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Clostridium Difficile

Volume 464: debated on Monday 15 October 2007

The Healthcare Commission’s report on the outbreaks of clostridium difficile at Maidstone and Tunbridge Wells NHS Trust is a truly shocking document. On behalf of the Government and the national health service, I would like to apologise to all those who have been personally and directly affected, and to offer my condolences to the families of those who have died. Clostridium difficile is the major cause of serious bacterial infectious diarrhoea. It can colonise the gut, causing inflammation of the colon and in the worst cases it can prove fatal. It is normally controlled by the presence of other bacteria, but when those are killed—for example, by antibiotic treatment—it can grow and cause disease.

Tackling health care-associated infections is a priority in the NHS operating framework. In October 2006, the code of practice on the prevention and control of health care-associated infections became a statutory procedure. We have made it clear that tackling HCAIs should be a priority for all local NHS organisations, and the aim is to reduce the number of C. difficile infections by 30 per cent. by March 2011. Mandatory surveillance of C. difficile infections was extended to people aged two and over from April this year—previously it applied only to patients aged 65 and over—to help with local monitoring.

We have doubled the number of improvement teams that are helping trusts to reduce hospital-acquired infections. We have announced deep cleans within all trusts, and we have published new guidance on uniforms so that staff are bare below the elbow. That assists with hand washing, which is crucial in countering such infections. We are also creating a new regulator with stronger enforcement powers, who will be expected to inspect, investigate and intervene on health care-acquired infections.

In July, we made an additional £50 million available to reduce HCAIs. The MRSA cleaner hospitals action plan has been expanded to cover clostridium difficile. It has already had an impact on efforts to tackle MRSA, and it is expected to have a similar effect on C. difficile. While all those measures are crucial, the report from the Healthcare Commission on Maidstone and Tunbridge Wells NHS Trust shows that we need far more vigilance and determination in our drive to eradicate hospital-acquired infections. The NHS chief executive has written to every NHS trust today, appending the Healthcare Commission’s report seeking reassurances from every NHS chief executive that infection control is regarded as a major priority in every NHS organisation.

We established the Healthcare Commission in 2003 to ensure continuous improvement in health services and to undertake specific investigations into trusts when allegations of serious failings are raised. Because Maidstone and Tunbridge Wells NHS Trust had consistently been among the 25 per cent. of trusts with the highest rates of C. difficile since mandatory surveillance began in January 2004, the strategic health authority proactively asked the commission to undertake that investigation in July 2006. The commission interviewed more than 200 past or present staff, and it also reviewed in detail the case notes for 50 people who contracted C. difficile on admission to the trust and then died.

The Healthcare Commission report reveals significant failings in efforts to stop the spread of C. difficile. If the 50 cases reviewed were representative of the 345 people who died, and if one extrapolated from the reviewer’s assessments, C. difficile was probably or definitely the main cause of death in approximately 90 of the 345 cases, and definitely the cause in 21 cases. The Healthcare Commission found that the trust board was unaware of the high infection rates, and did not spend enough time considering issues relating to infection control. The commission’s report made it clear that the individual appointed director of infection prevention and control did not have any real understanding of their role from the outset. Management of the infection control team was considered inadequate, and there was confusion about who actually managed the team. Overall, the governance system that was intended to bring clinical risk to the board’s attention did not function effectively, and the board appeared to be insulated from the realities and problems occurring on the wards.

The Healthcare Commission makes recommendations for action by the trust, including reviewing its board leadership; the priority of infection control at board level; risk management; clinical guidelines; and staffing levels and training. Those actions will be performance-managed by the strategic health authority. Following the recommendation of the Healthcare Commission report, the South East Coast strategic health authority has commissioned an independent review of the leadership of the trust during the period of the outbreaks. An interim report will be made available to the strategic health authority by November.

Although employment is a matter for the local NHS trust board, I have instructed the trust in this exceptional case to withhold any severance payment from the former chief executive of Maidstone and Tunbridge Wells NHS Trust pending legal advice. I can tell the House that James Lee, the chair of the trust, has today offered the Department his resignation, which I have accepted. I have asked the chief executive of the NHS to ensure that a suitable replacement is found so that the trust can move quickly to act on the recommendations of the report and restore public and patient confidence in NHS services locally.

In addition to the independent review of leadership at the trust, I have asked the Department of Health to carry out a separate review of the role of the chair of the trust and the decision-making process that led to the terms and conditions of the chief executive’s departure. That will conclude urgently, and it will be shared with the Appointments Commission.

