Examination of Witnesses (Questions 179-199)|
TUESDAY 3RD DECEMBER 2002
179. Good morning, lady and gentlemen, I am
sorry to keep you waiting for a few minutes. I am very pleased
that you have come along to talk about virology as part of our
inquiry. First of all I would like to ask you to introduce yourselves
and then, secondly, if you have any opening statement to make
now is the time to make it, before we got on to the questions.
If you would like to start introducing yourselves, with a brief
CV, shall we say?
(Dr Zambon) Dr Maria Zambon, virologist,
head of the National Influenza Laboratory and Deputy Director
of the Enteric, Respiratory and Neurological Virus Laboratory
at the Public Health Laboratory Service at Colindale.
(Dr Pillay) I am Dr Deenan Pillay, also a clinical
virologist in Birmingham. I am Head of the PHLS antiviral susceptibility
(Dr Brown) My name is David Brown, I am a clinical
virologist and for the last 15 years I have run the Enteric, Respiratory
and Neurological Virus Reference Laboratory through which we deliver
national reference services for a range of virus infections.
(Professor Griffiths) I am Paul Griffiths, I am Professor
of Virology at the Royal Free and University College Medical School,
but I am here today as Chief Executive of the Clinical Virology
180. Are there any brief comments that any of
you would wish to make? Let us move on to the questions. I will
start off with the first one on how the training and day-to-day
work of clinical virologists differs from that of clinical microbiologists
and clinical infectious disease physicians?
(Professor Griffiths) Obviously, the patients present
with possible infectious diseases to our clinical colleagues,
who may be in infectious diseases. Infectious disease consultants
are a major source of the material that we process in the laboratory.
They are not, of course, the only source. For example, transplant
patients have big problems with virus infections, and so many
of those samples come directly from the physicians who care for
those patients. We then have microbiologists and virologists who
are laboratory trained, who do not directly see those individual
patients themselves but provide laboratory services to support
the work of the clinical colleagues, working out the differential
diagnoses and advising on treatments, for example. Without getting
too technical, you are asking the difference between microbiologists
and virologists. For many years virologists and microbiologists
were able to grow their infectious agents within the lab, and
so were able to provide quite a rapid service to clinicians. They,
therefore, have provided the phenotype of the organism they can
see. In virology it was not possible to do that, really, and it
was only when we got through to molecular assays that we were
able to amplify the virus and we can now provide routine, daily
diagnostic services to cliniciansnot just detecting virus
but, also, quantifying virus; telling them about distinct strains
that may be present, for example, some that are resistant to antibiotic
chemotherapy, some that require different courses of therapy,
as in Hepatitis C. Many of those assays require people to have
worked them up in their own laboratories, so-called in-house assays
rather than commercial assays. So with that difference it leads
into the training of the two different groups. If you are a virologist
you have to spend a lot of time learning how to make assays and
how assays can give you the wrong results, because quality control
and quality assurance of the assays is actually very important.
You cannot see viruses directly, you have to infer their presence
by the signal you get from one of these assays. In microbiology
a lot of it is looking at the phenotype of a particular bacterial
infection, but they have rather different techniques in the lab.
There is some overlap and some sharing of techniques but, in general
(I am not sure what my colleagues might think) that is the polar
position between the microbiologist and the virologist. Some of
the shared areas, for example, some of the routine tests which
are done for ante-natal patients could be done by either microbiologists
or by virologists, and in different parts of the country you will
see different solutions to providing those services. The reason
for that is that the assays are well-established, they are available
commercially with good quality control, there is a national external
quality assurance scheme that can validate the use of those assays
and anybody can be trained to do those. We are talking about the
cutting edge of virology herethe molecular type techniques.
(Dr Pillay) Just to add some issues to what Professor
Griffiths has mentioned. Because it has been difficult hitherto
to grow some viruses, I think virology has represented the cutting
edge of new developments in laboratory medicine by predominantly
molecular methods. So it has led to a separation, really, between
microbiologists and virologists in terms of the degree to which
virologists will cooperate very closely to develop these new methods
which Paul has already mentioned, and link them to clinical outcomes.
In the context of antiviral therapies that have now become available,
they play a much more important role in, I think, active clinical
management where, previously, virology represented more retrospective
diagnostics. So I think those are two areas which also separate,
to some extent, virology (in terms of the ethos of the subject)
and clinical microbiology.
