Select Committee on Science and Technology Minutes of Evidence


Examination of Witnesses(Questions 1-19)

TUESDAY 15 OCTOBER 2002

DR DAVID SALISBURY, DR MARY O'MAHONY, MR MICHAEL KERIN AND DR JANE LEESE

Chairman

  1. Good morning, ladies and gentlemen, how very good it is of you to come along. I am sorry to hear that Dr Pat Troop is unable to be with you. First of all, would you like to introduce yourselves to the Committee and then, after that, if you have any opening statement to make we would be glad to hear it before we go on to the questions.

  (Dr O'Mahony) My Lord Chairman, I come here today with apologies from Dr Pat Troop who is unable to be at the Committee because of illness. My colleagues who are with me today are Dr David Salisbury, Dr Jane Leese and Mr Michael Kerin, who are all involved in the field of infectious diseases in one way or another, and myself as Head of the Communicable Disease branch in the Department of Health. The Department of Health is grateful for your Lordships' continuing interest in infectious disease both now and in the recent past and we welcome your Lordship's inquiry at a time when infections are of growing importance and public health concern. We are very grateful for this opportunity to contribute to your deliberations. Your Lordships' work on anti-microbial resistance in the past five years has had a major input in the way the Department of Health has approached this topic, and is continuing to influence how we address both this matter and other matters to do with infection. Today I will outline how the Department of Health is taking forward work on infectious disease prevention and control. For the first time ever the Department of Health has a strategy for infectious diseases. The strategy document was published in January this year. In essence it did three things: it increased the profile of infections, it proposed a systematic way of preventing and controlling infectious diseases and it sought to align the control of infections with the control of chemical and radiation hazards. We believe that the profile of infectious diseases needs to be emphasised because of the global to local threat of infectious diseases. It is very clear that no matter where we live in the United Kingdom we are only hours away from any traveller or of food that may have come from exotic countries; we are having to deal with new technologies, such as transplants, donated organs themselves be a source of infection and we have got a greater number of patients with immuno-deficiencies that make them more susceptible or vulnerable to infection. Last but not least, we have the spectre of the deliberate release of pathogenic organisms. In order to take a systematic approach to the control and prevention of infections the Chief Medical Officer proposed that there would be a new emerging infections panel established that would seek to develop priorities in infection. As well as that, there would be key programmes identified in which we would seek to control infection. The areas that have been identified for particular action plans have been the field of antibiotic resistance, health care associated infections, tuberculosis and blood borne viruses. In addition, there is a great commitment to do more work in the field of vaccine preventable diseases. To do this work on infections there has to be key underpinning work involving multiple partnerships because we have people involved in infections from across the country, from across the professions and from other government departments. We have to have good surveillance, good research and development, appropriate training and the appropriate standards to do that work. The commitment from those across the NHS and other government departments is crucial to our success. Finally, we have to see infections in the broader context, and that is trying to align infections with chemical and radiation hazards. This was an area that was being developed before but has come to the fore very much since the events of September 11 last year, and again emphasised by the awful carnage in Indonesia recently. So it is imperative that the country has the capability to respond rapidly and appropriately to the threat of deliberate releases of, not only infectious disease agents but, also, chemical and radiation hazards. An example might be that we need to be able to respond, let us say, to an outbreak of gastro-intestinal disease that could be caused by a number of biological agents but, also, chemical hazards. We need the capacity nationally to respond appropriately and in an integrated way to bring that problem under control. The overall approach that is proposed by the Chief Medical Officer's strategy is to build on the current strengths of the health service and its special bodies. What the department now seeks to do is to pull those strengths together in an integrated way. The proposal is that general health protection work on the control of infections should be done by the health service and that it would be supported by specialist services provided by a proposed new agency to be called the Health Protection Agency. That agency, it is envisaged, will harness together the special services of the Public Health Laboratory Service, the Centre for Applied Microbiology and Research, the National Radiological Protection Board, the chemical focus and the local specialist public health teams in the health service. This means that at a local level, primary health care teams will do more work in public health protection and they will be supported locally by specialists—consultants in communicable disease control and specialist nurses and staff—and regionally and nationally by the new proposed agency. In addition, in microbiology services we propose the establishment of a public health microbiology post at a local level, a regional microbiology post for each of the NHS public health regions—and for the first time ever a new inspector of microbiology to oversee standards in microbiology services. We believe that such a configuration will help to give public health security to the nation in the control and prevention of infectious diseases. With the help of your Lordships' deliberations, we hope that with this proposal and your interest we will be able to achieve that aim.

