Select Committee on Science and Technology Minutes of Evidence

Examination of Witnesses (Questions 240-259)



Lord McColl of Dulwich

240. Mr Emery, you mentioned pay. What sort of scale are we talking about?

(Mr Emery) An environmental health officer will qualify and be paid somewhere in the region of £23-24,000, and may well go to environmental health manager, in the region of £35-40,000, depending on the size of the local authority. However, the pay scale is quite narrow; it does not move very much. Basically, you do not get much in the way of increments, so unless you change jobs often you are not likely to get much more money.

Lord McColl of Dulwich: Thank you very much.

Lord Rea

241. This question keeps surfacing during our inquiries. Do you believe that surveillance should be owned more by front-line staff than by local institutions? Would such ownership help to encourage clinicians—GPs and other clinicians—toreport suspect cases? What changes do you think should take place or be instigated in order for this to happen?

(Dr Gelletlie) My Lord Chairman, I think it is very important that surveillance is owned by all of those who contribute to and use the data. That includes, may I say, the public, on whose behalf we are doing all of this, and it also includes front-line staff. However, I think the remote institutions, possibly, in this context, do also need to own the data because they are the guardians of the national data set-up and they do a lot of the analysis and interpretation of data. So I do not think it is an either/or situation. What we could do to improve the situation, particularly with respect to front-line staff, I think, is strengthen public health teaching at under-graduate level because I think we produce doctors who do not understand the public health function and, therefore, perhaps do not contribute to surveillance as enthusiastically as they might. I think we need to involve front-line staff in the development of standard reporting procedures, so that they understand there is a dialogue about what data is needed, what it is possible to get and how difficult that whole process is. It would give greater ownership, I think, if front-line staff were involved in developing those protocols, which we will need to develop in the new Health Protection Agency. Then I think there is an issue about timely and relevant feedback to front-line staff—again, to reinforce that they understand how that data is used and how they can make use of it at the local level. I think it is also useful to show, where possible, how surveillance data has contributed to the allocation of resources so that they understand that we are changing policy in response to problems, and resources are being targeted at areas of need. It is not always possible to make those direct connections, but we should strive to do so, I think. Finally, particularly in relation to front-line staff, I think it is extremely important that the local CCDC again is a credible, authoritative figure who has good local relationships with local staff and that the data flows come in that way—front-line staff, local HPA team and then upwards—and then again with the data coming back by the same route. That ensures that there is an understanding of the purpose of the programmes, better collaboration with local clinicians and, generally, that the local population as well can be involved through their local clinicians and kept informed about the programmes.

(Dr Hawker) Firstly, I would like to endorse everything that Dr Gelletlie said, that surveillance is a partnership between local people and people working at some of the apparently remote institutions. If the question is What do we do in order to improve ownership amongst the local people that provide so much of the data?", the first thing Dr Gelletlie implied was to make the data more relevant to them, so that it actually has to give them information which they think is useful. Perhaps one of the more obvious examples is seen in hospital-acquired infection where if surveillance actually relates to surgical units and they can see how well they are doing compared to similar units, that is information they will find useful and information, therefore, that they will take a bit more care in actually providing the correct data for. I think that is equally important at the next level, if you like, the local management level, which in future will be the Primary Care Trusts. I am a very strong supporter of both Getting Ahead of the Curve and the Health Protection Agency, but one aspect of it that does worry me slightly is an impression, perhaps, that health protection will be the job of the Health Protection Agency, whereas I only see one aspect of health protection being the job of the Health Protection Agency. Primary Care Trusts will continue to be the people that commission, say, sexual health services—so the control of HIV, syphilis and gonorrhoea—and they will be the people who commission TB control services, the people who actually provide or commission child immunisation services and they will be the people who hold the contracts with the hospitals for the standard control of infection services. If we cannot provide useful data for them to assess, firstly, the size of the burden of these various problems and, secondly, how well they are doing in meeting the challenges and how well they are doing compared to other areas, then I do not think they are, firstly, going to be able to do the job and, secondly, they might not even realise that there is a job for them to do. The reason why I labour that slightly is because I do not think our current surveillance systems are that well designed for producing data for the new agencies. Because the health service organisation changes on a fairly regular basis it is actually quite difficult to keep up, so statutory notifications are produced by local authorities and sexually transmitted infections are collected by a system called KC60, which is actually produced by a treatment clinic so it does not provide any residence data at all. So if a PCT was to ask I have heard gonorrhoea is going up. How is it going in our patch? What do we need to do about it?", it would actually be very difficult to answer it without setting up a new surveillance system. I think, as we start to review all the surveillance systems, we could probably fix a lot of this for the long-term by collecting more residence-based data but residence-based data which we could then alter according to which boundary we needed to study. So within a PCT boundary for sexual health services, but we could use the same system for allocating people to water supply areas if we wanted to study cryptosporidium. It strikes me that the obvious way to do that is to collect post codes of residents. That might sound quite a technical matter, but the reason I am bringing it up here is that, of course, the obvious problem with doing that sort of thing is people's concern about confidentiality—if you were to say you wanted to collect the post code of residents on every case of every infection then that would have obvious overlaps with problems to do with Caldecott guidelines to do with patient information. I think, again, that needs policy and political help in order to make the changes that we need.

