Select Committee on Science and Technology Minutes of Evidence


Examination of Witnesses(Questions 20-39)

TUESDAY 15 OCTOBER 2002

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

Lord Patel

  20. Did I hear that we now have a national UK-wide NHS information technology strategy?
  (Mr Kerin) Under the arrangements for devolution, health care is a matter for each of the four countries of the union. Therefore, the strategy that we were talking about earlier, in the same way as the strategy for infectious diseases, is technically a strategy for England. Clearly, there need to be very good links with the other countries because of the cross-border transfer of patients and the benefits of learning from different parts of the union. Although technically we are talking about an England only strategy, there do need to be very close links across the whole of the United Kingdom.

Lord Oxburgh

  21. Do I understand that, at the moment, there are no talks between these disparate groups about having common protocols for exchange of information electronically?
  (Mr Kerin) I would have to defer to my colleagues on the detail of that but it would be envisaged in respect of the Health Protection Agency, which is my particular responsibility, that it would be closely working with the Scottish body in particular to ensure that there are compatible protocols.

Lord Turnberg

  22. In relation to that, the PHLS is involved in running services in Wales and in England. The HPA will restrict itself to England. You talked about a special relationship with Scotland. What special relationship will you have with Wales?
  (Mr Kerin) It is proposed that the Health Protection Agency will provide a range of country-wide services in both England and Wales. Indeed, the recent consultation document about the legislation was jointly issued between the Department of Health and the Wales Office. Where the position in Wales is different is that it is proposed that local services in Wales should be operated organisationally in a different way from that proposed in England. But in terms of the national services across infectious diseases chemicals and radiation the Health Protection Agency will be offering a service in Wales as well as in England.

Lord Rea

  23. Can we now turn to clinical services for those who are suffering from an infectious disease? Could you give an outline of the current provision and distribution of services at primary care and specialist level and whether you feel that we are in a satisfactory situation at the moment? Should the emphasis be on increasing the number of specialists in infectious diseases or should the emphasis be on improving the knowledge of infectious diseases through primary care physicians and primary care teams? Should there be centres developed where perhaps infectious disease matters could be looked at and used as a training base for both specialists and GPs?
  (Dr Leese) The infectious disease strategy was primarily concerned with health protection arrangements in the country and setting priorities, but it does in chapter five have treatment and care of people with infection and the long term sequelae of those infections as an integral part of infection services. Alongside the work that is being done, alongside the infectious disease strategy, a group has now been assembled to look at clinical infection services. We should remember that pretty well all clinical doctors handle infection at some point. The vast majority of infections are handled quite appropriately in primary care. Some infections are treated in specialist disciplines apart from specifically infectious disease disciplines. For instance, hepatologists do quite a lot of the hepatitis related work. Gastroenterologists see a large amount of infection related work. Respiratory physicians on the whole treat tuberculosis but over and above that there are these specialist infectious diseases physicians dealing with adult and paediatric infections. To begin with, the royal colleges had prepared a discussion document on the provision of these services across the country and we are now working with them to take this work forward. It will involve looking at the distribution of services across the country, how they can best be made equitable, what is required in a specialist centre and, as you rightly say, the provision of training, looking for the succession planning for the type of people who are necessary and looking at the multidisciplinary type of work that needs to be done. That will all be part of this work.

  24. Have you in mind the setting up of such centres, perhaps as part of the work of the Health Protection Agency?
  (Dr O'Mahony) That is still for discussion. There are various models of provision of specialist infection services. They might vary from place to place according to local epidemiology of disease and according to the other specialist services that are being provided in an area. One model is a networking arrangement with perhaps a regionally based specialist infection service attached to an academic unit, but with an eye to standards and the provision of care across the field by networking out across a region. That is one of the models being looked at, but no firm recommendations have come yet.

Baroness Walmsley

  25. You mentioned that the royal colleges are doing a report on this. When are we expecting that to be published?
  (Dr Leese) The colleges have already produced a discussion document. What we are now looking for is to put their ideas into some sort of framework for discussion. We hope to have that ready by the end of the year.

Lord Patel

  26. Do we have enough adequately trained people available to deliver this service?
  (Dr Leese) Specialist infectious disease physicians? It is a relatively small specialty but there are quite a lot. A lot of them are in academic units and that is one of the things that we need to look at: how much is in academia and how much is in providing a clinical service.