- From what you say, the number of diagnostic labs
that can actually grow viruses is few in number and they would
be more central than regional. Would that be a fair computation?
(Dr Pillay) I do not think that is necessarily true,
and clearly there are a number of viruses that can be grown: for
instance respiratory viruses and enteroviruses. However, I think
even for those infections there is an increased application of
molecular assays to those viruses which involve monitoring treatment,
and determining whether the treatment is going to be effective.
(Dr Zambon) A few further points. It should be noted
that the training of virologists is specialised compared with
clinical microbiologists, with a relatively short period in common.
Secondly, there are rather fewer clinical virologistssubstantially
fewerthan clinical microbiologists, and the consequence
of that is that they are usually, but not exclusively, employed
in academic centres and usually have quite a strong academic background.
The consequence of that is, further, that virologists are usually
also required to have quite an input into research and training,
both research as the development of clinical diagnostics but,
also, research into the delivery of antivirals, the appreciation
of outcome measurements and training not only of their fellow
clinicians but, also, laboratory staff. So, for me, the analogy
between microbiologists and virologists is, in a way, the analogy
between general surgeons and vascular surgeons; you have some
areas in common but you also have some areas where they are specialised.
(Dr Brown) I was going to follow up on Dr Pillay's
point, which is that molecular diagnostics have been used very
much for individual patient management and I think will replace
tissue culture nationally for that, but we do have a need to isolate
virus for public health purposes. If one thinks of the influenza
vaccine, for example, we need to make isolates of the virus which
will not be provided through routine diagnostic services. There
is sometimes a distinction between a public health need and what
is provided through clinical diagnostic services.
182. Can I tease out these comments that you
made about training and, also, on diagnostic services? How does
this compartmentalising of both training and diagnostic services
from clinical services (and you did not comment, I see, on the
training of microbiologists and virologists as opposed to infectious
disease physicians) help in surveillance, the delivery of patient
care in a co-ordinated way and, also, and much more importantly,
the surveillance of infectious diseases? Why is this model better
that you describe?
(Professor Griffiths) I am not sure any of us said
it was better. I think we answered the question "What is
it like?". The surveillance of virus infections could be
183. By changing this model?
(Professor Griffiths) You need to start from the position
of the way things are now and try to look forward and say how
would you like them to evolve in the future. We would very much
like to meet many of the things that are in the report Getting
Ahead of the Curve. For example, having standard operating
procedures throughout the UK; having standard ways of coming to
a diagnosis that differentiated between diseases. To take Hepatitis
B as an example, if you ask at the moment "Can you tell us
how many carriers of Hepatitis B there are in the country and
can you differentiate from acute cases of Hepatitis?" I think
the answer is no. That is unfortunate, from the point of view
of justifying the deployment of Hepatitis vaccine, for example.
Things could be greatly improved. We are not saying to you "This
is the ideal situation".
(Dr Zambon) I think it might also be fair to say that
surveillance of viral diseases does not only depend on clinical
virologists. One of the greatest areas where there is need for
improved surveillance of viral disease is in primary care, and
the ability to deliver viral diagnosis in the primary care is
really a serious challenge, I think, for any health system. In
particular, delivery of viral diagnosis is an expensive process.
In a seven-minute consultation, actually taking time to take an
appropriate sample is often regarded as a time-wasting exercise
because the ability to provide information to affect patient management
is not available during the time of the consultation or, indeed,
shortly after it. So the point I wish to make is that improvement
of surveillance of viral diseases requires improvement of diagnosis
in many different fields, of which clinical virology is only one.
(Dr Pillay) Another example, I think, of why the existing
model is not optimal, in terms of the separation somewhat between
epidemiology and clinical virology, comes with these new techniques.
For instance, the ability to quantify the amount of virus being
carried in chronic carriers of Hepatitis B and Hepatitis C (which
will become increasingly important) and HIV, is currently in the
realm of very "clinical" rather than "epidemiological
virology", but these measurements also allow the ability
to assess how infectious those individuals are to others. Here
is an example where with a more integrated epidemiology and clinical
virology network there is the ability to assimilate that new data
into a broad epidemiological framework.
