Select Committee on Science and Technology Minutes of Evidence

Examination of Witnesses (140-159)



  140. So in terms of prioritising, do you think that the NHS diagnosis side would take precedence over the public health aspect? That is the key thing people are concerned about.
  (Dr Kelsey) The point I was really trying to make is that surveillance you bolt on to good diagnostic work, and that once you have created the diagnosis, the surveillance is really something which comes quite easily. It is your inability to diagnose, because you have not got the breadth of investigations or you do not have the manpower and money to fully investigate an outbreak of diarrhoea, or even an individual case of diarrhoea, because you do not have the breadth of studies available to you. This is greatly seen if you go back to look at the E coli 0157 scares, when these became prominent, and the PHLS regional laboratories, I believe, were instructed that they should look for E coli 0157 on every stool sample, whether it appeared to be clinically indicated or not, which was probably a good strategy, but NHS laboratories were not funded for this, and therefore had to do additional work within their funding, and a lot of them said, "We will only look on children" or where you have a haemorrhagic or there is haemolytic-uraemia syndrome already established. I think those are the sorts of problems. The view is amongst NHS laboratories they do not feel that they have been as well funded historically with doing complete investigations as they would like to have done, so the belief is, whether it is true or not, that the PHLS region network have better funding.

  141. So is there going to be a problem in terms of timescale, bearing in mind the April 2003 introduction?
  (Dr Kelsey) I think the situation as it exists now in recent years is that the NHS was responsible for more surveillance data on microbial diseases going into CDSC than the PHLS regional network. Those figures have been established. So I do not think there is going to be any less surveillance data going in; I think that will continue.
  (Dr Spencer) I think all laboratories, whether they are NHS or PHLS, do surveillance, and surveillance can best be summed up as information for action. I think most medical microbiologists running a decent lab will collect information and act on it, hopefully in a timely manner. I think it is not beyond the wit of man that you could incorporate in the discussions when PHLS laboratories, other than those designated HPA, go back into the trusts to have some form of service level agreement that surveillance data will be supplied, and I think there is a role for local surveillance. I think it has to be at the coal-face. There is then a role for the regional epidemiologists, who are already recruiting regional infection control nurses to facilitate this, which is then fed back for national figures as well. I think it is the way the change-over occurs. But of course, the one underlying problem is IT. Many hospitals have different IT systems. Do they talk to one another? What are we going to do about information technology and surveillance in the community? What are the roles of the CCDCs and the health protection units, who will now be part of the field forces of the HPA? It will be different, but I do not see why surveillance should cease or be any worse than it is at the moment.
  (Dr Crook) We went through a PHL withdrawal, so in a sense three years ago we went through what the laboratories are going to go through at the moment. I am confident that passive surveillance, as it is provided for at the moment, will continue unabated and very well. There will be some minor transitional issues around that, and I think one can be very secure about. I think our reporting will continue. The PHL have withdrawn from other laboratories, and that reporting has occurred, and I am sure Professor Griffin would support that as being the case from St George's. There were studies commissioned by CDSC, and I think Paul Farrington, who was the person who did it, demonstrated that the NHS reported passively to a very high standard, so I will not be concerned about that. There are financial issues that impinged very heavily on the Oxford lab, and that needs careful thought and costing and needs to be unpicked. We receive a sum of money of approximately £0.75 million per annum from the PHL through the core funding that went to support the laboratory. It was poorly defined and when they withdrew, that money was removed, and through a vigorous process of—if I can use the jargon—re-engineering in the laboratory, which depended very heavily on my infectious disease colleagues going so far as refusing tests for clinicians, we were able to substantially reduce the costs of running the laboratory, may I say at no risk to the passive surveillance; we looked into that very carefully at the time. So these are going to be transitional arrangements that may incur extra cost to proceed through the transition; that will create some degree of uncertainty, and that uncertainty I would estimate will affect mostly that part of the PHL work that relates to doing what is being euphemistically referred to as food and water and environmental work. That is capturing that bit of work—and it is not a large bit of work but it is work which is very important to environmental health officers, to district councils and other organisations of that nature, where they investigate outbreaks, and that needs careful planning to make sure that that is attended to through the transition. I do not think a longer or shorter transition alters that. It is the quality of the planning that goes into that transition that will ensure it, and I believe with good CCDCs and good advice through CCDCs, who are going to be part of the Health Protection Agency, as planned in Getting Ahead of the Curve, will capture that satisfactorily, if it is carefully thought through.