  2. Thank you very much for that very comprehensive but brief review. You have been alerted to the questions that we want to ask you. Can I start off with question one, which refers to your publication Getting Ahead of the Curve? It identifies the problem of under-reporting infections as the key problem. I wonder if you can address the key barriers to reporting and include the issue of hospital mandatory reporting—the behaviour of clinicians, because, essentially, that is where the reports have to come from originally—and the provision and current capability of information technology?
  (Dr O'Mahony) Thank you, my Lord. Reporting of infections is part of our surveillance programme for infectious diseases. If we consider surveillance, the purposes of surveillance are several-fold. We need to get information on infections to detect outbreaks, to see what trends there are in infection—for example are there increases in infection, to assess our intervention and control measures appropriately and if there is something coming on the horizon that we have to respond to. So we need reports on individual infections. But in overseeing our surveillance programme we also need to get information from other sources such as vaccine coverage and information from other government departments that allow us to get the big picture. I would like to start answering your question directly now by saying that if we look at reporting in general on infectious diseases, we need to look at reporting from the health service, from other government departments and at European and international levels. Within the health service reporting comes from local, regional and national services. One of the key contributors to infection reporting is the primary care team because they see many of the infections that are notifiable at the moment, and, also, in hospital. However, if we look to the future and the changing pattern of health care we are going to see a health service in which a lot more interventions and infection control would be carried out at the primary care level. We are going to have people discharged from hospital sooner. For example, there is a commitment in the health service that 75 per cent of surgical patients may be treated on a day-care basis. So, therefore, at primary care level we have to look to the future and see where we can get information about those infections in the community. It is for that reason that we wish to strengthen surveillance in the strategy document. Nevertheless, at the moment we have some very good systems in surveillance and reporting at primary care level. The Royal College of General Practitioners has a very successful weekly reporting system that has undertaken surveillance for many years, but this is not in all practices, it is in a selection of practices. There are other reporting systems that are in place that contribute at the moment. However, if we look to the future again, I believe we could do more work collectively with clinical teams at the local level, looking at infections such as respiratory infections, and perhaps urinary tract infections, to see if we can prevent and control those more. We will see infections in nursing homes because many patients are discharged early from hospital to nursing homes. There again, we could do more work to get better reporting. We have started to address these problems but I think it would be fair to say we could do more. What I can suggest is that my colleagues give some examples, perhaps to do with vaccine preventable diseases, on which we could expand and give particular examples which are effective at the moment but which we could look in the future to doing more on.
  (Dr Salisbury) My Lord Chairman, you asked about under-reporting and I think this is an important element for the way in which surveillance will change in the future. Much of the surveillance in the past has depended on syndromic reporting when doctors have been reporting what they saw and interpreted as a particular disease. What we have to do is improve the ability to get that right, through laboratory reporting matched, for example, against syndromic reporting. One example of this, on which we have done a great deal, I would suggest, is in the way in which we monitor meningococcal disease. Doctors report what they think are cases of meningitis but it is terribly important to be sure that those are correctly diagnosed and we know exactly which organism has caused the infection. So we have got an ability now to link the laboratory confirmation of meningitis cases particularly using the newest of techniques, such as Polymerase chain reactions so that that can be specified against the individual patient where a doctor has made a report. This is a way of linking the laboratory results with the clinical results. There are other examples where in the past we have depended on doctors' diagnoses. Another example here is measles, which is frequently wrongly reported. So we have many reports coming from general practitioners of children who have got, they think, measles but it is only when you can do a test to confirm it that you can understand exactly what you are dealing with. We have a world-first here where we have introduced salivary diagnostic screening so that if a doctor thinks that there is a child with measles they only need to take a swab from inside the mouth—no blood test is needed—and then you can match a laboratory test against the clinical diagnosis. That was introduced back in 1994 and since then it has been the mainstay of our ability to match the reporting in primary care of diseases like measles, mumps and rubella against laboratory reports. There are a number of examples, as I have shown you, where we are moving from this concept of syndromic reporting to being able to use the laboratories in a co-ordinated and effective way.

