Select Committee on Science and Technology Minutes of Evidence


Examination of Witnesses (Questions 60-79)

TUESDAY 29 OCTOBER 2002

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


60. The discussion has been limited mainly to medical education, but what about involving other health professionals in terms of public health and infection and so on?
  (Professor Cohen) I think that the notion of multi-professional education is something which is very much being embraced certainly by the new medical schools and something which we very actively try to incorporate into our training. So, for example, just the other day we were talking about the teaching of basic hygiene to our first year medical students and that is going to be delivered by infection control nurses; they will be the lead people for delivery of that part of the curriculum. I think there are opportunities there which need to be built upon. I guess the other way in which one might think about it is at the other end of the curriculum when students are emerging and in their early years of training and whether it would be possible to incorporate experience in public health as part of the early post-registration PRHO equivalent type of training. After all, we allow young doctors to spend some time in medicine, in surgery, in general practice. Would it not be possible to say they could actually do one of their house jobs in public health medicine? That would be an innovative and interesting way of trying to not only increase the man power but more importantly to encourage young people to see it as a career in its own right.

Baroness Walmsley

  61. That sounds like a very good idea. Why is it not done? Are there any practical difficulties? Or are there career disadvantages? Why is it not done now?
  (Professor Cohen) I have absolutely no idea.

Baroness Emerton: When I was a nurse in training—some many years ago—we went and certainly did a spell in public health and it slipped from the curriculum. I think it is probably the same in medicine. I think it needs rejuvenating.

McColl of Dulwich

  62. At some hospitals one of the HP jobs was half HP and half resident pathologist. Those people often went into pathology and often into bacteriology but that was scrapped for some reason or another.
  (Professor Cohen) I think that is right. I think that would be very unusual these days.

  63. Is there any reason why we could not go back to that? It was a great method for recruiting people.
  (Professor Cohen) None that I am aware of.

Chairman

  64. Could we now move on to question number five which I think Professor Pennington might be interested in. In your written evidence you describe how surveillance systems need to be flexible and innovative. Do you think that this is the case for what is planned in Getting Ahead of the Curve and, if not, what steps should be taken to achieve flexibility and, I would add, integration and responsiveness.
  (Professor Pennington) Yes, Getting Ahead of the Curve is fine as far as it goes. It describes the sort of systems that will strengthen the quality of the information that has been collected passively. So, for example, on page 137 it talks about the duty of care of microbiology laboratories to report what they find; better case definitions for reporting; co-ordinating, analysing and reporting on different systems; integrating information. It is all about collecting information and also having good systems of accreditation and laboratories. All this is necessary but it is not sufficient for a surveillance system that is going to catch, for example, new and emerging pathogens. What it will deal with are the ones we know about using the procedures which are well established and it will make sure that all laboratories are operating to a common standard. There are even problems with that in the sense that unless those standards are kept continually under review, unless those standards are taking account of new developments, they will always be out of date. I think there is almost an inevitability that if you are going to have tests that will satisfy a legal requirement, that have been validated (and this was one of the issues, for example, in the foot and mouth outbreak using tests that had been validated) this takes a long time and by the time the test has been validated very often better tests are on the horizon. This is why flexibility is very important in terms of surveillance. For the ordinary, small district general hospital laboratory what Getting Ahead of the Curve says is absolutely right because many of these laboratories are not accredited yet and they need to be so that we can be certain that the quality of the data they are sending—and certain that they are sending in the data that they are collecting—is done properly. Looking for the real problems, the new problems for example, this will not be sufficient. I think part of the answer to the question about the key steps taken to achieve flexibility and responsiveness comes down to the Research and Development side. For example, to do surveillance it is not enough just to passively collect the data that has come in generally speaking because of a general practitioner or a hospital consultant requesting a particular sample; it will require active surveillance by surveys in the community and it will require active work on samples that have been collected to do detailed typing and so on. Very often this requires more than just the basic funding that a laboratory requires for doing its ordinary day to day service work and also just sending in information and collating that information. At the end of the day, I think Getting Ahead of the Curve addresses a significant problem but it does not take it far enough in terms of us being "ahead of the curve" in a sense. We need to be aware of new developments and new pathogens because—as I think we put in our report—one of the essential features of microbes is that they evolve in real time. Using tests of the past is not going to be enough to identify the problems of today, never mind the ones that are just round the corner.