  142. With respect to the present situation, do all NHS microbiology labs currently report centrally to the Public Health Laboratory Service?
  (Dr Crook) I cannot be sure of that. That could be provided by a CDSC, but the vast majority do report.
  (Dr Kelsey) I think the answer is no, not all laboratories report, and there are reasons for not reporting. Initially, and it still is to some extent, it was a paper-based system. It takes time to fill out forms. The workload on NHS diagnostic laboratories has gone up and up. Staffing levels have not gone up particularly in line. We have made cuts in methodology, etc, to try and keep up with the work. One of the things which does fall off is the paperwork, so I think fewer labs report now than did 20 years ago. I would also make the point that the PHLS was not terribly helpful when it came down to information technology. They provided a system which was called Coserve, which was meant to electronically capture information, feed that in via the regional epidemiology network into CDSC. As an NHS laboratory that wanted to help them, we tried to implement it, and it was not a very user-friendly system. One of the reasons it was not user-friendly was that you had to manually enter data. Even what you could capture from your own laboratory information system was not enough; they wanted more information. One of the problems we have had with laboratory information systems in surveillance is there is no standardisation of what an epidemiological data set should be: what it should be for a stool, what it should be for urine, what it should be for a blood culture. If we are going to look seriously at surveillance in the future, given that there is no obvious end to the manpower shortage or the funding problems that we have, then we are going to have to capture data electronically. That means capturing it on our laboratory information systems, which means that we are going to have to have standardised systems of data capture. I do not think the problems of forwarding from those systems are that difficult, because there are large amounts of middleware software systems which can take data from almost any output and convert it to almost any other output. I would say that the PHLS were told on many occasions that their system was unfriendly and probably unuseable, and which may explain why it was not taken up more widely by the NHS. Of course, the PHLS regional systems were mandated to use it.

  143. So there is a substantial lacuna there.
  (Dr Kelsey) Yes.

  144. But from what you are saying, it could be remedied with not too much difficulty?
  (Dr Kelsey) It could be remedied with forward planning. There are a limited number of suppliers of laboratory information systems. We have national guidelines from the NHS Executive in Leeds about our IT systems. How much effort would it take to actually get the Leeds NHS Executive to write a system of structures of software which would capture the data we need to capture? In the next few years we are mandated to going over to what we call "order comps," which are basically that a GP or a hospital doctor or anyone will have to order whatever request or out-patient appointment or operating list through a computer system. This gives us a tremendous opportunity for actually screening the work that comes in, having to go through all the base systems for saying a test is appropriate. If it is for a stool, for example, you ask the question "Has there been recent travel overseas? Is there a food source suspected? Is this part of a family outbreak?" There are very simple questions which can be asked at the point of entry by the doctor who has seen the patient, and this will then go into any laboratory information system and be forwarded to any surveillance system. So there are opportunities, but somebody has to make the decision that they write the standards.

Lord McColl of Dulwich

  145. Do you think the NHS Executive IT people in Leeds are capable of doing what you suggest?
  (Dr Kelsey) My infrequent trips to Leeds have not been very sensible, but not necessarily based around IT. I really could not answer that.

