Select Committee on Science and Technology Minutes of Evidence


Examination of Witnesses (Questions 43-59)

TUESDAY 29 OCTOBER 2002

PROFESSOR SIR PETER LACHMANN, PROFESSOR JONATHAN COHEN AND PROFESSOR HUGH PENNINGTON

Chairman

  43. Good morning, gentlemen. I apologise for keeping you waiting just for a short while. Sir Peter, presumably you would like to introduce your colleagues and if there is anything you wish to say or make any statement, perhaps you would like to do so.
  (Professor Sir Peter Lachmann) Thank you, My Lord Chairman. Yes, I would like to introduce my colleagues. On my right is Professor Jonathan Cohen who is Dean of the new Medical School at Brighton and Sussex. Before that he was Professor of Infectious Disease at the Royal Post Graduate Medical School, (subsequently Imperial College School of Medicine). He is an infectious disease physician with his principal interests in the pathogenesis of bacterial infections and bacterial sepsis and shock. On my left is Professor Hugh Pennington who is Professor of Bacteriology in Aberdeen. His principal interest is food-borne pathogens. He is probably the world authority on infections with E coli 0157. In addition, he is the public face of bacteriology in the United Kingdom. Just behind us is Mrs Mary Manning our Executive Director of the Academy whom, in all our deliberations, represents the view of the intelligent but lay public. We also have written comment, which we will incorporate, from Professor Andrew Haines who is the Dean of the London School of Hygiene and Tropical Medicine. He cannot be with us this morning; he is here in spirit and on paper, but not in the flesh. My Lord Chairman, may I say that the Academy of Medical Sciences greatly welcomes that you are holding this inquiry into Fighting Infection which did arise from some of the problems which we set out for you when we were before you before. We would also like to give a general welcome to the CMO's paper "Getting Ahead of the Curve" and I am pleased to see that the government is beginning to take an interest in the problems that infection continues to give to public health and to patients. We have quite major concerns about the persisting problems in infectious disease—with all classes of infectious agents (bacterial, viral, protozoal and, if you wish to include them as such, also prions). This has been getting worse over recent times because there is much greater movement of both people and animals round the globe, because of the growth of antibiotic resistance, and because of social dislocation in parts of the world and famine. All of these have made our attempts to control infectious disease much less effective. We are very concerned in this country about the state of academic microbiology and we have written a report on this which I am sure you have (and which we can make available). There are concerns about education in and development of microbiology and all its associated disciplines. In Getting Ahead of the Curve we have concerns about the changes that have been proposed for the Public Health Laboratory Service and about the creation of the Health Protection Agency. I might just quote for you a statement written by the late Sir Douglas Black (one of the greatest British physicians) in the very last paper he ever wrote called Lessons from Nostalgia. When writing about the National Health Service Registration Act of 1973 he wrote that it "was the first major step in a long series of vain attempts to improve function by tampering with structure". Improving function is probably better done by concentrating on improving function rather than by creating an entire set of new structures.

