Examination of Witnesses (Questions 220-227)|
TUESDAY 3RD DECEMBER 2002
220. Do you feel that you have adequate academic
time to develop advances because there are two aspects, one being
the service provision for the disease burden that is out there
now, and the other one being the thinking time of looking ahead
and trying to be more efficient. From what Dr Pillay said about
having to go out to get grants, to get in people, it takes time
just to look at the data you are already collecting, let alone
having thinking time to generate new ideas.
(Professor Griffiths) I think I speak for us all when
I say we do not have enough of that thinking time. What we have
said from the network point of view is we want to employ appropriate
people, non-medical scientists, grade C and grade B, in each of
the 20 centres whose specific job is to take that best practice
from other laboratories and apply it in their particular setting.
Those people will be kept busy doing that and rise to the situation
where everyone has validated assays nationwide.
221. What about rolling out into primary care,
how much of it is bedside assays?
(Professor Griffiths) It depends on the type of technology.
At the risk of being flippant, we have talked today about bio-terrorism
and there is a small potential advantage of bio-terrorism and
that is the diagnostic systems being improved as a result of new
technologies coming through to pick up infectious agents. That
could be rolled out possibly to general practice and possibly
also to pharmacists. We have plenty of work and we are not looking
to retain all this in the laboratory. We will support the developments
as they go forward. Somebody will have to do quality control and
quality assurance of those particular assays.
222. Thinking back to surveillance that may
be a problem in terms of getting the data in.
(Professor Griffiths) Yes.
(Dr Zambon) The generic point about the introduction
of new technologies could mean the introduction of highly specialised,
highly skilled technologies such as some of the molecular technologies
that Professor Griffiths mentioned where the hospital laboratory
is the clear place for those. Then there are other technologies
which could be defined as new which are more suitable for use
at the bedside or in the GP office. The introduction of such technologies
is only limited by the absence of information about how useful
they are in practice certainly but also a clear understanding
of how they are to be paid for within the health system. For example,
with the introduction of a near-patient test for flu, if we leave
aside the question of sensitivity and specificity, that may take
30 seconds of hands-on time to do but a total of ten minutes to
read. Somebody in the health service who is already over burdened
has got to be designated to do that. I think there are some questions
about how to introduce new technologies, where is the funding
for that? In hospitals in particular, as I have already mentioned,
if you introduce new technologies using a pathology budget it
is the clinical budget and management that will benefit but clinical
budgets do not translate into pathology budgets. The introduction
of technologies is limited by a number of different factors but
virologists have traditionally shown themselves to be very forward
looking in trying to introduce new things. There is plenty of
scope for that and loads of things coming.
(Professor Griffiths) One business plan that David
mentioned earlier on is that of a pharmaceutical company making
a new treatment for flu or another virus which may subsidise the
cost of the test and make it available in pharmacies so people
can come forward and purchase their own antivirals, saving Lord
Rea some of the work he would otherwise be doing diagnosing. You
can see that as a potential route forward. We would not want to
hold that back, but we are building up the question of what that
might do for antiviral resistance for those particular viruses
and also inappropriate treatment. So there are quite a few hurdles
and quality control checks that have to be put in that somehow.
223. That information is disseminated, how do
you get the information back to the centre to do that monitoring?
(Professor Griffiths) Potentially you could get the
information from the machine in every Boots shop on the corner.
(Dr Brown) Obviously that is something that has been
thought about. If you think of the influenza diagnoses being made
in primary care, you can say there is a case for that but what
we want to know is what virus caused that. We have done studies
to see whether you can characterise it from the near-patient testing.
These are issues that are being looked at.
(Dr Pillay) Coming back to cost, there is no doubtand
Paul has talked about the molecular techniques that have increased
costs tremendously within our own limited budgetsfor those
of us here who use commercially available assay systems the cost
is even higher. There is a potential through the network that
has been outlined by Professor Griffiths of laboratories that
are specialist enough to enable the innovation to occur but also
that evaluation could happen through a UK-wide network for tests
that are actually developed using our own skills. That provides
huge cost advantages over the alternative, which is waiting until
the diagnostic company has produced a kit, and, to be honest,
to fleece the NHS. We need to provide the evidence base to convince
clinicians and PCTs to pay for this but that is in our hands and
I think we should be encouraged to go down that route.