Baroness Walmsley

  146. My question is about collaboration, and what you have just described makes me worried that the thing that might fall off the cliff might be collaboration, and that this might be one of the transitional issues which Dr Crook mentioned. We have heard a lot of evidence that says it is very important to have collaboration between different kinds of surveillance systems, so how do you anticipate that the interface between clinical microbiology and food, water, environment and veterinary microbiology might work under the new system?
  (Dr Spencer) That is a good question. I think to a large degree quite a bit of cooperation already exists between PHLS, for instance, and local laboratories, whether they are NHS or PHLS. If we are contacted by environmental health officers to say "We think there is an outbreak in a particular hotel, the specimen has arrived," we feed back in a timely manner. Similarly with the CCDCs. I think it is opening lines of communication that is vital. Apart from the IT problem, it is actually meeting EHOs, meeting food standards people and also CCDCs, which most medical microbiologists certainly do. So although we are going to have problems with IT, and there is no doubt about it, provided we are committed to communicating with one another—and this goes right across the board—I think you can go a hell of a long way down that line.
  (Dr Kelsey) May I add a number of points? I think as far as the Health Protection Agency, the PHLS and the NHS are concerned, the cooperation will be there. There is a tremendous good will for all of us to work together. One of the areas, which perhaps if we are going to look at it, is food, water, microbiology and husbandry to some extent, and it is going to be the network of private laboratories that perhaps serve the food industry, that serve the veterinary industry and agriculture. They perhaps need to be brought in, maybe through a system of reporting which is voluntary—it may have to be compulsory. I am not sure the food industry is going to be very keen necessarily to let you know, unasked for, about what is going on in husbandry. That is one area which perhaps needs to be looked at carefully.
  (Dr Crook) I think this is a key question, and I cannot see in Getting Ahead of the Curve or any of the other policy statements that have been made that there is a mechanism for ensuring that different agencies come together and share data in such a way that you can make the analyses necessary to determine whether there are outbreaks or links between outbreaks, either between veterinary services and health or water authorities and the Health Department. How one captures that needs thought, and I do not think it is necessarily simple to get cross-agency support. I am aware from my colleagues in the United States that this has been difficult, and I am aware from colleagues in Europe that it is difficult to get the vested interests that lie within each one of those enterprises to share data in such a way that you can make the necessary determinations for surveillance.

  147. The system that we have at the moment, that Dr Spencer described, is very much a needs-based collaboration. When they need to collaborate, they do. Is that correct?
  (Dr Spencer) It depends what you mean by "collaboration".

  148. You mentioned that obviously they talk to each other when they have a case that requires each other's expertise, but is there a need for something more laid-out and regular and routine that is not based on specific needs?
  (Dr Spencer) I can only speak for Bristol, but our CCDC sits on our laboratory management committee, which is held monthly, so she comes along with her concerns and problems and we have our problems, and we interface that way to try and head off any foreseeable problems. I think if you look at the way the HPA is starting to develop—and of course, the problem with the HPA is that it is a "virtual" creation that does not exist at the moment, although it is now going to be a special health authority because they cannot get the RRO through in time. If you look at the emergency response division, that will hopefully capture what is happening in clinical microbiology, what is happening in food and what is happening in veterinary. It could be, for instance, if we talk about a deliberate release of an agent that is also active against animals, it could be the vets, as with West Nile fever, that will pick it up first, and they hopefully could feed in that way. That is a developing theme.
  (Dr Kelsey) I think there is a role for leadership somewhere in this organisation, and it is perhaps best going to be based in this regional microbiologist, an undefined post as far as we can see, as is the inspector of microbiology, which seems to be a totally undefined position. A good leader, somebody who can inspire, somebody who can bring together disparate groups would be more effective. One of the things that you have to do is feed back. If you are going to get people to add information to your system, it has got to be seen as worthwhile. There has been talk perhaps that we should set up data warehouses, where we enter our surveillance data coming from human practice, the vets enter their data from veterinary practice, and from other sources, CCDCs put it in, and that this then goes into a national or regional data warehouse, and those who submit data can ask questions of it. They will then get ownership and benefit from it. There is always a problem setting up systems where there are no benefits to those contributing. Finally, on this problem of the disparate groups, the vets, farmers, food and human sources—and I am sure we will come on to talk about standardisation—there are differences in methodology between the different groups. Veterinary microbiology and human microbiology have moved closer; their methodologies have become more similar. I am not sure this is true of food and water, where what they call an E coli may not necessarily be what we call an E coli. We have to be a little bit careful of that. Finally, I was always impressed by cancer doctors and their cancer maps. There may be an opportunity to produce infection maps, where you have the veterinary problems mapped against the human problems. We may be able with much better information technology to reveal things which are just not obvious.