I am particularly concerned by the Healthcare Commission’s assessment that

“The Trust delayed announcing the outbreak and then produced figures that almost certainly underestimated the number of deaths.”

I have asked that our independent report on the trust’s leadership at the time of the outbreak examine this specific point.

The report identified five national recommendations. It may be helpful to the House if I set these out, together with the actions being taken in response. First, the diagnosis of clostridium difficile needs to be regarded as a diagnosis in its own right, with proper continuity of management. National guidance has been available since 1994, and a revised version taking into account this recommendation will be published shortly. Secondly, the Healthcare Commission said that further consideration needs to be given to the education and supervision of trainee doctors, with a view to improving the recording of clostridium difficile on death certificates. The need for good reporting of health care-associated infections on death certificates has just been reinforced by a chief medical officer professional letter published on 4 October. Further measures will be considered in response to the report.

The third recommendation that has national ramifications was that antibiotics should be targeted, at the narrowest spectrum possible, and used for the shortest possible time. We recently published “A summary of best practice” on this issue, making that very point.

The Healthcare Commission recommended that the national health service and the Health Protection Agency should agree clear and consistent arrangements for the monitoring of rates of C. difficile infection. In April 2007, we improved the mandatory reporting of C. difficile by introducing a web-based reporting system and requiring data on two-year-olds and above to be reported. The final recommendation was that the board of every NHS trust must understand the roles and responsibilities of the director of infection prevention and control, and regularly receive information about incidents and trends. The report acknowledged that duty 2 of the hygiene code addresses this issue.

The situation uncovered by the Healthcare Commission at the three hospitals is truly scandalous. We must all shoulder our share of the blame, but I hope that the House will recognise that the awful failures in Maidstone and Tunbridge Wells are entirely unrepresentative of the standards of care that patients and the public rightly expect, and which are delivered in hospitals across the country day after day.

I am grateful to the Secretary of State for responding to my urgent question. I am sorry that he did not consider it right to volunteer a statement, given the scandalous events to which he refers, and I am surprised that, in the course of responding, he made no mention at all of the report from the Healthcare Commission in July 2006 relating to the outbreaks of clostridium difficile at Stoke Mandeville, and the clear relationship between the findings at Stoke Mandeville then and the findings at Maidstone and Tunbridge Wells.

At the end of the executive summary in the report on the Maidstone and Tunbridge Wells Trust, there was a long discussion about how both trusts had let down patients in exactly the same way. The report went on to say:

“Governance arrangements were weak or overridden by other imperatives”

in both cases,

“including targets relating to finance and access.”

The report continued:

“While it should be noted that improvements have subsequently been made at Stoke Mandeville, it seems unlikely that these similarities are coincidental. We are concerned that, if organisations are struggling, they should not compromise patient safety by making decisions and taking actions that put some patients at risk.”

So when the Secretary of State says that the events at Maidstone and Tunbridge Wells are wholly exceptional, I hope that indeed they are, but they are not an isolated case. We have had other cases, and the common link between them is that managers in the national health service have been more focused on the Government’s targets and the Government’s imperatives than on patients’ safety. I find it utterly astonishing that we should be here time and again, including in debates in Opposition time, most recently in January, pressing the Government to take the necessary action to deal with the incidence of infection.

The Secretary of State referred to the virulence of C. difficile, but he did not give us the figures. In 2001, 1,214 death certificates included a mention of clostridium difficile. By 2005, the figure was 3,807—comparable to that for deaths from road traffic accidents in this country. Between 2005 and 2006, there was a further 7 per cent. increase in the number of cases of C. difficile reported in national health service hospitals.

What was happening last year? Yesterday, we discovered from The Sunday Telegraph that last October the Government received internally from the head of the infection unit at the Department of Health a report saying that they should put in place a programme costing £270 million, including £200 million specifically for isolation facilities. What did the Government do last October in response to that report?

When we pressed Ministers about the impact of targets, as we have done repeatedly, did the Secretary of State and his predecessors not understand that, back in the middle of 2004, NHS staff in the clean your hands campaign were continuously being told to use alcohol rubs to reduce the incidence of MRSA? Staff should do that; however, as the Maidstone report makes clear, too many staff did not understand that at the same time they had to continue to use soap and water and a proper routine for hand washing to combat clostridium difficile. As we have seen MRSA figures peak and come down, we have also seen clostridium difficile figures rising dramatically, so that deaths from that are at least double those associated with MRSA.