  27. It is not quantified yet?
  (Dr Leese) We know the total numbers but you have to equate that against what is the workload of infectious disease physicians. Quite a lot of their work is giving advice to other people as well as clinical care for patients who need specialist attention.

  28. My question was about the rapid response to serious infections that may arise. How do you think your changes will improve this?
  (Dr Leese) There are two aspects of that. One is the expertise and the other is the facilities with which to care for people with very infectious diseases. This work that we are doing with the colleges is mostly to do with resources but we will have to look at the facilities to back that up. In a major emergency—this is slightly outside my field—but quite a lot of work has been done on the way we would house people if we suddenly had to deal with a lot of people who were very ill or very infectious.

  29. The work you have done already will help to improve this. Is that correct?
  (Dr Leese) Certainly, yes.

  30. We have the evidence of that?
  (Dr Leese) I do not know whether Dr O'Mahony wants to talk more about the surge capacity.
  (Dr O'Mahony) What we are doing is linking with our colleagues in infectious diseases teams. We have had a number of meetings with colleagues in the infectious disease world asking how would we best respond to a major problem with infectious disease. What would be the best way of caring for patients? What would be the best way of having public health control measures? These are plans in evolution. What we are doing very much is making sure that we strengthen our services on infection. We really want to bring together those who work in infectious disease in the clinical, microbiology and the public health worlds so that we have a very coordinated approach to the control of diseases, including patient care.

Chairman

  31. Can I go back to the question of supply of people? In the antibiotics resistance committee we did identify a great shortage of academic, medical microbiologists to take posts in the academic field. Has that improved, not only in microbiology but right across the infectious disease spectrum, in recent years? Are there people coming forward to take academic positions in medical schools and elsewhere?
  (Dr Leese) There are people coming forward taking posts in infectious diseases academic posts. I do not have numbers but I believe there is still a shortage of people coming into microbiology services. The profession, I know, has been looking at the way that services might be reorganised in order to cope with that. That is microbiology, including virology, which is one of the specialities where there are small numbers.
  (Dr O'Mahony) You asked about academic posts. We are still in the process of addressing that. We are also trying to make sure that we gather more people in training who are interested in infection so that they have the opportunity to move across a range of infectious disease specialities. I know the College of Physicians and the Royal College of Pathologists and the PHLS have put forward some very innovative programmes for joint training between infectious diseases and microbiology, as well as public health. Thus, in the years to come, there will be a cadre of people with a good understanding of infection in the round, who would be able to specialise in different fields and, who we would hope and indeed anticipate would be the future holders of the academic posts that we so need in this country.

Baroness Walmsley

  32. My question is about public information and public confidence. What will be the role of the new Health Protection Agency in informing and consulting the general public about the control of infectious diseases and how does it expect to be able to win and maintain public confidence? How would it be using the primary care services to get involved in that? Could there be a difficulty with the perceived independence of the organisation and to what extent will the HPA be allowed to publish independently? I am picking up a point, Dr O'Mahony, that you mentioned in your introduction earlier on. You mentioned the inspector of microbiological services. It occurred to me, for example, will there be an annual report from that inspectorate? Will it be published?
  (Dr O'Mahony) I will ask Mr Kerin to pick up some of those points about the Health Protection Agency.
  (Mr Kerin) We need to bear in mind that what we are talking about is a body for which legislation needs to be passed to bring it into effect. Some of these issues are covered in the consultation document, and in particular paragraph 4.33 flags up the issues around openness and whether legislation creating the agency should give it the right to publish its advice. The proposal in the document is a power akin to that of the Food Standards Agency. These are matters where the Department is currently considering the responses that have been received and will obviously be making legislative proposals in due course. It is certainly a crucial aspect of the proposals for the agency set out in Getting Ahead of the Curve and the subsequent documentation, that it has a major role in public information as well as information for professionals. These proposed statutory powers would be an important part of that, but it is also important how the agency will go about engaging with the public at both national and local level in order to win confidence. While it is too early to say specific measures, I think it is important to see how the public are engaged alongside other stakeholders in the formal committee structure and approaches of the agency. The communication strategy of the agency which we are starting to make preparations for needs to have a strong component of engagement with rather than talking to the public and I think that is important. Some of the existing organisations which will be coming into the Health Protection Agency are already giving attention to effective communication of what are, after all, quite complicated scientific concepts, looking at web based and other ways of explaining the issues in a way that will be understood and in which the public can engage, either through feedback off the website or in other ways. Although I cannot give you particular examples because of the provisional nature of the agency at the moment, this is an important facet at national level. At local level, the Health Protection Agency will be most obvious through the teams of people who work in the agency. Many of them already in their role as communicable disease experts, both doctors and nurses, have an important role to play both in explaining local issues through the local media experts in their area; but also working closely with the primary care trusts and the NHS as fellow professionals to ensure that the key issues are understood and that, in those bodies communicating with their public, they understand the health protection issues as well. I think you were right to ask a question with a number of facets because it is an issue where the answer will require a number of facets. I do not think there is any one step that is there other than that the agency will need to give careful attention to how, as an independent, national body which may not appear visible to the public on day one, it engages at both national and local level to ensure that the issues are debated and understood.