Chairman: Can I just say that I attended a meeting in Cardiff a couple of weeks ago organised by Stephen Palmer, who I am sure you know, and that brought together VLA and PHLS in a quite remarkable way. We had three days of working together very well indeed and doing things that you say should exist but did exist. They were swapping information very well indeed, and it just shows that the two bodies can work together very readily and are keen to do it, so long as there no officialdom in the way.

Lord Oxburgh

  149. One of the aspects of this business which I have been trying to get a feel for from various witnesses, but I have not really succeeded yet, is the need for speed in carrying out these various steps. The arrangements that one proposes and the kind of organisation that one needs is determined at least in part by the cost/benefit analysis of how quickly you need to know what is happening, because at the moment one is substantially based on pieces of paper travelling here and there with some electronics in there. Is anybody in a position really to give an answer to the desirable speed with which this series of processes that we are talking about can be carried on?
  (Dr Spencer) What is wrong with a telephone call? If I have a problem that I think we have an outbreak situation, if it is within the hospital, we do a visit; if it is outside the hospital in the community, we get hold of the CCDC and say, "Look, we have suddenly had a whole rush of meningitis/salmonella food poisoning" or whatever. So I do not rely on technology. As soon as my MLSOs come along and say, "Hey, guys"—we do a bench round every day so we pick these up for the medical people and we act on that. I do not rely on pieces of paper or computers anyway from that point of view. I think we have to be careful that we do not lose the human interaction.
  (Dr Kelsey) I think one of the problems we have with surveillance—and I think this is a very fundamental problem—is that we are relying to some extent, as we said, on cases that appear at a hospital or samples that come in from the community, and there are some areas which cause us quite considerable difficulties, such as winter vomiting disease, which at least two of us on this table have got beds shut because of the problem, yet there is no community surveillance of that. If we had good surveillance—and it may well be because we do not actually have the technology for good surveillance—this is not something you can diagnose with good methodology easily and quickly—we would be forewarned, because you would be able to watch the build-up of the number of cases, and to some extent we do this with RSV, which is a very predictable disease in children, but we perhaps need to start looking at the technologies and the way we do surveillance in the community, just as we do for influenza with spotter practices. It may well be that we are going to need to have microbiology spotter practices, and we are going to have to put some sort of research initiative into the areas such as winter vomiting disease where we need good technology, such as influenza, where we need good diagnostic technology before we can use the newer drugs that are becoming available. So I think timeliness is a matter of forethought and planning so that you are not hit by these nasty shocks. Of course, this would not happen with bio-terrorism, because it would be a nasty shock when it happened.

Lord Turnberg

  150. I think I should express my interest as ex-Chairman of the Public Health Laboratory Service. The question I have relates to the transition between what we have now and what we will have come April next year, the new HPA. There are a number of issues, of course, with any transition, but one is that the Department of Health is suggesting that this can be achieved with no additional funding. You have hinted at this before. I just wondered if you would like to enlarge on your response.
  (Dr Spencer) You could say, "They would say that, wouldn't they?" There is a need to increase community surveillance, and the way we practise modern medicine now is that if you want to look at the incidence of post-operative wound infections, you cannot restrict it to hospitals, because whereas 20 years ago people having a cholecystectomy had seven days in hospital and then they went to a nice little cottage hospital and had another seven days, it is a couple of days or a day case and out, and you talk to GPs, and I say, "I haven't got any infections in my hospital," and they say, "No, it's all in my patch, isn't it?" So there is a need to increase community surveillance. There is great disparity between the numbers of infection control nurses in the community, ranging from nought to four per 100,000 head of population, and of course, you have to talk about standardisation of surveillance. I know the government likes league tables—and that is why we get the MRSA bacteraemia league table, whatever that means; if we do not include things like risk factors, it is meaningless. If we are going to standardise surveillance, invest in IT, if we are going to increase our community surveillance, then we need cash.