Where are the other measures that could and should have been taken to tackle clostridium difficile? We know that there are cleaning technologies that will be increasingly effective, including dry hydrogen peroxide vapour cleaning systems. We know, for example, that nurses across the NHS have been looking for support in accessing Flexiseal, a faecal management system—but they are not getting it. We know why, as they report back to us, the Royal College of Nursing and others—it is due to cost concerns on the part of management.

Ministers constantly tell us that the health service is receiving unprecedented increases in resources; surely now is when resources should be devoted to infection control, isolation facilities and the relevant technologies. In his response to my question, the Secretary of State has said nothing about the target announced last Wednesday—I say “announced” advisedly; it was issued by the Under-Secretary of State for Health, the hon. Member for Brentford and Isleworth (Ann Keen), to the BBC, but not to anybody else, in a press release. The chief executive’s report to the NHS last week did not mention it at all. What is the target? Suddenly, the Government now say that the response to the problems is to have a new target to reduce clostridium difficile by 30 per cent. by 2011 on a 2008 baseline. We do not even know what the baseline is.

Frankly, we cannot carry on as we are. There is no tolerable level of clostridium difficile at 70 per cent. of the current level. If a hospital thought that, it would think entirely the wrong thing, and it is wrong for the Government to point hospitals in that direction. I have been in hospitals—good hospitals—whose attitude is one of zero tolerance. That is the attitude for which we have been arguing for four years, and what the chief medical officer mentioned in the “Winning Ways” report of December 2003. However, the Government are not promoting it.

Last Thursday, all those who were deeply shocked by what was reported at Maidstone and Tunbridge Wells NHS trust will have heard the Secretary of State blame the trust board and management and no one else. However, when did he receive the draft report? Why did he not act on it then? Why is he acting on it only now, when the public are shocked and outraged at what has happened and he has to recover his position? When he blamed the trust board, why did he not acknowledge that faults have continued at Stoke Mandeville hospital, at Maidstone and Tunbridge Wells NHS Trust and at other trusts? All that means that the Government’s policy is also implicated. Those who were shocked by what happened at Maidstone and Tunbridge Wells will want to know that it will never happen again. The Secretary of State will be able to reassure them only if he changes the Government’s policy and ensures that patient safety, instead of the Government’s misplaced targets, becomes the imperative.

Let me point out that I laid a written statement this morning, although I accept that the hon. Gentleman wanted a verbal statement made in Parliament, and I am very happy to come here and do that. The report was published last Thursday and there has of course been publicity about it.

The essential point to tackle is the allegation that targets are somehow responsible for what happened at Maidstone and Tunbridge Wells. Having read the report and the recommendations to us as a Government, I think that it is completely irresponsible to suggest that hospitals cannot meet what are very important targets. We can have a debate about targets. I said during my very first appearance at this Dispatch Box that the era of top-down targets was over and we needed to move to a new level. However, I do not accept the idea that there is a choice whereby one can either have a target to reduce time waiting in accident and emergency to four hours or have people forced to wait in accident and emergency for 10 to 12 hours, as they did in the past, as the price to pay for safer hospitals.

The hon. Gentleman is quite right about Stoke Mandeville, where the local trust and management said that their problem was in dealing with targets. That is little more than a weak excuse. Hospitals all over the country are tackling targets day in, day out. They want to get waiting times down; they want an eight-minute target for a blue light to turn up; they do not want people to wait more than four hours in accident and emergency; and they want to ensure that the level of hospital-acquired infections is reduced. It should not be suggested that this was the problem at Maidstone and Tunbridge Wells, given the selected findings in the report highlighting the two biggest reasons for C. difficile growing. The first is hand washing. The report says:

“Compliance with hand washing was … variable among staff, particularly consultants.”

The second biggest cause of C. difficile, as opposed to MRSA, is a certain complacency about antibiotics. The report says that in a sample of 50 patients reviewed by the Healthcare Commission, 42 per cent. had been given inappropriate antibiotics and in a significant minority of cases aspects of antibiotic treatment were poor. It goes on to list a whole series of the most appalling errors that took place at the hospital but do not happen at other hospitals around the country. That should not be put to one side as if there is an excuse for this hospital because it was also dealing with national targets. I do not accept the hon. Gentleman’s point, although it is of course typical of the Opposition at the moment. [Interruption.] I am sorry, but it is. A report such as this, which points out appalling failures, is being turned into an argument about national targets.