(Dr Brown) Just trying to address your point from
the surveillance perspective, which is the one that I am most
familiar with, clearly currently there are different approaches
that are used for detecting viral infections, although I think
it is fair to say that there is increasing convergence of those
techniques across microbiology, and in the future I think that
will be true. The reasons why we do need both areas were touched
on by Dr Zambon and I might characterise it by suggesting that
you would not want to let a general surgeon do paediatric cardiac
surgery, as we have seen in the past. There is a wide range of
infections here, we need expertise across the range. Virus infections
are distinct from microbiological infection and only yesterday,
for example, we have heard of the smallpox plan that has been
announced. That is a virus infection, and you want somebody with
an understanding and profound knowledge of the infection to contribute
to the expert advice needed to the Department of Health. So there
is clearly overlap but there is a need for virology as a speciality
within that to help drive the field forward to educate our microbiological
colleagues and to contribute expert advice for those specific
(Professor Griffiths) We would not want to give you
the impression that we do not get on with our microbiology colleagues
and support them. There is a proper team interaction, patient-orientated
team interaction, to solve individual problems that present.
184. I get the feeling that you get on with
them when you like them.
(Professor Griffiths) Just to follow up David's point
about the medical specialists, there is another example that has
been in the public domain for the last couple of years and that
is the public health policy on measles, mumps and rubella vaccine
being driven by a surgeon by training. I am sure you would agree
that is inappropriateas inappropriate as me, with my primary
medical qualification, offering to operate on patients. I suggest
public health would not be well-served by that.
185. If virology is primarily about laboratory
methods, how important is the clinical component of training in
virology? Could the service be delivered by a non-clinical virologist?
(Professor Griffiths) In some parts it is. We have
shared skills with our non-medical colleagues, who lead in some
of the laboratories, particularly on the research and development
side. We have put it in the document we sent to you, and we put
in specific examples of much more clinically orientated virology.
For example, some virologists go to out-patient sessions, invited
there by their infectious disease colleagues, to help out and,
obviously, maintain an interest in particular infections. So different
people labelled as virologists will do different things, largely
depending on the need of the service at that local site.
Chairman: I think we should move on to the next question.
186. I think question 1 leads very nicely into
question 2, which is on clinical information. This Committee has
received a considerable amount of evidence which points to a shortage
of co-ordinated activity, both between the clinical specialists
and public/environmental health officials. Do you think this is
justified, and could co-ordination be addressed both within virology
and between virology and other areas? You have touched on this
in your answers to the first question, but if you could just expand
on it it would be quite helpful.
(Dr Brown) I would accept the premise there is a lack
of co-ordination across a range of interfaces. Within virology,
because it is rather a small speciality, we all know each other
and the point made by your colleague earlier is probably the case,
that things work despite, sometimes, rather than because of the
system that is in place. In terms of how we improve that (and
this would apply to infectious disease consultants, GPs and clinicians
generally as well as clinical microbiologists and clinical virologists),
that is quite a challenge. The first point is that we are all
busy people and, therefore, you need to make that requirement
seem an important part of the job, which I think it often is not
perceived as at the moment. I think that laboratory medicine can
play an important role in improving that communication because
they are often the interface between the surveillance programmes
and the clinicians, and one way that that might be improved is
if laboratories took on some role in encouraging reporting and
surveillance. Certainly in my own lab, for example, we have a
system whereby if we identify an infection, which we are not obliged
to but a clinician is, we would put a sticker on that report saying
"This is a confirmed infection, you should notify this".
There are a number of practical mechanisms such as that which
could be introduced to try and break down some of these barriers
which I think are there.
187. Surveillance itself is a very complex area
and co-ordination is particularly difficult with a small number
of specialists. However, it is very important, from the patient's
point of view, that there is this co-ordination. What we hear
quite a lot in this Committee is that there is a lack of co-ordination
and it is very important we tackle that. Would you make a comment
(Dr Pillay) I wanted to follow up the discussion.
I think another problem in terms of this co-ordination within
virology is that the predominant role of clinical virologists
outside of the public health virology/public health arena is to
provide a clinical service. That service is, as we have discussed,
cutting edge in many cases but is under an enormous cost pressure
in the context of pathology. Budgets are decided and contracts
are negotiated in the context of a hospital Trust pathology budget.