Lord Haskel

  33. I agree with you that the public needs to understand the issues and you have obviously thought that through but what the public wants to know is what are the risks that it runs. What is the risk of catching an infection and have you given any thought as to how you will communicate that to the public and tell people what risks they are running?
  (Dr O'Mahony) Perhaps Dr Salisbury can give you some concrete examples which we are using at the moment and which we would like to use more of.
  (Dr Salisbury) It may be slightly tangential but the work that we do is all shared presently with the Public Health Laboratory Service. Again, it would be an opportunity that would be available to the Agency when that arises. We have a number of areas in which we do a great deal of work with the public, both finding out what they know, what they want to know and who they want to get information from. We feed a lot of that back. Twice a year we have 1,000 mothers of young children interviewed. Twice a year in between we have another 500 mothers of young children interviewed. These interviews are specifically focused on vaccinations and vaccine preventable diseases. The purpose is to find out what they know, where they get their information from, who they want to get their information from, who they trust, what information on vaccines and the matching diseases they have seen, where they saw it, whether they were satisfied with it, whether they were satisfied with the opportunities they had in primary care to discuss these issues. We have a huge wealth of information. We have over 20 rounds of these interviews done now, going back over a decade. We use this knowledge to develop our communication strategy and how we take information back to parents. We do not use our own prejudices on what we think people believe. We have concrete evidence of what they want to hear, where they want to hear it and in what form. We hear increasingly, for example, that parents want facts, so we have dealt with increasingly providing factual information directly to parents. We do this through NHS Direct where we have trained NHS Direct staff so that they can answer questions that the parents put to them and they give us regular feedback of the questions that they are being asked about infectious diseases from the public. We have a new "MMR: the facts" website which I commend to you, within which there is a facility for anyone to send us questions. They can go through the website. If they feel that their questions are not answered, they can e-mail their questions to us. We have an undertaking that they are all answered within five working days. We get about 50 inquiries at present per week and we have a facility that puts in a hierarchy of response to deal with the different questions. We are developing skills that are specific to what the public tell us they want to know and we do a great deal to make sure that we provide information in the way that the public can best use it. All of that is presently shared with the Public Health Laboratory Service, with our counterparts there, and I am certain that we will maintain that in the future so that all of this information on how to communicate and what it is the public wants to hear about to do with infectious disease and vaccines will be a facility that can be used in the future.

Lord Quirk

  34. Following what Dr Salisbury has been saying, the Department's evidence, paragraphs 34 and 35, deals with the issue of confidentiality and the issue of concern that clinicians feel about reporting data without explicit patient consent. Presumably, part of the HPA's remit in establishing the kind of confidence which is required by the public will be helpful when negotiating these issues of confidentiality. Is that correct?
  (Dr O'Mahony) Within the health service when collecting data on infectious diseases, it is vitally important that we get the appropriate data. There is the key principle that all data should be anonymised unless there is a strong reason to the contrary. On behalf of the communicable disease and infectious disease community, CDSC provides documentation to the Patient Information Advisory Group that was set up by the Secretary of State to deal with the requirement for communicable disease data collection, reporting and surveillance arrangements. It is important that we continue with that work, so that we have public confidence, through the agency and the Department, in the nature of the information that we collect and that we provide in turn. This is very much an evolving situation, depending on the wider context of the Data Protection Act and other legal requirements for infectious diseases that may change. I regard it as absolutely vital that we bring the public along with us and that their input will shape some of the way we collect data to provide information back. We have tried over the last several years to have public input in a variety of ways including our expert advisory committees and into the way we collect information. We have had public meetings and for example, we recently had a public meeting to do with matters relating to CJD. With a whole variety of input, we hope we can arrive at a position where the information that is collected and provided on behalf of the Department by the agency meets with public demand and public acceptance. This is something that we will have to keep an eye on because requirements and expectations will change over time.

