Examination of Witnesses (Questions 420-428)|
TUESDAY 4 FEBRUARY 2003
420. You are saying that most GP practices are
now connected to the net.
(Professor Little) Whether the connections between
the GP practices and the net is slightly fraught from my little
understanding of the difficulties that GPs have, but in principleso
long as that connection could be sorted out a bit more rapidlyGPs
generally have computers there. There are some pockets where they
do not. We have just set up a study in Brighton where even the
most interested practicesabout thirty or forty per cent
of themdid not have computerised consultation information
so I am sure they do not have lab links. I suspect it is patchy,
but I would think that most GPs have some kind of computerised
system and there is really no reason why there should not be a
better link between the GP and the lab.
421. Are there any incentives for GP's to make
sure that their practices are web literate?
(Professor Little) I am not aware of any incentives,
I must say. Do you mean financial incentives?
(Professor Little) I do not think there are.
(Mrs Howard) There are incentives for nurses within
those development plans through the local information technology
and implementation systems.
(Professor Little) I do not think so, but that may
just be ignorance.
(Mrs Williams) In London over the last couple of years
we have had a target to meet which has been that every chest clinic
should be connected to the NHS net in order to run a TB register
across London. All the enhanced surveillance and notification
information is put on to the TB register. The idea also is that
we have some mechanism for tracing patients that get lost. This
is in the early stages, but there have been a couple of patients
that have been found by this system. They turn up to another clinic
and there are certain patient identifiers which will highlight
that they have been seen elsewhere. There are still a few things
that we need to improve on, but it is actually working out quite
well in making the information much more readily available. The
only point I would make is that the money for this work has so
far been through the London Regional Office for Public Health
which then became the DHSE which, in the last week, has been disbanded
and as yet they do not know how they are going to continue to
support this particular project. It is very vulnerable.
423. Do you feel the systems that you use and
that are given to you to use or you are exposed to are sufficiently
(Mrs Howard) It is variable. Training in how to electronically
handle the data is lacking in all the professions probably. Also
I think there are insufficient health intelligent people within
the public health departments to actually support out into primary
care and for that type of training to be offered in any depth.
That is a big gap. There is probably also a need for software
packages that are more user friendly and will allow some local
interrogation of data as well as allowing us to send it upwards.
The other thing is to get the systems to talk to one another.
For example, the system within prison health care does not talk
to anyone. There are issues there in terms of, for example, commencing
immunisation against hepatitis B in prisons. In the prisons that
I have responsibility for the prisoners are moved so rapidly that
we can only offer that immunisation to very few inmates because
they are moved within a three week period. If we had a system
whereby they could actually talk within the system we could follow
through and ensure that the immunisation programme was completed.
But we do not have that sort of facility at the moment.
424. Are you saying that the prison systems
cannot talk to the systems in other prisons?
(Mrs Howard) Again, I am not an expert. From my understanding
talking to the health care managers of the two prisons I am involved
with there are difficulties. Certainly when they discharge a prisoner
they certainly cannot talk to the National Health Service.
(Mrs Perry) Could I just urge caution on concentrating
specifically on computer systems to be able to provide this surveillance.
Our experience in the acute sector is that we have tried to use
computerised surveillance systems. For ease of completion a lot
of areas have gone back to a paper-based system that uses an optical
scan reading to be able to feed in, so we do need to consider
those kind of systems, especially bearing in mind advances that
are happening in primary care with diagnostic and treatment centres.
We may need to be looking at post procedure surveillance where
the patients actually play quite a key role in providing surveillance
data to inform action.
Baroness Warwick of Undercliffe
425. This is really about broader communication
and co-ordination. So many of the very graphic examples that you
have given us to illustrate the points you are making have depended
on communication. How close and effective are the links between
the primary care team and the CCDCs and the EHOs?
(Mrs Howard) The links between the CCDC and the EHO
are very close. They have very good working relationships. The
links between the CCDC and the primary care teams are, generally
speaking, very good. However, the link between the three is probably
not so good. Where the planning takes place within primary care
trusts, there is joint planning between local authorities and
PCT'slocal authorities and healthand I think there
is a need also to bring people in from the primary care teams
and to involve them in that planning as well as the health protection
agency staff so that there is a planning in terms of local development
around prevention and control. There is also scope in the futureand
I am aware of certainly one post like thiswhere senior
nurses have joint posts with the local authority; they are partly
HPA and NHS employed and partly local authority employed. I am
aware of one place where that is actually happening and it works
very well. It bonds the two organisations together so there is
good communication, good working together. We already have DPH's
that are joint appointments between PCT's and local authorities.