They therefore lead to major differences between the diagnostic
test methods that are used across the UK even for some infections
that have now, within the sexual health strategy of the UK, been
put at the top: for instance Chlamydia. There are still major
differences across the UK which actually make a mockery of the
ability of the more clinical side of virology to link with public
health because the methodologies, the payment and the resources
for that are different. This may be addressed within a wider,
sort of more infection typecertainly a Clinical Virology
Networkwhich is more integrated into the public health
(Dr Zambon) The comments I would like to make are
that co-ordination is, in a way, rather variable in the system.
There are places where it is particularly good and there are places
where it is, perhaps, not so good. If you look at the national
centres for reference microbiology and national centres for epidemiology,
at that level, between those two areas, the co-ordination is good.
It becomes more fragmented the further away you get from the national
or regional picture. The second thing is that I think the distribution
of resources is important in the sense that, as Dr Pillay has
just alluded to, the introduction of new techniques and technologies
will affect pathology budgets but will actually deliver improvements
in a clinical care arena. There is not a way of actually improving
the pathology budget from a clinical budgeting perspective, so
that there is a constant tension between the introduction of new
techniques, at whatever level, and feeding through the information
to clinicians on how that can improve care and management, and
how that can improve co-ordination on ascertainment of disease.
I think it would be wrong to say that co-ordination is universally
poor because there are some very good examples where it works
188. One of the important things about co-ordination
is to be able to co-ordinate similar issues and I wonder if there
are standardised operating protocols for virological diagnosis
and procedures, not only for operating but for reporting too,
so that co-ordination can be made effective across the whole range
(Dr Brown) The process has begun. There is now, through
the Clinical Virology Network, a national process of trying to
agree standard operating procedures, but I think many of us are
concerned that if you want to have regionally generated data that
is compatible at a national level you have to actively manage
that process, and it is one of the concerns that some of us have
about the proposals made by the Chief Medical Officer, because
it was not clear within that how we were going to ensure that
the data generated could be consolidated and that it was compatible
to be used for national policy decisions. My experience is that
you have to actually identify the question and actively manage
the process, it will not just happen by rain falling across the
(Dr Zambon) One can also think of quite specific examples
where the introduction of, if you like, best practice methodology
will have significant cost implications for hospitals who should
take that on, which might well not be agreed upon locally. So
I think it is wrong to think that just having standard operating
procedures and best practice methodology will invariably lead
to universal improvement.
189. If there are no further questions on that
point, can we move to question 3, which is something that interests
me, which is the interaction between those investigating animal
viral infections and human viral infections, and the Public Health
Laboratory Service and the Veterinary Laboratory Agency. Two or
three issues come up. One is West Nile virus. Is there good co-ordination
between the people watching out for West Nile in animals and birds
and in humans, for example?
(Dr Brown) I think there are a number of issues around
this area. In terms of West Nile, I think now that we are two
or three years on from the outbreak in the United States we are
gradually getting to a position where we have human surveillance
and there is some animal surveillance that will give us the true
picture next year, perhaps. Clearly, if it was a major human pathogen
I would hope that we might have picked it up by now, but it is
probably a small-scale problem. The issues around this areaand
there are severalare, firstly, that we tend to have a fairly
good reactive response when a crisis hits us. I think that happens
quite often. Luckily, there have not been major problems in the
field of virology, although I acknowledge that BSE and foot-and-mouth
in animals did require a reassessment of how we respond to these
things. I think it is the planning and looking at where we are
going in the future and trying to predict and prioritise the work
that we need to do in this area which is most difficult, and I
do not see a clear structure for how this is co-ordinated, and
how horizon scanning and prioritisation of very different types
of threats is undertaken. There is a clear gap there. There is
co-ordination between the veterinary and human health services
but it is not positively and actively managed in a forward-looking
way; it is rather "We are working on influenza, so are the
vets. Have we got common interests there?" We are not identifying
where we need to be, it is rather looking at where there are fits
and responding to that. There is an important area here that does
need moving forward.
(Dr Zambon) I would like to add to that that funding
streams and the agency priorities are different, which makes co-ordination
rather difficult in overall policy. There is not really an appropriate
mechanism for joint development funding, and that is exactly where
the business of horizon scanning becomes a problem because you
may well be able to identify with your opposite number in the
veterinary field where the field should be moving to but not exactly
the mechanisms for ensuring funding. The greatest weakness, I
think, as Dr Brown has alluded to, is the fact that there is not
really a good mechanism for forward planning, for picking up potential
things which might be a problem, seeking to justify some small
amount of research or surveillance effort to take such things
forward. My conclusions are that overall the liaisons are rather
dependent on individuals and, as Dr Brown has indicated, good
in a reactive mode but not so good in a proactive mode.
