenge to health services around the world. The level of healthcare-associated infection among patients in the US, Australasia and most European countries, including the UK, is estimated to be between 4 and 10 per cent. Most countries are adopting similar strategies to control healthcare-associated infection.

Despite the efforts that we have made thus far, we have not made the progress that we would like to see in this country. That is why the Chief Medical Officer is proposing seven action areas where change is required. Those are: active surveillance and investigation; reducing the infection risk from the use of catheters, tubes, cannulae, instruments and other devices; reducing reservoirs of infection; high standards of hygiene in clinical practice, which many noble Lords mentioned; the prudent use of antibiotics; management and organisation; and research and development. I saw the CMO talking about this subject on television last week. He expressed it very graphically, when he said that it is a case of "no more Mr Nice Guy". The approach that we are adopting will involve a return to some of the good hygiene practices in hospitals that many noble Lords have mentioned.

The new report recognises the need for infection control to be everyone's business and it will ensure that senior management change the culture by the designation of a director of infection prevention and control. Perhaps I may assure the noble Baroness, Lady Emerton, that he will report directly to the chief executive and the trust board. That is set out in Winning Ways. The new Inspector of Microbiology and the National Patient Safety Agency will, for example, work jointly to ensure the use of "root cause analysis" and the methodology of hazard analysis and control point. This is a risk-analysis technique used successfully in the food industry to reduce food poisoning.

The Chief Medical Officer will publish on his website for the public a listing of rates of healthcare-associated infection in each area of the country. A new audit of deaths from healthcare-associated infection will be established and a proportion of the deaths that occur will be investigated in order to identify avoidable factors and lessons to be learnt. A programme of high-quality research and development involving £3 million will be established to underpin effective action and ensure that breakthroughs in the understanding of healthcare-associated infection are translated rapidly into benefits for patients.

I turn briefly to a number of points in this area raised by noble Lords. The noble Baroness, Lady Masham, raised the issue of vaccination against the Fujian strain of flu. Of course, when flu vaccines are ordered, new strains cannot always be anticipated. The vaccines being used this year, for example, provide some protection against this new strain. They are available to those aged over 65 and to high-priority groups, including children who suffer, for example, from asthma and other chronic conditions.

Baroness Masham of Ilton

My Lords, what about the other children who seem to be at risk?

Lord Warner

My Lords, I believe that the Chief Medical Officer has tried to give reassurance on that point. However, I shall obtain more details and write to the noble Baroness.

A number of noble Lords raised the issue of whether there will be sufficient microbiologists. I do not want to go over the details of that but I commend to noble Lords page 19 of the Government's response, which sets out the work being done to increase both the number of specialist registrars and the number of posts in and around the area of microbiology.

The noble Baroness, Lady Masham, also raised the important issue of sexually transmitted diseases. We are aware of the lengthy waiting times and staff shortages in genitor-urinary clinics. In addition to the extra £5 million to improve genitor-urinary medicine that we announced in response to the Health Select Committee's report on sexual health, we recently announced a further £15 million to improve genitor-urinary medicine's premises. We are working with strategic health authorities to ensure that those funds are targeted on those most at need. The Government have made it clear that they have a strategy in this area which includes a very powerful public education programme. However, we are not complacent about this matter and recognise that it is a very important area of public concern.

Perhaps I may also mention that general cleanliness, although not the answer to MRSA, has featured in performance ratings for NHS trusts over the past few years. From those one can see that there has been a very substantial improvement in general cleanliness in hospitals, which reflects the attention being given to this area by NHS trusts.

In conclusion, I thank noble Lords for their contributions on this important issue, in particular the noble Lord, Lord Soulsby, for the work he has done in chairing the committee and producing such a good report. A good deal of change is being made on this important and difficult topic of fighting infection. We hope and believe that the new structures and approaches will work towards improving public health and will co-ordinate matters in a better way, which is of concern to a number of noble Lords.

I assure noble Lords that this area is one which the Government will keep under very close review because of the dangers it presents to public health. We shall have an opportunity to return to some of these issues when we debate the detail of the Health Protection Agency Bill in the new year. Much of what we have discussed tonight is about getting human beings to change their behaviour. That is not always the easiest thing to do.

7.42 p.m.

Lord Soulsby of Swaffham Prior

My Lords. I thank all noble Lords for their important contributions to the debate, and in particular for addressing the major issues so effectively. There has been an air of strong support for the report, Fighting Infection, and it is important that there should be.

We take note of the Minister's response. We are encouraged by it and look forward to seeing the various actions put in place, in particular the development of the HPA. I think that we are slightly more optimistic than my noble friend Lord Skelmersdale about the HPA and its ability to cut what he describes as the Gordian knot on the many issues concerned with health care and the control of infectious diseases. However, as the Minister indicated, I believe we shall return to the many issues dealt with in the report at a later date. No doubt some of those will arise when the Bill comes to this House. In the mean time, I thank all noble Lords for their participation and strong support.

On Question, Motion agreed to.

The Deputy Speaker (Baroness Fookes)

My Lords, I have to announce that in the Division on the Motion on the Summer Recess 2004, the numbers voting "Not-Content" should have been 114, not 115 as previously announced.

House adjourned at seventeen minutes before eight o'clock.