  3. One of the criticisms about surveillance and reporting that I have heard from GPs is in relation to what is done with this information that they have reported. Nothing seems to come out of it. How would you counter that comment, or criticism?
  (Dr O'Mahony) If I may, my Lord, I will ask Dr Salisbury to continue the theme of vaccine preventable diseases, which I think may give you examples of where we do feed back to primary care level, and show their involvement.
  (Dr Salisbury) That is the case, my Lord, that certainly in the surveillance of the diseases I mentioned, where there is laboratory confirmation or the clinical diagnosis is not confirmed, that is fed back to the person who provided it. It is enormously important that if people are going to take the trouble to do the investigations, and if they are going to make the effort to get the tests done, they need to have the answers fed back to them. I think it is something that needs to be done to the very greatest of attention, because otherwise why expect people to be enthusiastic?

  4. Are there new technologies which you are looking forward to that would make life easier for the GP, for ease of reporting? We are all busy people. I wonder if you have something in mind?
  (Dr Leese) Yes. Increasingly, information technology will be an aid to reporting of infectious diseases. That happens to a variable extent at the moment and we all look forward to times when clinical information can be automatically captured for surveillance. That happens to some extent already in the RCGP sentinel surveillance scheme that you have heard about and will increasingly be possible as IT improves across the NHS. The same applies to laboratory reporting. At the moment, some laboratories are able to have their information captured automatically, but it is not universally the case. It is one of the pieces of work to expand.

Baroness Walmsley

  5. What is the most common reason given by GPs for not reporting something? What is their most common perceived barrier? Is it time? Is it technology? Is it "why bother"? What is the reason?
  (Dr Salisbury) It would be very much my guess. I suspect it is simply an element of inertia. They may make a diagnosis and not go through the effort of filling out the necessary forms and sending them back. Again, this will be an area much facilitated by online reporting so that a doctor simply is able to enter the diagnosis that they have made on their patient and that starts the process. One of the other changes for the future, which is a way away but is still something that is talked about, is the opportunity of doing near patient testing. You have an idea that a patient has a particular infectious disease and you have a test kit that you can then apply that tells you yes or no. With near patient testing, you may get a sense of ownership so that the person who is making the diagnosis at least has the immediate opportunity to see whether they were right or not.

Lord Patel

  6. In your submission and in your presentation just now, in the answers you just gave, you do put emphasis, quite correctly, on establishing appropriate information technology and making sure that the linkages between the different information technologies do occur. How confident are you and in what timescale do you think you will have this in place?
  (Dr O'Mahony) What I would like to do is put it in the context of where the health service is going generally with information technology. There is the wish to have an electronic patient record that will follow a patient through in all aspects of a patient's connection with the health service, to include prescribing and the tests that were done. A programme is being put in place this year which outlines the way forward for the IT strategy and we would hope very much on the infectious disease side that we would contribute our requirements into that development. It is anticipated that that will be coming online in 2005 but in the meantime, although there is a longer term plan, it is very important to build on the current systems that we have at the moment and tailor those as far as we can on a short term basis to facilitate information flow as much as we can. It is not ideal but I think it is the best way of getting ahead with some of the action plans that we have to put in place. I would like to offer the perspective that although we are far from perfect in this country in terms of information technology what we have is a surveillance system for infectious diseases that is a great credit to the health service and, despite the difficulties around some of the information technology aspects, we have been able to get a great deal of information for communicable disease purposes. I am looking forward genuinely to a time in 2005 with the roll out of the electronic patient record where we can engage more actively with the colleagues that are involved in the clinical, microbiology and public health worlds.