Baroness Walmsley

  35. Going back to the proposed agency's public information strategy, has thought been given to rapid response to the need for public information when that might be needed? For example, if there was a rapid spread of a serious infection, an academic providing the information that will help the public to recognise the symptoms to report and providing the measures they can take and so on? What about rapid response?
  (Mr Kerin) It is certainly one of the issues under attention with web based approaches. It is one way through NHS Direct that will be an important way of communicating with many people. One of the things that need to be investigated is how do the general public get information and how far are these new technologies appropriate or are there other ways that need to be found as well. There will be a need for it and it is certainly one of the things that is being considered.

Chairman

  36. Are there any problems associated with the Data Protection Act, especially with very sensitive data that may be accumulated and available? Do you envisage any problems there?
  (Dr O'Mahony) We are working under the new requirement about the need to be specific about data collection and about the methods used. Those are all now being taken into account. As far as possible, all data are anonymised unless it is a requirement from the point of view of control measures that we have some identification. I think Dr Salisbury has given examples where, for some diseases, particularly those where we are approaching elimination, we need to follow up individual reports and where we do need certain information of an identifiable nature. For those diseases, we need to be absolutely explicit and have agreement. For those, we would follow up individual patients. It would be the same for outbreaks of disease where we need to get in contact with people who have a particular infection or who may have been exposed to a particular food source for follow-up. There are requirements that are likely to be always there but how we collect that information has to be checked all the time under the new regulations that have been laid down by the Secretary of State. Of course, we will fit into that infrastructure.

Lord Turnberg

  37. This is about laboratory services. In your introduction you made, quite rightly, much of the need for integration, co-ordination and co-operation between the various bodies which are concerned with various aspects of public health protection and the need for the facilities for surge capacity and rapid response, all those things I would applaud. The question really relates to how you feel changes in the laboratory services will assist this process. The question that you have seen refers to the reference microbiology services, which are largely within the PHLS and, as I understand it, may well remain within the HPA as the central facility. There are suggestions in the Report that these services may in the future, at least in part, be commissioned. The question is, how does commissioning services as against doing them yourself help this integration process? The question also relates to the more routine public health microbiology protective function that PHLS laboratories do round the country, how the changes envisaged there—which are to ask the NHS trusts in which they currently sit to take over that role and to provide the service to the HPA and to the country from that position—how will that improve integration, co-operation and co-ordination do you think?
  (Dr O'Mahony) You have put a number of questions within that. If I may start with defining what we mean by general microbiology services and reference services. General microbiology services are described as those that provide the diagnostic capacity within the health service, and are primarily clinical in orientation. However, all microbiology laboratories do have public health functions, indeed there are four main public health functions for all routine microbiology services; these are the provision of information to those with the responsibility for control at a local level and a national level, for example giving reports of cases of diphtheria and salmonella; a second function is that they submit the appropriate specimens to the reference laboratories. These may be required for national programmes, as Dr Salisbury mentioned for vaccination programmes such as tuberculosis; they are also required to keep a watching brief on some of the rarer organisms that are carried in the country; the third public health function is that they assist local teams in control and arrangements matters; finally they give advice on local policy development and implement some national policies. Almost all laboratories in the NHS do these, some do it to a high standard and some do it to a variable standard. All public health laboratories carry out these basic functions. It is envisaged with the proposed agency that those PHLS microbiology laboratories where most of their work is general in nature would be transferred to the health service, where they would support local health services, and public health functions to make sure that this public health function has a clear focus. It is proposed to establish public health microbiology posts in all those PHLS laboratories that transfer so that public health microbiologists would be in the NHS to drive that public health component of the general microbiology service. The post would not be nominal but would have dedicated sessions to support the public health function. That is absolutely vital for a secure service. When we talk about reference laboratories we are really looking at highly specialist laboratories. These laboratory services are provided at the moment in the large part by the Public Health Laboratory Service and by the Centre for Applied Microbiology and Research and some academic departments, for example at University College London and the London School of Hygiene and Tropical Medicine. They are a source of expert advice, with expertise on individual organisms and diseases. They provide special functions like finger-printing organisms. An example might be salmonella infection that will be identified by general microbiology in the NHS laboratory but the finger-printing of that salmonella will be done by the reference laboratories. That service is vital for us to pick up outbreaks. For example at the moment there is a large investigation being carried out on an outbreak of salmonella of a particular type, the nature of which can only be determined by reference laboratories. It is that special nature of the reference laboratories that needs to be preserved and developed. At the moment the reference laboratories are managed in different organisations and in academic units. What is proposed in the strategy is that the two main providers of these very special laboratory services would be brought together in the proposed agency, namely the Public Health Laboratory Services and that they would work within a framework with other academic units so that they would have a true national resource for the very specialised microbiology laboratories. Lord Turnberg mentioned commissioning. At the moment most of the services are provided by the special agencies. It is envisaged in the future that this approach will continue. However, there may be instances within the National Health Service or academic units where they both have specific expertise and the agency may wish, to use that focus in the future. For example, if the nation requires a special laboratory to be set up then the agency would work with that special expertise in the NHS rather than setting up a separate, new laboratory. It may, as the PHLS does at the moment, work with the London School of Hygiene and Tropical Medicine and also with University College London. I do not believe or envisage that very many reference services side will be provided outside the agency; if anything it would be a minority, but it may well reflect, like I said, future expertise that may be in different parts of the health service. I am not sure if I have picked up all your points.