I fully accept the specific points that the Healthcare Commission’s recommendations directed to Government— they were all mentioned in my statement and they will all be acted on.

The hon. Gentleman rightly mentioned the hospitals that he has attended, as have I, where there is zero tolerance of hospital-acquired infections. It is an absolute priority everywhere; there is nobody in the NHS who does not understand that zero tolerance is the policy that should be adopted throughout the NHS.

The hon. Gentleman asked when I received the draft report. I received it on 9 October. He asked why I did not act on it then. I did. The position as regards the board, which I mentioned in my statement, is part of those actions. A residual power rests with the Secretary of State about the position of the trust board, but in exercising that I want to be absolutely sure, in relation to all its members—not just the chief executive or the chair—that the action that we take will not result in any action against the NHS, and we are absolutely sure of our ground. It is absolutely right to do that, given the seriousness of the situation.

The Secretary of State was right to take urgent action against the members who had responsibility for the trust, but will he explain where the clinical voices were that were not raised during the period in which the infection was allowed to take hold? Why is it that the general public have not heard an outcry concerning those who were directly responsible for infection control? Is he now prepared to instigate a ruthless programme to limit some of the actions of the general public inside hospitals to ensure that we return to a state where hospitals accept that they must restrict public access, or anything that will complicate the opportunities of patients to recover?

My hon. Friend is absolutely right to talk about the clinicians, such as the medical director and the nursing director. They are all part of the review that is going on about the leadership, and they are all subject to the action, which we are reviewing at the moment, that we take about that. It is not just a matter for the chief executive and the chair.

My hon. Friend was also absolutely right to ask where the patients’ voice was in all of this. I understand that 26 members of the public—relatives of patients—complained early on. Why were those complaints suppressed? The very comprehensive Healthcare Commission report—a commission set up for this purpose—identifies a whole series of issues. Therefore, the publication of the report is the start of the process, not the end, and we have to get deeper into the matter to ensure that lessons are learned and that the same thing does not happen at any other hospital.

I add my deepest sympathy to the families affected by this awful business. It is a traumatic and distressing infection to suffer from, and for anyone involved it is a horrifying process to go through. There are far too many people dying of this condition throughout the country.

It is right to stress the sense in which the individual hospital trust is primarily responsible for an outbreak of this sort, and the negligence that appears to have taken place. However, the report refers to occupancy rates in particular, and across the country hospitals are full to capacity, in breach of the national guideline of 85 per cent. Will the Secretary of State initiate a study that determines to what extent hospitals are over-full and considers the relationship between that situation and the outbreak of this infection?

With regard to the accountability of the chief executive and other senior staff, does the Secretary of State agree that failing to maintain the highest possible standards of infection control should amount to gross misconduct, and that it is entirely inappropriate for people to leave on substantial financial packages in the aftermath of such an event? He told the House, when he saw the report, that he could have intervened before the package was announced in order to discharge the whole of that board. Why did he not do so? Will he tell the House when he got to know of the financial package that had been put together? When exactly did that information come through to the Department?

Will there be compensation for the families who have suffered the tragic loss of a loved one as a result of apparent recklessness? The Secretary of State says that the chief executive is writing to all hospital trusts to give this matter priority, but will that override the myriad other priorities that are imposed centrally by the Government? Finally, it has taken more than a year for the Healthcare Commission to reach its conclusions, but the evidence that must have emerged during its study should surely have told it that urgent action needed to be taken. More than a year is far too long a wait for any decisive action to be taken by the trust, when the evidence must have appeared much earlier.

I will consider the occupancy rate throughout the country to see whether it is causing problems, but the top priority is always safety. One minute the NHS is being criticised for not being productive enough, and the next it is being criticised for being over-productive. Obviously, there must be a balance, but it must never compromise patient safety. [Hon. Members: “It has.”] Opposition Members say, “It has”, as if what happened at Maidstone and Tunbridge Wells were typical of the rest of the country—it is not. And it is an indictment of, and an insult to, NHS staff throughout the country to suggest that it is.