  65. In your submission on paragraph three you are somewhat critical of the service not being joined up. Of course, you might expect me to mention the Veterinary Laboratory Agency where, indeed, similar work is being done. What is your opinion about the two getting together much more?
  (Professor Pennington) I think there have been movements in terms of having committees which are looking at zoonoses, for example, which, by definition are linking the veterinary and the human medical scene from the microbiological point of view, but we still have laboratories which are working in quite different environments which, generally speaking, will only be talking to each other formally on fairly infrequent occasions. There will obviously be a network behind the scenes and those work well sometimes, but I do not think you can rely on those as a management tool, as a systematic tool to make sure that everything is being done that needs to be done. I think there is a real need to have a look—whether it is veterinary or human—from a pathogen base, look at the outcomes of what you want from surveillance. I think we draw E coli 157 as an example where there are different efforts going on looking at this organism which are not sufficiently co-ordinated in terms of having a full understanding of what is happening in real time in terms of the organism being in animals. Animals are the source, but it produces its major health problems in people because in animals it does not cause disease. It only causes problems in people when it spills over. So it is not a veterinary pathogen; it is a human pathogen but the main source of the organism is in animals. I do not think we have yet solved the problem of how we address that particular complicated situation as well as we might. It would not do just to rely on informal contacts between Colindale and Weybridge, and so on, in terms of solving that problem, or by committees that meet relatively infrequently.

  66. A good example of what might be proactivity is the question of the West Nile virus infection and what are we doing to co-ordinate the various groups such as the VLA and yourselves to monitor that and its entry into and spread in this country.
  (Professor Pennington) It is partly a missed opportunity that the Health Protection Agency does not use that as an example where the West Nile virus needs not just people interested in diseases in wild animals, diseases in humans, but also entomologists as well, for example, and the mathematical modellers bringing all these people together (which we alluded to in terms of talking about the public health aspects of infectious disease control). We still have not cracked the problem of bringing all these people together. I think that was shown remarkably well in the foot and mouth outbreak where the people were brought together after the outbreak had started; they should have been brought together long before the outbreak was started with a role in contingency planning. I think it does come down to the contingency planning argument that we need to have a system which brings all these people together and, in a sense, bangs their heads together, if you like.

  67. Has that happened in North America where the West Nile virus is causing quite serious problems? Have entomologists, veterinarians, virologists, et cetera been brought together effectively?
  (Professor Pennington) I think it is quite difficult to make a comparison, but CDC Atlanta obviously has a very broad range of experts either in the organisation itself or on tap. They have a slightly different tradition. Their shoe leather epidemiologist—and I am not being rude to our epidemiologists I hope—is not sitting in an office crunching numbers, but he is out there with a field role as well as a office role. We do have field epidemiologists in this country, but they have made a virtue of it rather more than we have. It is a very attractive career option for doctors to go into this kind of epidemiological activity. I would sincerely hope—and this is just a personal view—that we go down that same road ourselves. I think that some of the state health authorities in the United States—which we do not really have an equivalent of here—also play an important role in this. Again in the United States I think one has to be careful when making comparisons in that in some states their system is working extremely well and is well funded. In other states—and I am drawing on my E coli experience—in the western United States there was a significant lack of co-operation between the different states which led to a very large outbreak going unrecognised for a long time because of downsizing and so on. There are advantages in the American model, but they have to be looked at with a degree of caution, I think.

Lord Oxburgh

  68. Could I ask Professor Pennington, when you say "people getting together" do you mean there should be some kind of new physical institute containing these different disciplines, or are you talking about someone organising funding and maintaining some sort of network of activities?
  (Professor Pennington) I think I am talking about both, essentially. I think our infection centres would be a very good way of working towards this. We would still need the networks as well because there would be a very small number of infection centres. There will be a requirement in other parts of the country, for example, to have a network of people who are formally linked so that they do know what is going on. We do have very good networks of information. We have weekly reports and so on going out. But I still think that we do miss tricks on this, that we do not have it quite right. There is a British disease of disciplinary compartmentalisation which, we have already heard, has been addressed in terms of infectious disease physicians and medical microbiologists. We have a way forward in addressing that problem (although I think you heard that our optimism was guarded in how long that would take) and we need to move faster not just on that but in getting other disciplines (for example the mathematical modellers) and bringing them into the house. I do not have an answer how that could be done any better than it is being done now.