  44. Thank you very much Sir Peter. May I say that the two documents pertaining to our meeting this morning are quite forceful documents and they cover a wide area. I will start off with the first question which is pertinent to what you have just dealt with, namely education and training. The two documents do identify a lacuna there in the supply of personnel, but what are the reasons which underline the paucity of infection specialists in England and Wales, and what suggestions do you have for reversing that situation?
  (Professor Cohen) I think that part of the reason is historical. It is certainly true that during the 1960's when it was widely thought that infection was a problem that was going to go away as a real issue, many of the infection specialist posts that then existed were allowed to come to an end; the posts were not renewed so there was a general attrition. I think it is fair to say that, under this general heading of infection specialists, there were several sub-groups, as it were. There are infectious disease physicians, there are medical microbiologists and then there are experts in infectious disease and public health epidemiology. While it is true to say that there is a general shortage of those groups in the UK, I think here we were referring in particular to infectious disease physicians. It is striking, I think, that the total number of infectious disease physicians in England and Wales is about 70 or 80, which is substantially less than it is for New York City, let alone in other parts of the developed world. I think the lack of numbers is unarguable. Why has it come about and what could one do about it? I think that this is probably substantially due to the fact that the trusts—be they hospital trusts or PCT's—investing in these kind of specialists, do not see them as high priority. Inevitably where there are resources which are going to be limited anyway, where they have to make choices about where to invest those resources, they tend to focus on those areas which the government has identified as being high priority—cancer, heart disease and so on—and in particular where those high priority areas are linked to very specific targets. If, for example, a consultant physician post becomes vacant the great pressure would be to appoint another cardiologist or another orthopaedic surgeon—or whatever it may be—in order to cut the waiting list or to hit some particular target which has been identified. So, inevitably there is great pressure on fields such as infection which is seen, I suppose, as fire fighting rather than as a core kind of speciality. As a result, posts are either left vacant or unappointed or opportunities are not taken to appoint individuals to them. I suppose one of the ways to specifically answer your question would be to try and encourage a circumstance where, if you like, the appointment of these posts are linked to specific targets. There is clear evidence—and, indeed, the data exists in the literature—to show that appointing individuals with this kind of expertise can produce specific quantifiable measurable beneficial outcomes and perhaps if this were more explicit and if there were some guidance given to trusts to show that this was something that the government and the NHS regarded as valuable and important, there would be more incentive to appoint people to these kind of positions.

Chairman: Any other points? Baroness Walmsley?

Baroness Walmsley

  45. You have described a situation where targets are actually affecting this area of medicine. Are there any targets already in terms of infectious disease and, if not, how do you think they ought to be established?
  (Professor Cohen) If I may respond to that, there are, in one particular area. Lately, the government, through the National Audit Office and others, have identified infection control—a very specific area of infectious diseases—as an area which does require additional resource and investment. And so about nine months ago—by memory—there was some specific guidance given to trusts about the need to invest in that particular aspect of the subject. Other than that, no.
  (Professor Sir Peter Lachmann) The problem of the paucity of posts feeds back into the training. We have an actuarially determined medical training system where the number of specialist registrar posts depends on how many consultant vacancies are envisaged. This makes for a situation that is not rapidly reversible either because where there are few who have career posts, there will not be many people in the training programmes. Giving trainees confidence that they are going to have jobs at the end of training is very important if there is to be a good cadre of doctors able to fill infectious disease posts when they are made.

Lord Quirk

  46. Would it help if there were more intercalated BSc's in certain fields, specifically microbiology? Perhaps a number of intercalate BSc's over a certain period?
  (Professor Cohen) I think it would help in the sense that it would encourage individuals to see the interest and excitement in the field and might lead them in that direction. It tends to be the case that young people who are enthused at an early stage in their career will then tend to follow that through subsequently. It would certainly be something that would assist, I think.
  (Professor Pennington) There are problems in that area in the sense that—as the Academy has already shown—academic medical microbiology, academic bacteriology in particular are in serious difficulties. Without that running and offering intercalated courses is difficult. That is not to say that there are not some centres which can do this extremely well, but it is a limited resource unfortunately at the moment. Until we solve the problem of academic medical microbiology, that is going to be just one route that one can get people interested in the subject: through showing that it is intellectually interesting as well as practically interesting, professionally interesting and so on.
  (Professor Cohen) The Academy thinks an intercalated BSc is an essential part of training. We would be very happy about any encouragement you can give it.

Lord Oxburgh
  1. Is it a fair inference from what you have said that there is no body within the UK at all that takes an overall view of the appropriate numbers and their availability in essential but possibly non-mainstream medical specialities of this kind? If one may draw a comparison with the University Funding Council, in its addition to supporting disciplines across the field, it will have a special care that minority subjects are present somewhere because if it were simply left to the market they would disappear through a series of unco-ordinated separate decisions. Perhaps this is the case which you describe here. Is that correct?
      (Professor Cohen) I think that is absolutely right and I think it is particularly a problem now where much of the development funds or the opportunity to derive change resides primarily within the PCT's of course, and inevitably—and understandably—their priorities are seen as more local or regional than national. That oversight aspect, the ability to deal with areas which are, as you say, core but not immediate, I think is exactly what is missing.