Chairman: Lord Haskel, do you want to put your question?

Lord Haskel: That was my very point, whether there was any problem with confidentiality when you are moving this information around, and you have responded.

Lord Rea

242. I would particularly like to hear Dr Monk's view on this, having come up through the General Practitioner pathway to becoming a consultant in infectious diseases.

(Dr Monk) I do not know whether Professor Weinberg has drawn to your attention the Atlanta guidelines on the surveillance, but, if not, I have brought them with me and although they are heavily annotated I can leave them. They are updated guidelines for evaluating public health surveillance systems and give quite a useful framework for that. It is the world document that is used by WHO on how to look at surveillance. If I can just quote from it, The public health surveillance system should emphasise those attributes that are most important for the objectives of the system". If I think back on things that were important to me in general practice, for example, in the winter what you really want to know is what is it that is going around, What are my patients coming in with? Is this `flu? Is it a respiratory virus? What is it?", because it affects your management. There are a number of ways and approaches that one could take to that but it is at the front line and I think that the sentinel practice scheme is the way we do that locally. In other words, we have a small group of three practices scattered around Leicestershire who take a lead and who are interested in that. That data then comes to me and I disseminate that. That model works using these criteria for that disease because it is immediate and relevant. If on the other hand I said, What about meningitis? Would that be something that general practitioner data should own?", the answer is no; we should own that, but we should make sure that general practitioners are aware, as indeed I do, every time there is a case of meningitis in their area and if it is a particular problem in one area of Leicestershire I keep constantly sharing that with general practitioner colleagues. My reflection on this is that it depends on the relevance to primary care. If it is an issue that is important and happens to you frequently then that should be owned by primary care. Again I could illustrate that within our own patch. Within the eastern half of Leicester city tuberculosis is a big problem and some of the GPs there are beginning to take more ownership and interest in the surveillance data around that problem, but if I move out into the rural shires of Rutland it is not the biggest problem that GPs there have ever faced. Therefore you have to have very flexible systems. Going back to the thinking behind the question, what CCDCs are effectively saying is that what we are trying to do is have a system that detects the health related events that are relevant to your clinical practice and then move them up the system sensibly. Therefore that is going to be different in different parts of the country and at different levels but the majority of interface with health care takes place at primary care and that has got to be the fundamental building block that we come up from.

Baroness Finlay of Llandaff

243. Could I ask, Dr Monk, whether you feel that a change in the list of notifiable diseases would make a big difference or would it just be a list that would become obsolete very rapidly?

(Dr Monk) My view on that is that all lists become obsolete as infections emerge and become important and then become less important. What we need is the flexibility to have local reporting of diseases that are important. For example, we have a system with `flu. That is not a statutorily notifiable disease but it is incredibly important both for general practice, because your surgeries get absolutely flooded with patients and you need to know what it is, and also for hospitals which get flooded with new people coming in and you need secondary care to be able to cope. I would personally advocate that lists have to be far more flexible. I think we are coming on to the debate about public health law but it is an inflexible instrument that automatically rules itself out of date very quickly.

Lord Rea

244. Do you think that the clinical usefulness of the material sent by front line Practioners should be the incentive for them to ask for more analysis or identification of their samples rather than a financial one? At the moment the GP gets a small amount for each notifiable disease reported but I do not think that really has much influence on the fact that they are not doing it very satisfactorily.