224. How much should that be linked in with
public health medicine because I have a concern which was raised
before and you did not answer it really which is about the management
of the epidemic because it is not clinical laboratory virologists,
so who is going to be handling directions that go out to clinicians
on managing the information in the long term in terms of policy
making and direction?
(Dr Brown) There are a couple of points there. The
first is what is the relationship between the Department of Health
and the agency that is responding and I do not think that has
been completely established for the proposed HPA in the future.
In terms of what happens at the moment then it does tend to be
that a group of people representing the different specialties
that can contribute to a response to an outbreak do join with
colleagues from the Department of Health to try and make a plan,
see what information is needed and how that response is to be
made. It is often co-ordinated either at the Department or by
colleagues in the Communicable Disease Surveillance Centre. Certainly
for virus infections for which I have some responsibilities, I
have often taken part in those multi-disciplinary teams although
usually as a contributor rather than taking a personal leadership
responsibility for it.
225. Professor Griffiths, in some of your evidence
you talk about the UK Clinical Virology Network. When was this
formed? Is it a statutory body?
(Professor Griffiths) Not at all. It was formed informally
by the virologists ourselves. We had a couple of meetings, September
2000 was the first one and we were working through our protocols
when the document Getting Ahead of the Curve was published
and we very much agreed with many of those things so we decided
to update our document to make it a response to that. Basically
we have no funding. It is internal funds from each individual
laboratory supporting our own particular website. I think we can
claim to have achieved a few things so far. On the West Nile virus,
which David mentioned, there is no evidence of West Nile virus
in human CSF samples so far. Although it is negative it is quite
good and reassuring in that sense. We have talked about bio-terrorism.
There is a pox virus proficiency panel which is being prepared
now and sent out to the laboratories that diagnose pox viruses.
Hopefully we will not find the smallpox virus in the future but
it is important to be prepared. We have mentioned standard operating
procedures. We have also made some critical decisions on treatment
recommendations. There is a particular infection that I am studying,
the cytomegalovirus infection, and our American colleagues have
completed a treatment trial showing that those children are at
risk of hearing loss but, if they are given an antiviral drug,
it significantly decreases the loss of hearing. That is quite
important information so we put that on our website. We know from
our paediatric colleagues that 50 per cent of children in the
UK receive that treatment yet the paper has not been published
in the primary literature. That shows the advantage and strength
of electronic communication. The last thing that David might want
to mention is the use of enteroviral PCRs because we are required
to continue telling the World Health Organisation that we are
a polio-free country, but how do you tell that? Our own laboratories
are looking for enteroviruses using the PCR method. That information
can be taken and passed on to David to prove that they are not
the polio virus, which is our expectation. All of those things
are currently moving forward at the moment despite the fact we
have had no funding so far.
226. Is there a similar body in bacteriology?
(Professor Griffiths) No, but we would suggest to
you this is perhaps a potential model of the professions in one
particular area getting themselves organised. We would much rather
if funds are to be made available for different areas they are
spent on the things the professionals need to run the service
rather than on bureaucracy.
227. Would it be better if microbiologists and
virologists were combined together?
(Professor Griffiths) That is a possibility. Of course,
where do you stop? We have our immunology colleagues, we have
our haematology colleagues, we have our chemical pathologists
and our histopathologists. That is another sort of network in
the pathology modernisation network. We need to inter-act with
lots of different people. Do we need to be all in one group all
at one time? Surely you group together in order to achieve a set
of aims. We feel a natural affinity for our particular specialty
and a certain amount of enthusiasm for it and if we are going
to put our soft money funding into getting that going, that is
what we would like to run for.
(Dr Pillay) I would add that one of the pressures
on developing this in virology particularly is it is a very, very
small specialty. We are quite diffuse geographically and yet clearly
we would benefit enormously from the potential to interact much
more than we have done to date. Since there are only 30 consultant
virologists in the UK there may not be local support to provide
all the professional backing required, so it is the clinical governance
issue that needs to be addressed as well.
Chairman: Thank you very much. Are there any other
questions? My Lords, if not, that brings us to the end of this
session. May I thank you very much indeed for coming along and
being so open and informative on our questions. If there is any
issue which we have not touched upon but the questions and the
answers have caused you to think again, perhaps you can let us
have that in writing. I know Lord Patel wanted something from
you. Thank you very much.