Lord Quirk

  69. Would this networking—and indeed any new institution that might be set up—be better on a European basis or an individual national basis? You compared our situation in this country with the United States. With BSE you were obviously greatly involved with work in other countries.
  (Professor Pennington) I think the UK has a very good opportunity here to set a European lead. If I may say so, there are many European institutions being set up to address this particular problem, a formal network is being set up. For example, on the IT side and certainly on the public health side, certainly on food safety, there are European initiatives which will drive this. I think if we get our house better in order we could continue the lead role that we have been taking in Europe on this because in terms of most European countries I still think we have a better system. Although we are drawing the disadvantages to the fore here, I still think we have a better system than many European countries and they are eager to learn from us. Clearly, if European networks are going to be set up, it is to our advantage to be in on the ground floor as well with that.

Chairman

  70. I am just going to ask about the World Health Organisation rather than European people. Is WHO well schooled in this and operating along the lines that you would wish to see?
  (Professor Pennington) It acts as a forum and as a support and has particular interests as well and can facilitate in particular areas. At the end of the day I do not think it has a particular interest in British problems. We have a particular interest in WHO rather than the other way round.
  (Professor Sir Peter Lachmann) WHO is very focussed at the moment—and quite correctly—on problems of the third world. Can I just mention to you that there is a new body called the Inter-Academy Medical Panel which brings together all the world's academies of medicine and medical science who had their inaugural meeting in Paris last March and have just published their proceedings in a book Confronting Infections: Antibiotic Resistance and Bio-Terrorism Round The World. Their work is going to be developed much further with financial support from the United States, but is concerned essentially with the problems of the third world. Because of global travel we are not isolated from the infection problems of the third world; but compared to their problems, ours seem rather small.

  71. Could we have a copy of that or will you leave it behind for us?
  (Professor Sir Peter Lachmann) We will leave it behind.

Baroness Walmsley

  72. What you have just said, Sir Peter, brings me neatly on to something that struck me very much in your evidence, that you were somewhat concerned about the limitation of the brief we have imposed upon ourselves to focus on UK health issues. Although we do not have five years to do this report, we have had to restrict ourselves to some extent and we are perfectly aware of the fact that infectious disease is a global problem. Could you suggest any area of our brief that we might particularly emphasise in order to address your concern about the limit of our brief, this sort of networking, for example, that you have just been talking about, or something else?
  (Professor Pennington) Could I respond by quoting an example where international collaboration has worked well and if you could give support to that kind of collaboration and that kind of enterprise and working, I think we would all benefit from it, not just in this country but elsewhere, and that is tuberculosis where there has been a very successful international collaboration in terms of typing the tubercle bacillus so that one can work out the source of the organisms. This has been done by countries in North America and Europe and Ethiopia; it has been a truly international effort. You can type your organism and look at its profile on the World Wide Web, for example, because the scientists have got together and agreed a typing system. Anybody who knows anything about the typing systems for bacteriology knows that this is one of the most fertile sources of dispute amongst bacteriologists, which system to use. The paradox is that tuberculosis is one of the most difficult organisms to work with—it is very slow to grow, it is very difficult to handle in a laboratory, it is very dangerous to handle in a laboratory, extracting its DNA to do the fingerprinting is very difficult because the organism is very tough—and these have all acted as a stimulus to people to actually get their act together and work out an internationally agreed system which, at the end of the day, depends on good IT. I think any support that could be given to this kind of enterprise in other organisms—as Sir Peter mentioned, these are not organisms which are resident in the UK, we get them from other countries and we export them to other countries—would be, I think, a very powerful way forward in terms of protecting the public health of the citizens of this country, never mind others as well. It is partly a question of banging together the heads of the scientists, or finding people who can do that and push people in the direction of much more collaborative effort in terms of putting the science to work properly; the science is there but it has not been put to work properly.

Chairman: Are there any more points on that? If not, can we move on to question six, Lord Oxburgh?