190. What can we learn from medical virology
generally, from the massive outbreak of foot-and-mouth disease
or swine fever, for example? Are there lessons to be learnt in
virology in general?
(Dr Zambon) I think one mechanism is to improve institutional
learning. For example, things which the PHLS have learnt about
the introduction of information technologies should be available
to be shared with equivalents in the veterinary agency and the
Home Office and vice versa, and there are not good mechanisms
for sharing institutional learning on the introduction of new
techniques and new technologies and new approaches to surveillance.
I think that is one lesson that could be learnt. Secondly, clearly
vets must be working on diagnosis of foot-and-mouth, which may
also be appropriate in trying to test for cases of human foot-and-mouth,
for example. There is not ever a sharing of that information until
there is a crisis. That is not necessarily a good situation to
be in. I think it is the business of sharing information.
(Dr Brown) Could I add two quick points to that? One
of the key issues in handling the foot-and-mouth crisis was the
ability to find the surge response that was needed to do the testing.
I think there is a generic issue there that applies across the
range for new infectious challenges, be they in animal health
or in human health. I think, also, the need for some contingency
planning for how we could respond to these things being in place
in advance enables one to get a much more rapid and effective
191. This is really addressed to Professor Griffiths.
Thank you for explaining the difference between virologists and
microbiologists because that helps me to understand the question.
In the written evidence from the Clinical Virology Network, of
which you are the Chairman, you express concerns about the integration
of virology into the Pathology Modernisation exercise and the
HPA. I wonder whether you could elaborate on this and describe
how you would see an integrated virology service working?
(Professor Griffiths) The Clinical Virology Network
was set up by the virologists ourselves to act as a series of
specialised laboratories to roll out best practice across the
UK. Basically, if you had a relative with any given virus infection,
there is someone in the UK who can make the diagnosis for you
and advise you on the prognosis and the potential treatment, but
there is no one laboratory that provides all of those services
nationwide. We think we should try to roll out that best practice
so that wherever you live you have access to those diagnostic
services. So the network is professionally led, we are unanimous
in wanting to achieve that objective and aim to pool our resources
to do so. Before I get on to the criticism, we very much approve
of and support the objectives set out in Getting Ahead of the
Curve; specifically, to have standard operating procedures,
the use of modern diagnostic methods, the reasons for reporting
for the whole of the UK and having disease policies for managing
conditions throughout the whole of the UK. Our criticism is that
at the moment the focus has been very much on what you might call
the bureaucratic side, or related to the transfer, perhaps, of
the PHLS to the HPA and there is not very much coming through
on the professional side that will make a real change at the sharp
end of clinical practice. I think you are also picking up a letter
that I wrote on behalf of the Network to Dr Mary O'Mahony back
in September when it was announced which laboratories would be
designated HPA laboratories. To precis the letter, it basically
said what is the point (I work in London) in designating a laboratory
in North London when the current concern is to do with smallpox
where if we have a case, which would be considered atypical chickenpox
(as I am sure would be the initial case), we would make the diagnosis
rapidly using electron microscopy, we would rapidly be able to
phone to my colleagues up at Colindale, who would confirm the
diagnosis, and we would take all of the appropriate steps? None
of this would involve the laboratory that had been designated
for North London. Therefore, what is the point in designating
one? We see no reason for having a parallel system to set up as
a Health Protection Agency series of labs; we think that if extra
resources are to come through to cope with bio-terrorist problems
they should be used to improve the infrastructure generally for
infectious diseases. So that for most of the timelet us
hope for all of the timethe resources will be used to improve
the diagnosis and treatment of individual virus infections and
if there was a bio-terrorist release then, of course, people would
stop what they were doing and deal with that particular issue.
That is our criticism. In short, there should be a HPA function
in all of the specialist laboratories rather than having designated
HPA laboratories which alone are thought to cope with that problem.
We do not see that working.
192. In that way, are you satisfied that there
would be sufficient quality assurance and sufficient incentives
to use new techniques and this sort of thing?