Lord Turnberg

  48. Is it not true that a high proportion of infectious disease consultants are university academics, employed mostly in academic departments and the number of NHS employed physicians in infectious disease is quite small. It would be interesting to know what the numbers are. But is it not also true that there is no problem with attracting people into the discipline, that it is an attractive discipline for many academically able people, and it attracts very bright young men and women. The difficulty is in finding posts for them.
  (Professor Cohen) That is exactly the case. Albeit the numbers are now very small—I mentioned the figure of 70 or 80—that represents a substantial increase over, perhaps, 15 years ago. Virtually all of that increase has been driven by academic developments funded by largely the Wellcome Trust and the Medical Research Council. That is absolutely a correct analysis. The NHS itself has put very little resource into this area in terms of NHS funded consultant posts. It is also true that it is an attractive speciality; we are fortunate in that extremely bright people want to come into it, but they are put off if, for obvious reasons, there does not seem to be an exit.

  49. The paradox is that microbiology, which is very closely related, has a big problem in attracting people and maintaining people in the discipline. I wanted to ask you a question later, but perhaps we can deal with it now instead of later, is there no way of bringing the training of microbiology and infectious diseases together because you would then cancel out the problems on each side?
  (Professor Sir Peter Lachmann) That has largely happened. The two colleges (the Royal College of Physicians and the Royal College of Pathologists) agreed on joint training about 10 years ago, but it has taken rather a long time to get going. One of your specialist advisors runs a joint training program for microbiologists and infectious diseases physicians in a leading London teaching hospital.

  1. Do you think it will then answer the problem?
      (Professor Pennington) In the fullness of time, yes, but it is a question of how long that will be.

Lord McColl of Dulwich

  51. Is the problem not much more deep-seated? Given that young people go into some branch of medicine and although the senior training posts are matched to the number of consultant vacancies, at the lower level no-one has ever accused the system of matching anything. There is just a great hoard of people with no future at all, no security, and is it not time that we followed the line of most other countries where if somebody wants to go into, say, surgery or medicine or obstetrics or microbiology, if they go into it and they are of a reasonable standard they ought to have a reasonable chance of reaching trained status at a reasonable age in their early thirties, not forties as so many of them are today.
  (Professor Sir Peter Lachmann) That is certainly true. We are very much in favour, particularly for academic trainees, of shortening training. NHS training has got shorter in recent years. A report is pending on the future of the SHO grade which proposes a seamless transition from the moment of leaving medical school until becoming a consultant. That entails a lot of inflexibility in training and a lot of inflexibility in career pathways which will certainly have a serious downside. We have not yet responded to this consultation, and I do not wish to pre-empt what our working party will say, but it will certainly be worried about the academic consequences of this seamless approach—you can call it a "seamless treadmill", if you like. Many people, when they come out of medical school and do their pre-registration jobs have no very firm views of what the practice of medicine is really like and change their minds as they go along. Again, particularly for those who are going to have academic interests, it is important that they have the ability to move sidewards and to do interesting and unusual things. Therefore these are difficult areas.

  52. They manage to do it in other countries and have done for half a century. That is my point.
  (Professor Sir Peter Lachmann) I think the American system is one which should be carefully looked at. It is shorter and it achieves a slightly different objective, and people often go on academic training afterwards. Americans also go to medical school when they are rather able. Training in this country, particularly for academics, is certainly too long.

Chairman: I think this will have to be the last question on this matter. Lord Haskel?

Lord Haskel

  53. I was interested in what you said about appointments being linked to targets. How can we make sure that appointments are linked to priorities? We know about the weakness of targets.
  (Professor Cohen) I suppose it is by correctly identifying the priorities and making sure that those who have to implement them have the resources to deliver them. I think that the difficulty is that unless the trusts—and it is largely down to the PCT's now—can be persuaded that something like infection in this context is a core function, unless this is adequately addressed and dealt with, understandably they are reluctant to put resources into it. While, at one level of course they understand that, in terms of all the other pressures on them I guess it simply does not have sufficient priority. That is exactly the problem.