Lord Turnberg

  7. I have recently retired as chairman of the PHLS. At the end of the day, when a patient has an infection, the GP may or may not report it but unless it has a laboratory report behind it it is extremely difficult to know exactly whether it is `flu or not or hepatitis or not. It has to go through a laboratory until there is near patient testing. The laboratories are in the best position to report and that is where we hope most will come through that will be reliable data, and yet there are variations between laboratories up and down the country in reporting. There is a lot of effort needed there and it is good to see that that is to be emphasised. Do you not think we should be thinking about mandatory reporting or making reporting notifiable for all infections? Are we moving in that direction?
  (Dr O'Mahony) In the strategy document there is a clear commitment to a review of the law on notifiable diseases and that will be taken forward after the establishment of the proposed Health Protection Agency. I would not like to preempt some of the discussions that will take place around that. However, I would offer one or two observations. I believe it is important that we look to a number of sources of information on infection. I think historically we have looked to clinicians because it was doctors who were asked to report in the past. If we look to the future, we are going to see doctors, nurses and patients themselves reporting. We have to make it as easy as possible for people to report and at the same time for certain ways of reporting to become more defined. That is why there is a wish to review the law on mandatory reporting. However in the meantime I do believe that we have a great opportunity of working with colleagues across the NHS to improve the reporting that is currently underway. If we look at laboratory reporting, surveys show that over 90 per cent of laboratories in the health service report and that they are reporting to reasonably good standards. We could do better and we wish to do so. We have moved in the last year for the first time ever and, for the first time I am aware of, compared with other countries, to get reports on hospital associated infections around severe blood poisoning. That again is a world first, even at a time of great change in the health service. I think there is a real commitment by people to contribute to the control of infection. We need to make every effort to make it as easy as possible, to have a framework that is there legally to support that as part of the strategy. It is absolutely vital that we maintain an interest in infection as well as putting a framework there to make sure that reporting is—

  8. You agree there is room for improvement?
  (Dr O'Mahony) There is always room for improvement.

Lord Oxburgh

  9. It is easy to underestimate the value of what has been achieved and it is a matter of great congratulation to everyone, but I think there is a serious problem. As someone who one way or another has been involved in trying to prod the NHS on its IT strategy for nearly a decade, my heart sinks when I hear that we are tied to that timescale for something which may be a much more urgent problem. Do you know what proportion of GPs have computers on their desk and are linked to the internet?
  (Dr O'Mahony) I cannot give you an answer.

  10. Do you think it is 50 per cent or more than that? It seems to me you cannot have a strategy that involves GPs until you have that.
  (Mr Kerin) It is a high percentage and the aim is for 100 per cent for that very reason, in order that primary care can be safely integrated.

  11. You think it is over 80 per cent at the moment?
  (Mr Kerin) I would not like to give a specific figure. It may vary from area to area, depending on how quickly it has been rolled out but certainly when I was an NHS manager the aim was to have computers in every practice as quickly as possible.

  12. There is no reason why the NHS should not supply a CD to everyone in the reporting business which effectively allows them simply to check an item on a menu which could be automatically despatched centrally. That is something which, if you wait for the whole strategy to come out, will be a long time, but it is not a big job to do separately. How much time do you have, do you feel, in the case of some of these infections? How rapidly do you really need the information in order to be able to respond adequately from a clinical point of view?
  (Dr O'Mahony) Our experience in this country has been that for serious infections, clinicians, be they at a primary care level or in hospitals, have been very good about notifying health authorities microbiology and public health colleagues about serious infections that demand appropriate action. If I can give you an example at the more extreme end, in this country botulism is a rare disease. Very few clinicians will see botulism; yet on the rare occasions when it does happen it has been my personal experience—and I have worked for 20 years in the field of infectious diseases—that clinicians, be they at a primary care or secondary care level, have notified the relevant control authorities, have sent in the specimens that have been requested immediately for microbiological confirmation and have enabled local authorities to be alerted to investigate the usually food-borne cause of that infection. At that severe end, the experience to date has been that the health service is very good on that aspect. Where perhaps we could improve is in some of the milder infections or those that are perceived to be milder. It is for those reasons that we would wish to have a greater engagement with the clinical teams to get their participation.