(Professor Griffiths) Yes. I think the way we would
like to manage it is to have a service level agreement with the
HPA and say "These are the things that need to be achieved".
We will deliver (depending on what resources are available) as
many of these things as we can agree on and roll them out throughout
the UK, including the standard operating procedures and including
reporting back to a CDSC. It is crying out for all the laboratories
to be linked electronically to the CDSC to report things instantaneously,
and all the laboratories are not connected electronically at the
Lord Patel: I would like to enlarge on this but today
there might not be enough time to do so. All that you have just
said is not in the written evidence that you have supplied and
it would be very helpful if you were able to put a detailed paper
in as evidence.
Chairman: Are there any more comments on this question?
If not, can we move on to Lord Rea?
193. This is really a question divided into
two parts. It concerns the area we have already touched on, which
is the relationship between practitioners, clinicians, and laboratory
workers. We have heard from many of our witnesses that most clinicians
under-report largely because they feel too removed from the surveillance
activity. What role do you believe virologists can play to ensure
that other clinicians and nurses feel that they are part of that
surveillance process? The second half of the questionand
I speak particularly as a former general practitioneris;
do you feel that GPs have a sufficient understanding of viral
infection and its treatment and have adequate access to virological
information and advice? I could say one or two things from my
experience but I would rather hear from you.
(Dr Zambon) I think it is important to recognise that
public health activitiesand that would include reporting
of infectionstake time. As we have already heard, most
clinical virologists are in service jobs and, indeed, most infectious
disease specialists are in service jobs. So I think I would argue
that it is not so much a failure to see the point of reporting
as a failure in being able to find the time to do the thing where
you do not see the immediate outcome in your immediate environment.
I think it is true to say that virologists, perhaps, could play
a bigger role but I think it is also important to recognise that
there are limited numbers of virologists and their ability to
interact with a multitude of different people is also resource
limited. To try to pick up on points about GPs, I think the question
of virological diagnosis in primary care is one which is grossly
under-developed and under-recognised, largely through lack of
availability of appropriate, easy and cheap tests to be used in
primary care, but I think it is also not necessarily a good reflection
on the way that public health has been structured when we do not
find it easy to develop the burden of illness data based on important
syndromic disease. For example, it is considered that 20 per cent
of all consultations in general practice are due to respiratory
viral infections, yet we actually have very little diagnostic
information underlying that. We could also have some data on the
burden of illness due to enteric virus infections in primary care.
We know that there is an enormous burden of illness out there
with very little evidence underpinning it in the way of notifications
of tests or tests being done. On the one hand it is fair to criticise
and say there is little reporting but, on the other hand, the
systems are not necessarily geared to allow diagnosis and then
capture of information.
194. The problem, seen from a practitioner's
point of view, is that the result that you get, which may be,
as you say, many days later, is often after the patient has got
better. However, even if you did get it a bit earlier it would
not necessarily help you in the treatment of that case, although
of course it would be important to differentiate it from other
(Dr Zambon) Indeed. It may not be essential to have
such information coming from every single GP in the country but
it is clearly important to set up surveillance systems perhaps
involving sentinel GPs to deliver at least a snapshot of disease
in the community. We had some excellent examples with the Royal
College of General Practitioners in particular on influenza surveillance,
but it is important to note that the surveillance structure is
fragile and is largely funded on the goodwill of participants;
it is not well-funded and I think there is not a good succession
195. Should the sentinel practice system be
strengthened, do you think, and how is it working at the moment?
(Dr Zambon) I personally believe it should be substantially
strengthened, not only to look at respiratory syndrome disease
but, also, many other diseases including enteric syndrome diseases.
I believe the Food Standards Agency has used the model which has
been developed on surveillance in primary care to address the
question of enteric viral infections and the overall burden of
disease. So I think there are many gains to be had from strengthening
surveillance in primary care with a good network of GPs so that
we have a snapshot of disease in the community.
(Dr Brown) I would entirely agree with that and as
somebody developing the enteric primary care surveillance that
is something that we are trying to put in place. There are some
constraints to that, and I think one central issue is the question
of where surveillance lies between patient management and research.
At the moment surveillance tends to be captured by ethical committees
as requiring informed consent for each patient investigation.