The hon. Gentleman asked about gross misconduct. I believe that gross misconduct has taken place. He asked when I knew about the financial package. The answer is 11 October. When I knew about the situation and saw the report, I immediately sought advice about what I could legally do. It is easy to have a knee-jerk reaction, believing that there are residual powers, only to find that the NHS has been opened up to damages. The hon. Gentleman is a former employment rights lawyer and therefore knows that one has to ensure that one has the correct advice before taking action. I have ensured that that happens.

The hon. Gentleman mentioned writing to trusts. The NHS chief executive is not only writing to trusts but doing so with a copy of the report. The hon. Gentleman will have seen a copy, including the photographs. It is horror story, which needs to be brought to trusts’ attention, not simply through a bland letter from the NHS chief executive saying that there was a problem, but by showing photographs and examining the chronological order. The hon. Gentleman asked an important question about why action was not taken earlier. I shall discuss that with the chair and the chief executive of the Healthcare Commission tomorrow.

Blaming targets is an unacceptable argument for incompetence and worse, and I am glad that my right hon. Friend has rejected it. Will he confirm whether the police are making investigations to ascertain whether appropriate charges can be brought against those in senior management at the time?

My hon. Friend will appreciate that that is a matter for the police. The Health and Safety Executive passed on the issue to Kent police, who are looking into it. I do not think that anything I can say would help the situation at the moment.

May I draw the Secretary of State’s attention to the debate in the House on 23 January 2007? After listing a catalogue of neglect and disaster at Maidstone hospital, I said:

“One of my constituents telephoned his brother to say that he was in Maidstone hospital with C. difficile, sitting in his own diarrhoea, and that he wished he was dead.”

I asked the then Secretary of State:

“Can anyone believe that when that is the standard of nursing, it has nothing to do with the spread of infection?”—[Official Report, 23 January 2007; Vol. 455, c.1321-2.]

That was 10 months ago.

May I draw the Secretary of State’s attention to something that I identified at the time, but that has not been mentioned in his responses so far? It is the crucial role of ward sister. Ward sister, unlike management, matron or the director of nursing, is there all day. She used to fulfil the role of boss: “Nurse, why is that drip empty?”; “Nurse, why is this man in his own diarrhoea?” If she still fulfilled that role—[Interruption.]

Order. I hear the hon. Member for North Durham (Mr. Jones) saying from a sedentary position, “It is a speech.” We are considering a serious matter, which is why I have allowed an urgent question. Let the right hon. Lady speak, because I understand that she has lost constituents.

I am very grateful, Mr. Speaker. I apologise for the length of the question, but we are considering my local trust and I am concerned about what is going on.

Does the Secretary of State accept that, if ward sister fulfilled her former role, many of the difficulties might have been avoided? Does he agree that there are three main reasons for her not fulfilling that role? First, short-staffing means that she is nursing when she should be bossing and supervising. Secondly, she has become too much a commissioner of bandages and blankets rather than active on the wards. Thirdly, she spends too much time filling in forms—whether that is related to targets or anything else is not the point; she spends too much time on officialdom. Does the right hon. Gentleman accept that I was right to say 10 months ago that if we get the role of ward sister right we will make a huge impact on the situation?

I do agree with that. If the role of the ward sister or matron is got right, we will go a long way towards tackling the problems. The right hon. Lady made important points, and I have no argument with the amount of time that she took to make them. She should be congratulated on raising the issue in January. Of course, as she will accept, the Healthcare Commission was in the midst of its investigation then.

I also agree with the right hon. Lady that the standard of nursing had everything to do with the problem, as the Royal College of Nursing and others have pointed out. We made an announcement a couple of weeks ago. I do not say this with the benefit of hindsight in relation to what happened at Tunbridge Wells and Maidstone. The right hon. Lady made the point that the matron and ward sister should have direct control not only over the cleaning arrangements and the contracts agreed for the hospital, but over the making of a report, at least quarterly, to the NHS trust board. The views of the ward sister and matron could not be filtered through various layers of management because the report, on these and other specific issues, would go directly to the trust board. That was the gist of our announcement.

I am afraid that I do not entirely agree with another point made by the right hon. Lady, because I think it detracts from her point about the standard of nursing at the particular hospital and her graphic account of patients being told, “Go in the bed.” That is the term that was used. The right hon. Lady and others will surely accept that that is not the standard of nursing that we find in our hospitals across the country; it is absolutely exceptional.

The excuse cannot be given that the management of the trust did not receive the right support. The right hon. Lady spoke of a staff shortage, but there are now about 85,000 more nurses in our hospitals than there were 10 years ago, and 280,000 more care assistants and the like. As she will accept, there is no excuse for the dreadful things that happened in that hospital.