Lord Oxburgh: What you are describing is people doing exceedingly well with the existing system but my question really was is the existing system, with everyone doing their bit as well as they can, fast enough?

Chairman: I wonder if Mr Kerin or another member of your team could provide us with some supplemental information on this point? Could I ask Lord Oxburgh to carry on with question two?

Lord Oxburgh

  13. In your response, you describe in rather general terms "general surveillance". I think experience in other countries may have suggested that targeted surveillance, where there is a clear programme with clear, focused objectives, can be more effective. I can see there is quite a difficult balance to be struck here, but do you have any view on this?
  (Dr O'Mahony) One of the purposes of general infection surveillance is to keep a watching brief on the big picture of infections in this country. We collect every week information on about 69 organisms on a regular basis. Basically, we ask is there a lot of it about? Are we seeing a trend? If so, are we seeing it in different parts of the country? That enables us to feel comfortable that we have a system that has an overview. Behind that are specific programmes that address particular topics and we have a number of examples which show that this country is good at targeted action plans. It is based on that experience that the Chief Medical Officer proposes an additional five areas for further work in the coming two to three years. I will ask Dr Salisbury to give you examples of targeted surveillance around particular diseases, on vaccine preventable diseases, and Dr Leese will talk about tuberculosis, which is a disease that we are concerned about at the moment.
  (Dr Salisbury) We have one specialist reference laboratory for meningococcal disease. That reference laboratory works to a world leading standard. All of the samples that are collected from public health laboratories and NHS laboratories around the country go to that one laboratory. Within a week, we have updates on exactly what is happening throughout the whole country by age, by locality and by type of meningococcal disease. If we are managing an intervention programme, it means on a weekly basis we can see what is happening throughout the country. This is information that other countries would dearly love to have. It is an enormous privilege to be able to see what the effect of an intervention can be when we are able to act. That is just looking at one particular focused or targeted surveillance activity where there is a system in place. In a different context, not looking necessarily at the disease but looking at our programme to prevent disease, we are able to get national immunisation coverage data—that is the uptake statistics—on a quarterly basis within a matter of two months of the whole of the cohort of children having been targeted for their immunisations. That is using information technology, using local computer services, linking them centrally. We again have data that is more accurate, more timely, than probably anywhere in the world and it allows us to manage our intervention programme against communicable disease in an effective way.
  (Dr Leese) Tuberculosis is a good example of how surveillance has to be adapted to the problem as it is at the time. Up until 1998, we relied on notifications of tuberculosis plus every five years a more detailed survey of those notifications, but when it was clear that tuberculosis was not only a worldwide problem but impinging on the UK as well we introduced routine enhanced surveillance of tuberculosis which looked at the risk factors and the risk groups for TB, so that we could tease out where the effort for control needed to be. We will use that enhanced information for setting our targets in the first place, for looking at where we need to do the work. We have been doing that over the last few years. Increasingly now though we are moving on to look at the outcome of management of tuberculosis as an integral part of the surveillance programme. We have now moved on one further step. I think it is a very good example where we have clinical, laboratory, detailed, epidemiological information all now feeding into the tuberculosis surveillance. On a broader picture, increasingly, when we are setting up new programmes particularly for vaccination, the surveillance that is needed to support that programme is an integral part of our planning and our budgeting.

Lord Patel

  14. This question relates to whether you feel it is now timely to review the Public Health Acts and that doing so might help improve the management of communicable diseases.
  (Dr O'Mahony) As part of the strategy it is proposed that we will review the Public Health Acts in relation to the reporting of notifiable diseases.