Baroness Walmsley

  54. The next question is about a possible structural change so it may not prove very popular with Sir Peter. Do you think there is any merit in establishing designated infection centres and could they take over the training function of the PHLS and improve the situation you have just been describing?
  (Professor Sir Peter Lachmann) Yes, I do see merit there, it shows how inconsistently these Centres of excellence were proposed in the Academy's report on Bacteriology. It would be a very good idea to have multi-disciplinary centres of excellence in microbiology, infectious disease and epidemiology, where all these strands come together presumably in an academic environment. They would provide valuable training in the whole area. We very much hope that some way of funding these Centres of excellence is found. They are not a major change in structure; it is just bringing the threads together which we do believe would help. The Centres would have tentacles reaching out to the peripheral laboratories so that these laboratories would have access to multi-disciplinary centres. Indeed, it is the Academy's view that this is exactly the way we ought to go. There should be a limited number of these centres. They would be the focus for developing new techniques and maintaining excellence in this area and would bring together all these different specialities, not just the infectious disease physicians and the clinical microbiologists, but also the public health doctors, the epidemiologists and all those who are necessary for the control of infectious disease. They should all be able to work together. This should be facilitated and we think it would be facilitated particularly by having a centre of excellence. I would refer you to our report on Academic Medical Bacteriology in the 21st Century which outlines these suggestions in some detail.

  55. How would they link with the universities?
  (Professor Cohen) I guess most of them would actually be based on an academic department or even several academic departments.

Chairman

  56. Are there any other points on this question?
  (Professor Cohen) I entirely agree. The only addendum I would make is to say that one has to be careful in doing this not to forget that the coal face, particularly in aspects of surveillance, for example, is still going to be at the periphery. You still have to make sure that you have the means to pick up the events where they are occurring on the ground. In a sense I think one has to have both. I absolutely agree with the merits of an infection centre, but it should not be at the price of losing the radar tentacles, if you like, around the edges because that is where you actually pick up the events that are occurring on the ground.

Baroness Walmsley

  57. So this would be extra.
  (Professor Cohen) I think it is a different emphasis and it is simply making sure that you have both. Neither can work on their own, essentially. I think you need both bits of it to make the system work properly.

Chairman: Lord Turnberg, you partially asked a question. Are you happy with it or do you want to press for a further answer?

Lord Turnberg

  58. You talked about joint training between microbiology, epidemiology and physician training. Is there a public health element in that? Has it been agreed that there should be a three-way training program or is that still not quite there?
  (Professor Sir Peter Lachmann) I am not sure I am the right person to answer that. Does public health come on board in the training?
  (Professor Cohen) My understanding is that they are interested in that possibility, but it has not been developed to the state that it has between microbiology and infectious diseases.

Lord Turnberg: I think we have dealt with this question. You obviously feel that this is an important way forward, but it will take time.

Chairman: Are there any other points? Baroness Emerton?

Baroness Emerton

  59. You have touched on medical schools and I wonder if I could ask Professor Cohen to describe how, within the crowded medical curriculum that there is today, public health is adequately covered.
  (Professor Cohen) It is, of course, the case that GMC do expect that public health is part of the curriculum and I am sure that all medical schools will incorporate that within their curriculum not only because of that but because they think it is a good thing to do. It is, of course, very crowded and that is a problem. Public health, it is worth remembering in this context, covers not just infectious disease epidemiology but all the other aspects of public health as well. Inevitably, again, to some extent, the same pressures arise. For example, in the public health part of our curriculum, quite rightly, issues around smoking and heart disease will figure. Those kind of pressures mean that the infectious diseases aspect of public health inevitably finish up with a rather small slice of the cake. I think we do try to cover it but it is probably a pretty small part of the curriculum inevitably.


 
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