I accept that there are issues that we need to tackle in relation to ward sisters and matrons. We should give them more power and make them much more assertive, and remove any bureaucracy that they feel is a hindrance to their role. As I said in my statement, I am perfectly willing to shoulder that responsibility. My point is that nothing must detract from the failure that occurred in those three hospitals, and nothing must excuse the appalling standard of nursing that was in operation.

I agree with my right hon. Friend that this is a scandal, and that we all have responsibilities. When I worked in the national health service a domestic came on duty at half-past 7 and worked until 2 o’clock, and another came on duty at 4 and worked until 8. As the right hon. Member for Maidstone and The Weald (Miss Widdecombe) said, that domestic was directly accountable to the sister or the charge nurse. Sadly, as a result of the compulsory competitive tendering introduced by the Conservative party, whether contracts were in-house or went to the private sector the number of cleaning hours fell substantially—by as much as two thirds in some cases. Surely it is time to bring those services back into the national health service, remove private contractors, and make such people directly accountable to ward sisters and charge nurses.

Unfortunately, I must take issue with my hon. Friend. There is no correlation between this problem and whether cleaning contracts were in-house or in the private sector. At Maidstone the contract was in-house.

The solution lies in what was said by the right hon. Member for Maidstone and The Weald (Miss Widdecombe). What is needed is the right degree of management on the front line which can be pushed through to senior management. That is why it is crucial for the matron to have a say in how the cleaning contract is organised. She might believe that in-house cleaning was insufficient and should be put out to tender, or it might be the other way around. It is not an ideological argument; it is a question of how the wards can be kept clean. It is about consultants and medics washing their hands, and about the prescription of antibiotics, which is crucial to the problem of clostridium difficile.

The report makes clear that the physical condition of Kent and Sussex hospital has contributed to the problem of infection control. Ministers have announced that a new 100 per cent. single-bedded hospital is to open in Pembury, with financial close expected to take place in March next year. Will the Secretary of State assure my constituents that the costs of any extra investment in infection control, any compensation payments that may be made, and the change in leadership of the trust, will have no impact on that financial close?

If there is one thing that my constituents would never forgive, it is a failure to learn the lessons of this episode, causing what has been a nightmare over the last three years to become a continuing nightmare for the next 30 years.

I can give the hon. Gentleman that assurance and I know that he and his colleagues are coming to see me soon to talk about this issue. Given the age of the hospital and the buildings involved, it is more imperative that we go ahead with those new hospital facilities than it was before this report. Nothing that happens here—no change in the management or fines levied on the trust—will in any way damage or inhibit the need for that new hospital to be built for his constituency.

The chairman has now resigned, but is the Secretary of State aware that the chief executive was allowed to leave by mutual consent, that the then director of nursing has been re-employed by the trust as a PFI adviser and that all the other non-executive directors remain in place? Why is no one at the top of these trusts ever dismissed?

As I said, a strategic health authority review of the leadership is taking place and I have asked for a separate review to be carried out urgently of what happened with the chief executive’s package. That review will also take into account all the leaders, including the medical director and nursing director who were on the board, and the non-executives. The hon. Gentleman makes an important point. We decided—there was agreement on both sides of the House—that Whitehall should not be making appointments, and that that should be pushed down to local level, but if the Appointments Commission is responsible for appointments, somebody has to be responsible for the un-appointment, as it were. That is an important point; who takes the blame?

I accept the Secretary of State’s assertion that there are more nurses employed in the NHS. Has anybody looked to see whether there is a correlation between nurse-patient ratios in the hospitals that have more C. diff than others?

I do not know whether such an assessment has been made, but I undertake to ensure that one is made. The Healthcare Commission pointed out that there were fewer nurses employed at the hospital in question than at hospitals of a similar size, and that the level of training on hospital-acquired infections was very patchy. Between 40 and 50 per cent. of nurses received training, so between 50 and 60 per cent. of nurses did not, which just added to the catalogue of failures.

The Secretary of State will be well aware that the different nursing regimes that apply in different hospitals have the most important effect on the outcomes that we are discussing today. How can we spread the best practice that is exhibited in hospitals such as mine, the West Cumberland hospital, throughout the country?