  15. Do you have any particular areas that you want to address?
  (Dr O'Mahony) I believe—and it is a personal view because I do not wish to preempt the work that is going to be undertaken as part of that—that it would be very helpful, if we look to the future, to say, "Where can we get appropriate information on infectious diseases?" At the moment we are looking at NHS Direct which would be the first port of call on information. When people have problems, they will ring NHS Direct and we are now gathering information directly from the public, through NHS Direct, on trends in infection. We also will look at nurses who will do more and more health care delivery. They will be a huge source of information to us in infectious diseases. There will be clinicians, laboratories, microbiology and pathology laboratories as, for example, we get more involved in work that links infections with cancers. As part of the review, I imagine we will be using the breadth not only of clinical input in this country and patient input but we will also see it in the broader context of the work now being undertaken by the World Health Organisation on international health regulations which will have a bearing on some of our work. What is interesting is that we are looking to review where we are with reporting in this country and, the WHO on an international basis is looking at the appropriateness of mandatory reporting for its needs.

Baroness Walmsley

  16. Talking about the first port of call, would the review cover how quickly we can identify people who are bringing disease into the country and how we manage that and whether there is any legislation required?
  (Dr O'Mahony) At the moment, there is legislation dealing with infections in port health matters and under the Immigration Act. That is part of the review of the law that may well be undertaken. In the past, comments have been invited from the Department on those two particular aspects. But, in anticipation of the need to get a better handle on imported infections, the Department in the last year has provided funds to some of the academic units and the Public Health Laboratory Service to really start gathering better information on imported infections because, with a large number of people travelling across the world on business, for pleasure, visiting families, emigrating into this country and migrating from this country, getting a feel for the extent of infections associated with travel is extremely important. We are trying to run the two not quite in parallel but I suppose somewhat in tandem.

Lord Haskel

  17. We have had quite a lot of discussion about how we are going to assemble all this information. What steps will be taken to ensure that this information, when it is passed back to the end users, will be appropriate to their needs so that they will use this information to improve the change in practice which will reduce the threat of infectious diseases? How will they use this information so that the outcome will be that we will have fewer infectious diseases?
  (Dr O'Mahony) I will give some general examples. If we look at the users of information, we have users in the health service; we have users in other government departments; we have users internationally and at a European level. If we take users within the health service, because these will be the groups that we will link in particularly with, we have identified in the strategy a way of prioritising those diseases that we should look at, but until that work gets underway, in the meantime, the Chief Medical Officer has highlighted several areas for immediate action. The information to make sure that we can deliver a reduction in those diseases that we have targeted will depend crucially on the information that is available. We have to work with the specified requirements of those in primary care, hospital care and public health to identify their needs for information and work with them. That will be the principle of our approach. However, for other government departments—for example, in the field of zoonosis (infections that are common to man and animals)—following the Phillips Report, the department set up a UK Zoonosis Group, which is chaired jointly between the chief veterinary officer and the Chief Medical Officers of the four countries in the UK, to look at the needs of both the users and the health service and other government agencies. In general, we are trying to put in a framework in which we look at users' requirements both in the health service and other government departments and contribute to a wider basis. Perhaps I may look to my colleagues for specific examples in vaccine preventable diseases and the wider respiratory infections.
  (Dr Salisbury) Feedback of information which is both rapid and accurate is of great importance in outbreak control, as is management of outbreaks so that public health action is driven by the specific cause of the outbreak. It is also important to the clinician who is dealing with a suspected case of infection and it is important to the individual so that they have a correct diagnosis as to what they actually have. There are a number of levels through which feedback of accurate information is most important. It of course must be timely. There is a problem in some of the classic techniques that have been used for microbiology and virology where you have to grow organisms and it takes time. Modern techniques are reducing some of those intervals to allow much more rapid identification of the infectious agent and then feedback of information. There are a number of areas where we will see improvements and there are a number of reasons why it is most important that we do have this accuracy in the way in which information is both collected and sent back. There is another element of information that is most important in the prevention of infectious disease and that is the ability that we have to use our computerised immunisation registers to identify who is and who is not immunised. If you know which of the patients in the practice are immunised, you know those are individuals who are protected. It allows you then to identify who is not protected, vulnerable to infection, and it allows the primary care provider to go and deal with that disparity. Not only do we want to know who has an infection; it is also important that we know who is vulnerable to infection and that we do have means of identifying right down to every general practice which individuals have been immunised and which have not.