  38. That is very helpful about the reference laboratories. As I understand it, most, if not all, current PHLS and CIAMR laboratories are in the new Agency and in future, of course, it may wish to commission other services from outside rather than farming off existing reference laboratories. If I can turn to the network of what you describe as routine public health laboratories, which provide routine microbiology, the key to this arrangement is that they work as a network, so that in a group of laboratories in a region, for example, as you know, each of them does not provide all the services but between them they do, and one will do virology and one will do food and environmental work, so they have the total resource between a group of laboratories. If you then hand these over to individual trusts how do you envisage that co-ordinated network approach being continued?
  (Dr O'Mahony) The development of microbiology services needs to be considered within the wider development of pathology services. The Government has set up a strategy for the modernisation of pathology services, in which it is envisaged that there will be a network of pathology services broadly mirroring strategic health authority populations, populations of around 1.5 million people. Microbiology is seen to be an integral part of general pathology services. It is envisaged that there would be a series of pathology networks across the country, probably about 30, which will have pathology services—histology, haematology and microbiology—within them. It is important to see that microbiology will be part of that overall pathology development. However, in discussion with colleagues in the modernisation of pathology services, it was recognised, as Lord Turnberg says, that there is particular expertise already developed in PHLS around networking arrangements. We would hope that we can capitalise on the microbiology expertise in PHLS in developing wider pathology networks within the NHS, and maintaining as far as possible some of the work that has already been done by the PHLS in managing what may well be a forerunner of the pathology services, for example by distributing tests where appropriate by doing them where there is particular expertise. These are some of the particular areas that are being considered at the moment by the implementation team. We are very aware that the PHLS has developed expertise in standard operating procedures throughout its laboratories and we would hope the PHLS will work with the NHS in putting in good quality protocols for microbiology. The PHLS has had a lot of expertise through its network in procurement of good media and, again, we would hope that the NHS would benefit from this huge expertise. I believe that the PHLS has a great deal to give to the NHS and this is being considered as part of the implementation work that is being carried out by the Department.

Lord Rea

  39. Could I ask a supplementary at this stage. I think our final report will very much require figures about manpower and woman power—the microbiologists available, their training, infection control nurses, training available, possibly laboratory technicians. Some of this information, of course, is available in the public domain already and I think it would be quite useful for us to have all the information that there is on this whether it is in the public domain or not to help us with our deliberations. Do you think that a reasonable request?

  (Dr O'Mahony) Indeed, my Lord, we would be happy to provide any supplementary information that we can.


 
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