My hon. Friend is right; the good practice that is going on day in, day out is essential, which is why we gave the code of practice a statutory basis by including it in the Health Act 2006. That cannot be ignored and should be driving the way hospitals work day in, day out. We also need to make safety the absolute priority in the operating framework, all of which means that what happened in those three hospitals should not have happened. We hope to ensure that it does not happen again. Best practice is one of the most crucial ways that we can ensure that this is tackled.

May I remind the Secretary of State that it was as long ago as 19 July 2005 that the then Health Minister told me in a written answer that learning and best practice arising out of the Stoke Mandeville investigation

“will be shared across the national health service”?—[Official Report, 19 July 2005; Vol. 436, c. 1666W.]

What has gone so wrong with the delivery of that promise that we are having to debate yet another tragedy today?

I do not think that anything has gone wrong with the promise, in the sense that the vast majority of NHS trusts and hospitals are placing the correct emphasis on this matter and understand completely that washing hands, with soap and water in the case of C. diff, is absolutely crucial. The “bare below the elbow” policy was a piece of best practice that operated at the Royal Marsden for years, and which we have now made best practice and standard procedure across the country.

On Stoke Mandeville, I forgot to mention that the Healthcare Commission set out four reasons for the high rates of C. diff: poor environment, poor practice, lack of isolation facilities and insufficient priority given to infection control. Next week, we will have a Healthcare Commission report on Stoke Mandeville one year on, and it is important to see how the hospital has tackled clostridium difficile. That report will be of benefit to MPs in the Maidstone and Tunbridge Wells area, whose main concern is to ensure that such infection is turned around there as well. We need to keep track; we must have not only Healthcare Commission reports, but regular updates on how its recommendations are being implemented.

In my constituency, there is a sheltered scheme for everyone who has returned from hospital in the past year who has been infected with some infection that they did not have when they went into hospital. The fact is that central management through targets is not the way to beat infection in hospitals; it needs to be managed locally on the wards. Bed occupancy of over 70 per cent. is a problem, as is managing the cleaners. Health staff travelling in medical uniforms on the buses is also a problem in respect of infection. There are many good cleaners, but bad cleaners are followed by infection. Will the Secretary of State give ward sisters the power to sack a bad cleaner?

I agree with all the hon. Gentleman’s points about the key issues in respect of cleanliness, but I would add one more: public information. The public need to be aware of what goes on in hospitals.

I have mentioned the powers given to the ward sister. Within the realms of proper employment practices and the proper way to treat staff, we want the front-line staff—ward sisters and matrons—to have the power to determine how the wards are cleaned. That would include pointing out in their quarterly reports to the NHS board where there are failures, including among cleaners. However, merely a cursory reading of the Healthcare Commission report reveals that hand washing was patchy among not only cleaners but medics, including consultants, and nursing staff. The blame was spread among all participants, not only cleaners.

Eight years ago, the Government took the decision to put the cancer ward at the Kent and Canterbury hospital under the control of the Maidstone and Tunbridge Wells NHS Trust, even though a joint cancer centre had happily operated for years without such administrative nonsense, and patient outcomes were consistently better at Canterbury. In view of the considerable hospital trust changes that will take place, may I urge the Secretary of State to consider transferring responsibility for that cancer centre back to the East Kent Hospitals NHS Trust where it belongs, and where all staff at all levels would like it to be?

I accept that the hon. Gentleman is taking this opportunity to ask us to look again at that matter. The important point is for this to be driven locally—by the local clinicians and strategic health authority—to ensure that we reach the right decisions, rather than for me to hand down tablets of stone from Whitehall.

The accusation that targets played some part in all this was not dreamt up by the Opposition; it is clearly there in the Healthcare Commission report. Another factor it identifies is that management spent too much time dealing with hospital trust reconfiguration and too little on patient care. On behalf of all my constituents in the mid-Kent part of my constituency who use Maidstone hospital, I ask the Secretary of State to give an assurance today that there will be no further work on that reconfiguration and no services will be taken away from Maidstone hospital until this matter is brought under control and, preferably, the reconfiguration is abandoned altogether.

That is just a variation on the Opposition policy of a moratorium on reconfigurations. In respect of the reconfiguration of maternity services in Greater Manchester, all the clinicians and other health care professionals were telling me that they had been trying for 40 years to make the changes, which would save between 30 and 40 babies’ lives per year, and that that had been rejected by politicians defending bricks and mortar. That is a general point about moratoriums.