(Dr Monk) I think that the importance for me, and I think for a number of my GP colleagues, is knowing what is going on. The incentive is to know what is going on so that you know what is coming through the door so that you know how to deal with it and you can plan your surgeries accordingly. That is ultimately the incentive, and also so that you do not make mistakes. For example, with meningitis, if you know there is meningitis in your area you are going to be much more careful about a request for visiting a kid.

(Mr Emery) Certainly as regards under-reporting, if GPs felt that environmental health or whatever the system was could be more effective in, for example, tracing the causes of food poisoning, then they may feel more inclined to make the report. One of the problems that we have is that we have lost the interface between the EHO and the GP. Our relationship now is with CCDC rather than the GP. We used to have this system, harking back again, before 1974 when there was a much more direct working relationship. The importance of that is that we could get in much more quickly before we waited for a positive faecal sample result. We could be visiting people in their homes and getting information about what their occupation is, whether it is a high risk activity, etc, trying to find out where they ate, getting into the restaurant early so that we could intervene and be effective. If GPs felt that the reporting was worthwhile with something like food poisoning, then I think they might be more inclined to make the report. I am not a GP so I cannot say for sure, but I would certainly welcome it from the EHO's point of view. We would welcome a closer relationship with the primary care team rather than have to go through a loop, be that loop in the health authority or the Health Protection Agency or wherever it is based.

Lord McColl of Dulwich

245. Could you expand on the prevention and surveillance on treatment of TB in this country and how it could be improved?

(Dr Monk) Do I have concerns? Yes. I think TB is a seriously worrying emerging disease. I think it is verging on being very difficult to control. If you asked me the analysis for that, there is a separate set of issues in London as against the rest of the country and they come up at two levels. First of all, it is unbelievably difficult to have a joined-up approach. If I could get slightly technical, my Lord Chairman, if you look at a patient within the current Isoniasid resistant outbreak who presents, for example, in King's College, that patient has probably got contacts in other areas of London who will have picked up and go to other hospitals or other TB services in the northern sector of London. When you get there, and particularly children, there is no way of knowing that you have got a child with a very positive HEAF test, ie, exposed to TB, and you do not know that the source case for that patient was Isoniasid resistant, so you will treat that child with Isoniasid. Joining that up is incredibly difficult. The argument that is currently made is that there is a TB database. If you speak to the clinicians their immediate answer is that they cannot use it, it is not there where they need it. We have to be really radical and say in London, as probably elsewhere, This is a public health problem". In the old days we actually had a pan-London solution to this where we had a team that dealt with it. I do not believe that the fires can be put out in any other way. There are therefore organisational and structural barriers. The second issue is even more complex and that is around how you both contact a trace and how you enforce treatment. The people that we are dealing with who have TB are very difficult, many of them, in social terms. If you talk to TB nurses in London, they are going into houses where people are armed with both guns and knives because they are drug dealers. We are now in the position (and we have the same issue in Leicestershire) where we do risk assessments and we have now got patients we are refusing to support in treatment and we are adopting a different way of controlling their TB, in other words trying to find contacts and ring round them, because it is too dangerous to have nurses visit their houses and then force their taking on TB treatment. Secondly, these people with TB sit in crack rings or heroin rings and it is becoming an increasing problem with people who you would otherwise assume were City people, respectable people who will go and shoot heroin rather than go for a drink in the evening. There is no way we are going to find out who those people are. They will not tell their families. The people they are shooting heroin with will not tell anybody else and that is a behaviour pattern that is currently existing in London and it is spreading out of London. Back to your question: how can we control it? We need, I believe, to have in London a public health team that deals with TB. We have got to have some radical thinking about these very difficult, very violent patients—and they are unbelievably violent. We had one who has beaten up nurses in hospital. The law does not allow us to treat these people adequately. The public health law is completely inadequate and even if it was not we do not have the institutions in which we could adequately care for these people. It is really a very difficult scenario we are facing, incredibly challenging in public health terms.