Lord Oxburgh

  73. The Academy's evidence and comments upon the proposal to transfer the research funds from the PHLS to the central NHS on the budget is fairly clear and not very supportive. Would you care to elaborate on this and really say how you think that research into infectious disease and public health should be funded?
  (Professor Cohen) I think the way into this, in a sense, was to identify that the PHLS in its current role has, I suppose, two very broad functions. One is that around surveillance; the other around serving as reference laboratories as centres of expertise. Focussing on that second part, clearly a reference laboratory is only going to be effective if it is able to continually develop new procedures, evaluate new tests and so on and validate them. I think the reason we flagged this up as a concern is that quite properly the role within the PHLS of this kind of work focusses more on D than R; it is a more developmental than basic science role. I would say that I do not think we are talking about very basic science aspects of research; we are talking particularly about the D part of R&D. It is certainly true that by and large funding for development is seen as less of a priority than funding for research. It is always generally more difficult to get funding for D than it is for R. Yet without that adequate funding the very important role of the PHLS in being the forefront of developing new tests—as Professor Pennington was talking about earlier—is going to be threatened. I think our concern here was to point out that if all that resource (not just the resource which is currently allocated to the central PHLS laboratories in Colindale and so on, all the amount of R&D support which currently is associated with the peripheral centres which would be lost then because they would not exist as part of the revised HPA) were to be moved into a central NHS pot for research, our concerns would be that inevitably the call on those funds would again be driven by things which were seen as a higher priority, things which were perhaps more pressing in terms of the priorities being set by others. Particularly given that D is traditionally funded rather poorly, our overall concern was that this would mean that the admittedly already rather limited resource the PHLS has for R&D would be further weakened and this would be at the expense, therefore, of the public health function because the ability then of the PHLS to develop new tests and to respond to problems in relation to public health would therefore be severely weakened. That, I think, is the point we were trying to make.

  74. Are you really saying that experience suggests that the NHS R&D directorate would give insufficient priority to this kind of work? Is that what it amounts to?
  (Professor Cohen) I think what we are saying—as we were saying earlier, indeed—is that throughout the NHS (not just the R&D directorate) this is seen as an area which is of less pressing importance than some other areas, yes.

  75. Do you have an alternative suggestion? Or would you simply say we should retain the status quo?
  (Professor Cohen) I think that it would follow inevitably from what we have said, that we would see it as important that a mechanism be found to ensure that there are adequate resources to support particularly R&D (and particularly D) within the public health arena. Whether that means that the Health Protection Agency should retain a specified R&D budget or whether other means should be found to ensure that within the general NHS budget there was a mechanism to ensure that public health was protected—there are a number of different models—I think we would recommend that there is adequate means of ensuring that there are funds to ensure development of public health R&D.
  (Professor Pennington) Could I just illustrate what Professor Cohen is saying by two examples of what the PHLS did in the past using its own internal funds, work which would have been quite difficult to fund in terms of putting in an application to a body. This was the original work looking at Campylobacter -the commonest bacterial cause of food poisoning—which was done in PHL laboratories like Worcester. This was done as part of their routine diagnostic work developing culture media and so on. The same sort of work was done more recently in Sheffield in terms of E coli 157, developing a medium in which you could grow the organism successfully. This is extremely mundane work in terms of putting it down on paper and saying "I want to modify a culture medium" which was invented by Robert Koch in about 1890 and has not moved technically very much since, but is absolutely crucial if one was going to get a good return in terms of sampling faecal samples for the pathogen. It sounds trivial when you write it down, but it is so important in terms of surveillance and in terms of diagnosis. My preference would be for some kind of fraction of the budget to be allocated—not to salaries or to consumables—but to this development fund where people could do the kind of work where, if you applied to the MRC, it would not get past the office (and rightly so). The MRC is not in the business of funding that kind of work. Somebody has to fund it. The PHLS has funded it in the past; somebody has to fund it in the future.