On the hon. Gentleman’s point about what is happening in Maidstone, my response is that I will not intervene. That is a matter for local physicians to decide, provided that it is clinically led—that clinicians are making the argument. If it is referred to me, I will refer it to the independent reconfiguration panel, which is clinician-led, so that there is a clinical argument for any change.

Is there any correlation between trusts mired in debt and those performing badly on C. diff rates? My own trust, the West Hertfordshire Hospitals NHS Trust, is No. 17 in the rankings—above the 21st-place ranking of the Maidstone and Tunbridge Well NHS Trust, in Kent. There, but for the grace of God, goes my own trust perhaps having deaths on its hands. Will the Government look into whether there is a correlation between such debts, the cuts that were made and the outbreaks of C. diff?

Look, there is no correlation here. The simple fact is that trusts must live within the extremely generous funding that they are getting from the centre. Trusts have to be in surplus, not in deficit—that is a simple fact of life. A similar point applies to reconfigurations. I reject the notion that those who are reconfiguring or those who are moving back from being in deficit to being in surplus cannot have patient safety. That is a ludicrous proposition. It does not cost a fortune to have patient safety. It is about washing hands and ensuring that people do not get complacent about prescribing antibiotics. It is about the simplest of procedures, which, as was mentioned in an earlier contribution, the ward sister and the matron would know everything about. This is not lots of money. I reject the argument that we should give up on saying to PCTs, “You should not be in deficit—you should spend your money on taxpayers’ behalf wisely,” in order to promote patient safety. It is possible to do both.

Having opposed the Salmon report those many decades ago, which changed the role of matron, may I say that my right hon. Friend the Member for Maidstone and The Weald (Miss Widdecombe) has knocked the nail on the head? Will the Secretary of State give a total commitment to this House that he will act immediately on the roles of matron and ward sister, so that they include dealing with cleaning and with the question of whether nurses can come to work in their uniforms rather than changing into them at the hospital, and so that matrons and ward sisters can take the decisions rather than the remote and generally rather inept board of a trust?

The hon. Gentleman’s experience allows him to talk with authority about the Salmon report and the history of this issue. There is a sense of déjà vu regarding the importance of the figurehead of matron. We announced recently another 5,000 matrons. It is about not just the name and the title, but giving that person the authority to override junior managers and to report straight to the top about what is happening on the ward. That is why we made the recent announcements about extra matrons and about enhancing their role.

We must not be sidetracked in this debate by the question of whether cleaning is done in-house or out of house. This is a failure in leadership of monstrous proportions. This chief executive was either a monster or an incompetent—probably an incompetent. A number of chief executives in this country are not performing, and when they do not perform people die. I urge the Secretary of State to intervene where chief executives are failing, before more people needlessly die from preventable illnesses.

That is an important point that we need to look at. As the hon. Gentleman may remember, the document on the constitutional changes that the Prime Minister announced shortly after taking over had a clause on how we make such appointments. We should not take them back to the centre, but we need to ensure proper accountability throughout the system. In particular and as the hon. Gentleman suggests, we should be spotting these issues much earlier and getting rid of incompetent chief executives or chairpersons who, fortunately, are in the minority, rather than waiting for a report such as this, by which time, frankly, most of the damage has been done.

Legal Services Bill [Lords] (Programme) (No. 2)

Motion made, and Question put forthwith, pursuant to Standing Order No. 83A(6)(Programming of bills),

That the Order of 4th June 2007 (Legal Services Bill [Lords] (Programme)) be varied as follows:

1. Paragraphs 4 and 5 of the Order shall be omitted.

2. Proceedings on Consideration shall be taken in the following order: new Clauses relating to Parts 1 to 4; amendments relating to Clauses 1 to 70; amendments relating to Schedules 1 to 9; new Clauses relating to Part 5; amendments relating to Clauses 71 to 111; amendments relating to Schedules 10 to 14; new Clauses relating to Part 6; amendments relating to Clauses 112 to 161; amendments relating to Schedule 15; remaining new Clauses; amendments relating to Clauses 162 to 214; new Schedules; amendments to Schedules 16 to 24; remaining proceedings on consideration.

3. Proceedings on consideration shall (so far as not previously concluded) be brought to a conclusion at 9 p.m. at this day’s sitting.

4. Proceedings on Third Reading shall (so far as not previously concluded) be brought to a conclusion at 10 p.m. at this day’s sitting.—[Alison Seabeck.]

Question agreed to.