  151. Can I pursue that response a bit further? What you say is, in order to improve the services and do what everyone wants, we need to inject money. What I was really referring to was simply the process of changing from one system to another. Do we need money for that?
  (Dr Spencer) I think we have already alluded to Dr Crook's experience with PHLS withdrawing out of Oxford. It is always a question about what we are going to do with so-called core funding. Where is that going to go?

  152. Is it not said to be coming from the primary care trusts? Is that creating any anxieties amongst the microbiological community?
  (Dr Spencer) It is a question of where primary care trusts see their priorities. What is important to them may not be what we think is important. They may think it is to do with cardiac disease, cancer, infection control.

  153. They will have a lot of priorities to satisfy.
  (Dr Spencer) Yes, indeed.

Lord Patel

  154. We recognise that we do need more resources to do all the things that you have said should be done. We recognise that we need more resources to do new things in Getting Ahead of the Curve. The Government has said health has to be cost-neutral. The question was whether the transfer of responsibility is going to cost more, without the extra resources necessary to do all the newer things.
  (Dr Crook) I think the transfer is cost-neutral based upon a couple of assumptions. If there is a very substantial investment by the PHL in their management, and that money is released, which it may be, it is said that they spend 15 per cent of their total budget in management, whereas an NHS hospital typically spends about 5 per cent. If they went down to the 5 per cent level, that would liberate the funds.

Lord Turnberg

  155. I think that is erroneous actually.
  (Dr Crook) But say that that was true, and there was a release of funds that would be able to fund the transitional arrangements. If the money is not there, as you imply, it is not there and there will not be the resource to fund the transitional arrangements. It is clear to me that a component of the core funding that goes to laboratories was never used for the public health function that it was said to be; it was used to support the laboratories in the work that they did, and even though the PHL, if I may suggest, argued very strongly, it was all done that way, but looked at under the cold, harsh light of day, that money was actually used to underpin NHS functions, and there is no doubt about that, and there is no escape from that. In that sense, to maintain the status quo, the money that goes to laboratories will need to be funded and our NHS trust had to find a scarce resource and under competing cost pressures, to fund and maintain a reduced level of microbiology over that that the PHL laboratories are used to. I must say PHL laboratories could get used to a far lower level of funding, but that transitional arrangement is costly in many different ways, including in pounds, shillings and pence, and in addition to that in terms of people's morale and ability to cope under those sorts of pressures.

Lord Oxburgh

  156. Evidence from the Association of Medical Microbiologists argued that it is fundamental for laboratories to use accepted standard methods and to diagnose a standard range of pathogens. Perhaps you could expand on this and say why it is important that there be a standard range of pathogens and whether NHS labs will be able to work to these standard operating protocols currently used by the PHLS.
  (Dr Kelsey) I think there are a number of areas here. First, I do not think that the United Kingdom and Ireland live in a separate universe. We have to communicate with other countries. If we look at the history of MRSA, it probably came from Australia and came this way. If you look at penicillin resistant gonococci, etc, probably in the Far East. So I think we have to be prepared to communicate with the rest of the world. We need to know that such things as antibiotic-sensitivity testing reach if not the same standard, that they are believable by other people in the world, and that when we say something is resistant, the rest of the world says something is resistant. So I think we are operating on a global stage, so our standards have to be internationally acceptable. I referred earlier to the problem of E coli 0157. The same problem occurred with cryptosporidium. You are told by a letter from the Department of Health that everybody has to look for cryptosporidium in every stool. The truth of the matter is that not every hospital laboratory could do it because they did not have the manpower and the resource, so it was not done. If we are all going to operate to the same standard, so that surveillance means the same thing in the south of England as it does in the north of England, for example, then we need to operate to standard operating procedures which are the same. That brings us on to the other problem of what is the framework in which we are looking at things. Are the same numbers of general practitioners submitting stool samples or urine samples or high vagina swabs in different parts of the country, different practices? That again brings us back to the problem of should we have spotter practices looking at particular diseases. I do not think that is mandatory and I am not sure it will turn out to be necessary, as long as things stay the same. It will become a problem if suddenly everybody stops sending in high vagina swabs because the primary care trust says "We can no longer afford to do microbiology and therefore we are going to give less money to the microbiology in the hospital," in which case you say, "In which case we are not going to do your work." There are risks like that, I think. I think we need standardised care. Some labs will need to raise their standards.