Chairman

  76. Are you suggesting some ring-fencing?
  (Professor Pennington) I think there are problems that not every laboratory in a network of laboratories—whatever the Health Protection Agency network develops into—is going to be fit and suited to do that kind of work. There is an argument for having some kind of central control over it. But at the end of the day I think it is very difficult to predict where that work is going to be needed; it will depend on local circumstances. Local outbreaks might throw up a problem which would require somebody to exploit that particular material, that clinical material. That is something we have not discussed so far this morning, but that is another aspect of the R&D that laboratories do have a very rich resource of material which we neglect at our peril if we do not do R&D on it. At the end of the day, some kind of ring-fence money, yes.
  (Professor Sir Peter Lachmann) I just want to add that we are not being critical of the director of R&D in the NHS; far from it. The point is the regional laboratories of the PHLS were very well adapted to their function of providing that local, reach-out public health service which is required for infectious disease surveillance. This is going to be replaced by asking ordinary NHS laboratories to take this work on board. That may or may not turn out eventually to work well, but it will initially be quite difficult. These laboratories are very heavily stretched. Their prime function is to provide bacteriology services to their own Trust not to do infectious disease surveillance. It is not at all clear that the directorate of R&D and the NHS has the mechanisms or the authority to make sure that this public health laboratory work really gets done. This problem extends to other areas as well. It maybe quite difficult to force Trusts—who are under pressure from other parts of the Department of Health to concentrate on service delivery—to engage in R&D activity. It is not immediately clear to the Academy—as it says in our report—where is the benefit of destroying the peripheral PHLS laboratory system in favour of a system which is untried and which seems to us to pose considerable difficulties with conflict of duty, loyalty and work.

Lord Oxburgh

  77. In a way what you are saying is that what is a de facto national strategy at the moment would disappear.
  (Professor Sir Peter Lachmann) I think that is a fair way of putting it, yes.

Baroness Walmsley

  78. Can I just go back to what Professor Pennington was saying just now about the sort of development work you were describing. What is the potential for that sort of work being done in the private factor and what are the pros and cons of that?
  (Professor Pennington) I think there is an opportunity for the private sector to take part in that kind of work, but it is really very limited. And, of course, at the end of the day, the private sector involvement will require it to make a profit. That restricts its input. I think the private sector comes in, in the examples I was quoting about development of media. They then exploit the work that has been done in the NHS laboratories (under whatever rubric those laboratories exist) or academic laboratories and then develop the media further in terms of commercial products. That is the way it has always happened. That is what actually has happened with the examples I quoted, up to a point. It may be cheaper to make them yourself or it may be cheaper to buy them from the commercial sector; it depends on local circumstances and so on. They do have a role, but they do not have the access to the clinical material, for example. Generally speaking, the laboratories that are in that kind of line of business will find it difficult to get the scientific input to be done in real time. I think one of the problems is that this does need to be done in real time. This is not something one should develop over a period of years. In respect of the examples I was talking about (which are rapidly evolving organisms or organisms that come to light because we made some small technical discovery and we find we have a pathogen which has been all the time but we did not know about, as in the case of Campylobacter, we were incubating at the wrong temperature in the laboratory) then yes, the commercial sector has a role, but not in the initial stage; downstream from there.

Lord Turnberg

  79. Can I return to the R&D business. It is true, is it not, that the amount of money that the PHLS put into its own R&D program is relatively small—a couple of million pounds a year out of its budget of about a hundred million—and it relied heavily on that bit in order to formulate bids for more research money. It gained research grants from the MRC and from WHO and elsewhere in the European community many times for definitive research, basic research including new molecular techniques (which was a big program). It did rely very heavily on that seed corn not simply to do the sort of work you have described, but also to build up projects, to put forward bids and in order to provide the sort of philosophical background that R&D was an important function for the PHLS. It is that which will be lost, is it not?
  (Professor Pennington) Can I just say from a personal point of view that one always saw the PHLS as a formidable adversary in terms of bidding for funding in a particular area because it always started off from a very good position because—as you have been describing—it had this seed corn, it had been able to do the preliminary work essential to build up a good proposal and its proposals were often successful because it had done that work and then the outcomes were also very successful because of the fortunate position it occupied in having the clinical material coming in and the other expertise in other areas of the PHLS. I am just expressing that from a personal point of view. We always regretted when the PHLS put in a bid in my area because they usually won. They had this structure which helped them to structure a bid for research so that it was successful.
  (Professor Cohen) I was going to agree with Lord Turnberg and say that my personal view would be that the amount of money the PHLS was able to allocate to R&D was lamentably small given the importance of the kind of work they were doing. I would agree with him that without some identified resource to carry out this kind of work, it would, as we wrote, have a risk of undermining the public health function quite substantially.

Chairman: Any further points? If not, can we move on to question seven, Lord Haskel?


 
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