Chairman

  18. May we move on to integration? You have already touched on that and it is important obviously to integrate the Health Protection Agency, the regional labs, local authorities and veterinary surveillance, which you have dealt with. We have not heard too much about this but the Royal Society of Edinburgh argues in a submission that it should be more multidisciplinary. They point out that this does exist in Scotland with the Scottish Centre for Infection and Environmental Health. I wonder if you have comments on the integration of all the surveillance that is necessary and that you have pointed out?
  (Dr O'Mahony) What we have majored on is the past where there have been some success stories, and where a lot of the action has been within the health service—for example, vaccine preventable disease programmes—and also in the field of HIV infection where I think this country has done a lot to be proud of. However, if we were to look to the future where we could do better in terms of surveillance are areas of joint interest to the health service and other government departments. The example I mentioned earlier was in the field of zoonosis, infections common to man and animals. We have started in the last few years the UK Zoonosis Group, a group brought together to see how the Department and other government departments should tackle these diseases. Obviously, getting to grips with the scale of a particular problem and how we use surveillance to respond to emerging problems is absolutely critical. Work has started already that we would hope to build on. If I give you two particular examples where we have begun to assemble information from a variety of sources, from different government departments, it may help to explain where we are at and where we would like to get to. In the past few years, we have started to collect information on human and non-human diseases—for example, salmonella infections. The Public Health Laboratory Service established an environmental surveillance unit in the mid-1990s, that collects information on food samples. We can now map across the number of human infections with salmonella isolates for example, in poultry. Then we can marry that up with information from the veterinary service looking at poultry flocks. We can then see an overall picture from humans through the food and animal chain. A zoonosis report was published by MAFF with input from the VLA and Public Health Laboratory Service in the past couple of years and we would see that as the beginning of a future approach. What we have done in the last two years in particular is to build on that approach and work with other government agencies, such as DEFRA and the Environment Agency. At the time of the foot and mouth disease crisis, we had a major animal problem but, because of the scale of the disposal of cattle carcasses, there was a potential for human infection and contaminated water supplies. Large numbers of troops were involved as well as slaughtermen in the culling of animals. What we did was work across government departments to produce one national surveillance document which was signed up to by all the government departments. This looked at human surveillance, animal surveillance, environmental pollution matters, water surveillance. I think that is where we would like to go in the longer term. What is very good is the great willingness of government departments to work together and that is where we would like to feel that we could aim collectively for this sort of joint information work. From the point of view of the Health Protection Agency, it is proposed that we bring together microbiological, chemical and radiation strategies and we would envisage similar approaches in terms of surveillance outputs.
  (Mr Kerin) You referred to the evidence of the Royal Society of Edinburgh and it is interesting that the outgoing president of that Royal Society is now the shadow chair of the proposed Health Protection Agency. We will see that integration being one of the important aspects of the development of the new body. Clearly, it has a possibility not to regard surveillance as just a general activity but to integrate it effectively with each of the core functions of the new agency and to ensure that good practice and expertise in one area can be transferable to other areas within the agency. One would hope to see a strengthening, a coordination and a sharing of expertise across the range of the activities. You also referred to some of the links that the agency might need with others, including some of the regional observatories. Here, the role of the regional directors of public health is crucial. They will have a key role in ensuring effective public health networks in their area. As part of that, they will have the role of in effect setting the agenda jointly with the Health Protection Agency for activities within their region. They also have the oversight of the regional observatories. Clearly, they have an important linking role to make sure that in the context of their regional needs there is coherent picture and an absence of duplication between them.

  19. I suppose one of the important things here is compatible software so that you can talk to north of the border.
  (Mr Kerin) Yes. I think some of this goes back to the earlier question about the development of the broader IT strategy for the NHS because one of the key differences between the strategy now and some of its earlier manifestations is a far clearer central drive for ensuring compatible systems, rather than leaving people to progress at their own pace. They have certain flexibility still as to the equipment they buy but from a fairly tight list, ensuring that there is compatibility across the system. I am sure that the Health Protection Agency will want to make sure it is aligned with that because of the important links it will have across the NHS in a number of ways.


 
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