In general practice, essentially, that means that you cannot have
it. I think there is a generic issue on surveillance around that
(Dr Pillay) Just to follow up on your personal view
of GPs' perception of virology, I do think that the relationship
between reporting, seeing the national benefit, and the individual
clinician is, to some extent, based on an understanding of how
useful virology can actually be. I would argue that (I agree with
Dr Zambon) there are cost limits to the extent to which diagnoses
can be undertaken in primary care, and it may be seen that it
is of no use in the acute management situation. However, of course,
the net effect of an active diagnosis of the viral cause of respiratory
illness is in reducing, perhaps, the amount of antibiotics that
are prescribed, which have huge other consequences in primary
care and the spread of antibiotic resistance. I think an economic
case can be made for more active diagnoses which then feed into
surveillance, but of course I come back to my previous point that
the diagnostic budget is negotiated locally with PCTs which makes
it very difficult to push those arguments as a basis for virology
196. I am a little concerned at your mention
of patient confidentiality being a problem here. Could you amplify
on this because, in fact, practices or hospital clinicians that
send in samples, are not aware, I think, at the moment, that they
might actually be contravening any kind of ethics on this?
(Dr Brown) The point I was seeking to makeand
it does apply, I think, most precisely to primary careis
that if you have a case in front of you of a child with diarrhoea,
do you do an investigation for the direct patient management?
In most cases, I think, the situation is that you would not. However,
if we are to have an understanding of the burden of disease due
to different enteric pathogens in the community, clearly we needbecause
they all present in the same way with diarrhoea and vomitingto
do a laboratory test to confirm the cause. Can that be covered
by normal patient management (you would not do it for the individual
patient management) or do you have to get informed consent from
each of those patients from whom you are requesting a clinical
sample that the information will then be used for surveillance?
I think there is an issue there, because clearly in general practice
it is impractical to do proper informed consent for each investigation
197. Also, the patient does not know whether
the sample is being taken to aid the doctor in diagnosis and treatment
or whether it is going to be used mainly for the purposes of surveillance.
Surely, the data can be anonymised, to an extent?
(Dr Brown) One might hope so but I think the ethical
committees may take a different view.
Baroness Finlay of Llandaff
198. The description of samples coming in and
diagnosis depends very much on the diagnostic acumen of the individual
person in primary care. I just wondered, following on from what
Dr Zambon was saying, whether you see a knowledge and training
deficit within the current training systems available to GP trainees
and, also, on-going postgraduate educationwhether actually
there is a huge educational gap in terms of recognition and accurate
diagnosis so that they can start to ask even for the right test?
I have a concern that if the wrong sample is sent and sent to
the wrong laboratory we will never get anywhere near, however
good your laboratory services are.
(Dr Brown) I would suspect that is true but I have
lived in a national reference centre for 15 years so perhaps I
should ask my colleague, who is a little closer to the coalface,
to answer that.
(Dr Pillay) I would agree there is a big variety in
the ability to send appropriate samples and test the appropriate
(Dr Zambon) Just to make the comment that one of the
benefits and hidden spin-offs of sentinel schemes is that the
GPs that are involved do, if you will, undergo a learning process,
learning about results from these samples. Eventually, there develops
intuitive knowledge which accumulates from realising the kinds
of person who are likely to give positive samples. I do not quite
know how to explain it, but it is part of the diagnostic acumen.
There is a learning curve in it, which can be very beneficial,
and those sentinel GPs can oftenand do oftenend
up with an important educational role within their own practices
and for local practices. I do see encouragement of sample taking
as being beneficial on the learning side, but I think it has to
be tempered with resources. I think you cannot say that for everything
you will have to investigate.
Baroness Finlay of Llandaff: Some of that educational
acumen has dropped out of some of the GP training schemes around
the country and certainly does not necessarily feature in the
MRCGP exam, so it may have fallen from the high profile in the
minds of trainees, who are our future practitioners.
- I would like to ask whether you feel the infection
control nurses have a part to play, both in the community and
within the clinical field? If so, do we set maximums?
(Dr Pillay) They certainly do have a very important
role to play, and in my experience good infection control systems
within hospitals are, to some extent, a function of close working
relationships between the laboratories as well as the clinicians.
So they provide that ideal interface and understanding as well
about the importance, in some cases, of making a diagnosis and,
in other cases, the fact that it is more for surveillance than
diagnosis. I would agree with you.