  157. Putting this another way, are you in fact saying that these NHS laboratories will have responsibilities that actually go beyond their immediate authority because their results have effectively regional or national implications; they have a double obligation?
  (Dr Spencer) You could argue that this may be one of the roles. I understand that the job description for the regional microbiologist is currently being arranged. It may be his role to ensure that the non-PHLS laboratories or ex-PHLS laboratories, ie NHS, do form standard operating protocols or it could be a function of the CPA.

  158. Will he have any levers to implement that?
  (Dr Spencer) I do not know. I have not seen the job description yet. There is one concern, in that of course, at the moment the PHLS is subsidised in its medium production, and the statement about ten days ago explaining the creation of the special health authority also said that the PHLS for the next 12 months will stay in operation, and one of its main if not only functions will be concern over medium production. This has produced a very substantially subsidised rate so we can afford to do more than an NHS laboratory which buys it commercially. The question is, at the end of 12 months, if the medium production departments close, and we are therefore prey to market forces, are we going to have to pay more? I think the answer is yes, in which case we are going to have to say, "Hang on a minute, maybe we don't need to do this or do that." That is an interesting problem that we are going to face 12 months down the line from April 2003.
  (Dr Crook) If I may say a few words about this, the first is that the variation in reporting between laboratories has less to do with methodology within the laboratory and more to do with the case definition that is used by clinicians in deciding to send samples or not. The greater variation, vastly greater variation, depends on how, when and under what circumstances a clinician decides to do a test. So the laboratory is entirely the victim, as it were, of the circumstances of who it is and when samples are sent. If you want to get a comparable standard of surveillance across the country, you need clinicians to have the means of agreeing with one another how and when to send samples. Microbiology is pretty mature around the world; irrespective of the nuances in methodologies that microbiologists are getting excited about, the degree of variation that that causes is tiny, and there has been, I think, an over-emphasis on that. It would be far better were the effort put into deciding which cases to send the samples on and to allow clinical judgment to determine that, and to move away from this obsession. I think it is ducking the question where it is allowing surveillance to be much weaker than it necessarily ought to be. Furthermore, if many NHS laboratories went the route of PHL standards, it is going to cost more, and there is absolutely no question about it. We (Oxford) had to move away from PHL standards to come within budget. Were we to have to return to that (PHL operating procedures), we would need another quarter of a million pounds to satisfy the need to do that.
  (Dr Kelsey) I would not disagree with what Dr Crook says. I am not an obsessive microbiologist, and most of my colleagues are not, but there is an area where we will be facing perhaps a lowering of microbiological diagnostic standards. Point of care testing, where the test is done in the primary care setting, or in the Accident & Emergency Department to diagnose a microbial disease is going to be with us fairly soon and some technology has been around—not highly taken up, but as technology does go forward, it is going to be much easier to do these tests. There are two problems we face. One is capturing that information, because you are going to have to capture it from primary care or accident and emergency departments, and the other problem is going to be around quality assurance. We know that there are very good point of care tests which when done by a biomedical scientist give you a sensitivity and a specificity in the 90s, but the moment these tests move out of the controlled environment into primary care, specificity tends to drop quite severely. So there is going to be a large role for quality assurance at point of care testing that is going to be done, and we have not looked at that in terms of how we will cope with that.
  (Dr Crook) I want to enlarge on what Dr Kelsey said, that there are areas which are new to microbiology where standards are absolutely critical, and when I refer to microbiology as mature, I am referring to methods based on culture essentially. If you start to go towards new technology such as measuring the presence of nucleic acids and manipulating that to determine diagnostically what is going on with people, they are in their infancy; they need to be validated, yet at this stage they are already being used and presented as though validated, and it is in that area that there needs to be a very substantial improvement in the standardisation and understanding of the performance of those tests, lest we be misled, and it could easily be the case that if those data were early captured into surveillance, that we could be misled into believing there was an outbreak perhaps. There is also the potential for the loss of data through point of care testing, which means a general practitioner doing it right by the side of a patient in a sense, and if that data is not captured into the entire data set, you lose, and you might, for instance, have a delay in identification of a disease process. New technologies are bringing the means of doing that at the bedside, so for instance, there may be a case where you could do a salmonella test at the bedside in a general practice, and that is lost to the data set for the national surveillance. So those areas clearly need standardisation.