I think there are a lot of other agencies that perhaps should
be included in this in terms of health protection being linked
to the inequalities agenda. This includes the voluntary sector
and drug abuse teams, all these types of agencies. The National
Commission for Standards and Care is another agency. We need to
have much more formal communication. It is quite good on a local
level but there needs to be a communication. For example, in Scotland
they are actually working with public health nurses to develop
standards for infection control within care. That is not happening
here in England at the moment to my knowledge. There are further
education colleges. There are training companies that actually
manage the NVQ training programmes for the carers. We need this
cross-community communication. It needs a leadership and a steer
to have it there. Universities as well. We touched on the content
of training courses et cetera, but also more broadly within the
university courses as well. There needs to be a steer to help
us at ground level develop those links and to work with people.
(Mrs Perry) Could I add in there that the links of
acute care need to be considered as well. For example, the trust
that I am employed by also employs the school nurses. Traditionally
you would consider the school nurses to be primary care workers
but they do in fact come under the umbrella, in some areas, of
secondary care. Other examples would be nurses specialising in
cystic fibrosis, blood borne viruses, nurse practitioners in new-natal
care, respiratory care nurses. The links between the acute and
the primary care in terms of sharing information and agreeing
consultative action are variable throughout the country. Many
years ago we did have infection control committees that were district-wide
where we would have linked all these people together. Currently
we have infection control committees that will be based in acute
care, infection control committees that are now being developed
by the primary care teams. I believe the key is in having some
kind of link-up between all these different committees so we are
all having consistent action across the two levels of care because
patients move between the acute and the primary care constantly.
426. Are there too many committees?
(Mrs Perry) In some areas I do believe you do have
to have the committees around the table with the key people. You
need to have your committees that focus on the action that you
are going to take in your specific area that can concentrate particularly
on that. You also need to have that joined up linking of working
so you are agreeing consistent action across all areas of health
care. I would argue for both.
(Professor Little) I am not sure I would be able to
comment on how close the links are generally. My contact with
the CCDC is that they do give us periodic information. If local
feedback from surveillance information is going to be rapid I
suspect it would come through the CCDC. I anticipate that we will
get better and more frequent communication from the CCDC. I have
never personally contacted the environmental health officer and
I suspect that most GP's do not, but presumably if they suspected
food poising in one of the local restaurants they might give them
a ring. Probably they would give the CCDC a ring and tell them
that it might be something they have to look at. I would say there
are links. They are not very close. They are probably reasonably
effective given the level of surveillance and feedback we have
at the moment, but it would be nice if they were a little bit
closer. They have been good, for example, when there has been
an outbreak of meningitis in students in Southampton. We have
had fairly rapid feedback from them about what we should be doing
and advice about treatment contacts et cetera. I have no complaints,
but I suspect we need slightly closer links.
427. Following on to what Mrs Perry said, are
there infection control standards in the acute sector?
(Mrs Perry) There are guidelines for infection control
in acute care. There are also Controls Assurance Standards as
to how we should be operating our services.
428. Are these monitored?
(Mrs Perry) They should be monitored by strategic
health authorities, yes. I am afraid I am referring to a document
that I do not have in front of me, but a recent survey of strategic
health authorities demonstrated that they are not monitoring compliance
to these standards.
(Mrs Howard) May I go back to the point about too
many committees? I think there is a need to separate out the infection
control committees which essentially will deal with issues within
acute trusts and primary care trusts around clinical infection
control, that type of prevention and control. The concept of having
an umbrella committee would draw in all the various factions like
the environmental health officers, DEFRA, all the people that
we work with on a regular basis. There is a need to differentiate
out what the purpose of the committee is and what the reporting
structures are. There probably are too many committees in some
respects, but on the other hand would what you are discussing
at an infection control committee be relevant to the chief veterinary
officer for the county who is attending the environmental committee,
the over-arching committee, the health protection committee. It
is horses for courses in many ways.
Chairman: I think we are now at an end of our session,
but I wonder if I can ask Mrs Williams to reply to the last question
in writing. There are two reasons why I ask that. One is that
we have run out of time. Secondly, it is a big issue that we are
particularly interested in because when we were in the United
States we saw what the US was doing both in Atlanta and also in
New York. We were most impressed by that so we would very much
value your extended commentary on this, if you would not mind.
Baroness Walmsley: As I was going to ask the question,
could I add a rider that I was going to ask. Could we have your
opinion on the adequacy of supply of negative pressure isolation
rooms in this country?
Chairman: I am sorry to give you this chore, but
I am sure you will give us a good reply. All I have to say now
is to thank you all very much for coming along. I hope you felt
the questions were reasonable. Your answers were very good indeed.
If there is any point that you feel has not been explored enough,
please feel free to submit a commentary in writing to us. You
will of course get a transcript of what was said today and you
will have the opportunity of correcting it factually. Thank you.