Baroness Walmsley

  159. The situation you described, Dr Crook, was where the laboratory is very reactive to the clinical decisions of the clinicians to send the samples in for testing, so in that situation how on earth do you stick to a budget? If you have problems, does the primary care trust have to make decisions that certain kinds of work will not be done, in the way Dr Kelsey was just hinting at earlier on? Which decisions are they going to make? Are they going to make decisions based on how their performance is monitored?
  (Dr Crook) I think your point is very well made, and there are going to be major issues around what ought to be passive surveillance, in other words, which of those elements that you capture because samples course through laboratories and you get results, and you have IT systems that capture that data that allow people to peruse it and make a decision whether there is a departure from the endemic or normal rate of that particular organism or syndrome or whatever it is, versus circumstances where you wish to determine in a structured manner the burden of disease in a population. That, I have to suggest, is separate; it needs to be designed differently, and in a sense we might be getting confused between capturing data that is coming from laboratories and is referred to usually as passive surveillance, versus that component of surveillance which is specifically designed and has as its aim and end point understanding the burden of disease, knowing the organism that you are going for, and measuring that, and I would suggest much of what we do today could be done that way. It does not mean you have to go to every laboratory. You can carefully devise those studies to occur in a restricted area and you could make it fit very well with improved evidence-based testing, which decreased the pressure of testing on laboratories, which is a major cost pressure for laboratories, the growth of testing, much of which is not necessary.
  (Dr Spencer) I have to say that the majority of GPs already practise a kind of syndromic approach, which is in question 7. If you go and see your GP with symptoms of a urinary tract infection, he will reach for the trimethoprim and send you on your way, but he may test your urine if you come back and your symptoms have not alleviated. Similarly with chest infections. They think, "Yes, I will give you Amoxil" and it is rare that we get any sputum samples from GPs unless they are complicated with longstanding chronic disease. So I think GPs are already practising this syndromic approach. In hospital it is a bit different because the junior doctors are very stressed with their European time directive, they are looking after far more patients, and they tend to screen for everything. They ask for every biochemical marker known to man—similarly with microbiology—just in case the great man comes round the next day and says, "What is the serum rhubarb?" "It is 2.3." "You are very impressive, aren't you?" So that is a problem. Now that, of course, is tied into teaching of undergraduates and you find that microbiology teaching for undergraduates is getting less and less, and I understand that in the newly created Peninsular Medical School there is no time set aside for teaching microbiology so we have these junior doctors who have qualified with no microbiological education at all, and we have to educate them on what specimens to take, what antibiotics to use, etc, so it is a problem.
  (Dr Kelsey) Really, to go on to say a little more about Baroness Walmsley's question, surge capacity was what we were referring to which was the ability to take on additional work because of an incident or an outbreak. This was something which the PHS used to provide us with. I can remember many years ago handling outbreaks of diarrheal disease, which used to occur in hospitals more frequently than now, and you could not cope. So we used to lay off the work to the local PHS laboratory who would assist us. That may be something which needs to be covered under the new arrangements, and I see this as something to do with networking and modernisation of pathology which I am sure we will go on to consider. So there is a need to take on surge capacity; we must think ahead for the outbreaks; we may be hit by a major food poisoning scare—we just do not know.

previous page contents next page

House of Lords home page Parliament home page House of Commons home page search page enquiries index

© Parliamentary copyright 2003