(Dr Hawker) I just wanted to flag up one aspect of tuberculosis. I think people are aware of the concern about the increasing amount of TB, the increasing number of new cases, but perhaps the bigger risk within that is the increasing amount of multi-drug resistant TB that there is around the world of which fortunately we do not yet have that much in the UK. Drug resistance can occur in two ways. One is that we can import it, and a lot of cases in London are of course imported. The second method is that we can create it by half-treating TB. Treatment for TB usually involves between two and four drugs over a six-month period and quite a lot of it is given to people who usually find that commitment quite challenging. If they manage to take one drug a week or two drugs every other week that is a good recipe for selecting out the most resistant organisms. In order to make sure that does not happen we need to have a much closer liaison between the patient and their care providers so that, first, we can spot whether such problems are occurring and, secondly, we can encourage them to do something about it. In so many cases you will hear us talking about resources but this is yet another instance where the local TB services do not have the resources to do that job adequately. One other thing on the subject of multi-drug resistance is that I constantly see academic papers suggesting that we should stop providing BCG because it is not that effective a vaccine and the risk as assessed over, say, the last 10 years for TB has not been that great. That analysis is fundamentally flawed because we do not give vaccines according to the risks as they have occurred in the past 10 years. We give them in order to prevent future risks and BCG prevents MDR TB, drug-resistant TB, in the same way that it prevents any other kind of TB.

(Dr Gelletlie) I want to make a different point from the points my colleagues have made. One of the areas where we lag behind in this country, I believe, by comparison to the United States is where they have made huge efforts in controlling and reversing the rising trends in the incidence of tuberculosis. One of the things that they have got to grips there is the laboratory diagnosis of tuberculosis. I am not a microbiologist but I understand that it is quite a complex procedure to diagnose tuberculosis and there are methodologies that are in use now which really, to be cost benefit efficient, ought to be concentrated in fewer laboratories. That is something which we need to consider. There willbe cost implications with this. Traditionally tuberculosis took about six weeks or more to grow in the laboratory. There are now methods by which you can grow it much quicker. Growing the germ allows you then to say to your patient, Yes, you have got tuberculosis. Yes, we are treating you. Yes, we will follow up your contacts." There is a whole raft of things which are easier to organise. It is extremely important that we get the laboratory diagnosis done in laboratories which have sufficient expertise to do this and that will require us to look at how TB currently is being diagnosed. It may be that local general hospitals no longer should be permitted to do this and that the resources should be concentrated in fewer places where the expertise is available.

Baroness Emerton: Chairman, my questions have been answered. I was going to ask about the prevention with BCG but I think there may be differing opinions on that.

Lord McColl of Dulwich: I think so, yes.

Baroness Emerton

246. I would like to ask Dr Monk if he could give his view.

(Dr Monk) I beg to put a counter view and I think I would refer your Lordships to a paper in the British Medical Journal by the world leader in multi-drug resistant TB, Michael Eismann, in the Jewish hospital in Bethesda in Maryland. Michael is the world guru on multi-drug resistant TB and his paper said that BCG has limited use in prevention of any TB, including multi-drug resistant TB, because the problem is that it does not prevent pulmonary tuberculosis and pulmonary tuberculosis is the major public health challenge of any form of TB, including multi-drug resistance. What BCG is good at doing is in preventing disseminated TB, particularly in neonates. Therefore we should have a completely different national programme. We should find the neonates at risk and we should vaccinate them. Whether it has any value at all I very much doubt. The other public health problem is that people who think they have had BCG think they are protected against BCG. GPs think that they are protected against TB and they do not investigate them. In our recent outbreak every child who had got TB had had BCG. The death we have just had from TB as part of our outbreak had had BCG. It does not prevent pulmonary disease and world experts, including Michael Eismann, are saying this.


247. You concentrated on London. What about other major local authorities in the country, such as Birmingham, Glasgow, Edinburgh and so on?

(Dr Hawker) We probably have among the three of us the three main areas, Birmingham, Leicester and Bradford. We have one element in common which is that, unlike in London, a lot of our TB is seen within the settled ethnic minority communities. This is not a group where we have that good an idea of their risk factors. There are some studies from about 20 or 30 years ago that describe the risk factors then, but of course times have moved on. We know that the reason why people from Asian minorities are at increased risk is because of their links to higher prevalence countries. What we are not clear about though is whether they contract TB by continuing long term visits to higher risk countries, three-month visits staying in close proximity to a local population away from tourist areas, or whether they have visitors who come from higher prevalence countries to visit them here, or whether, just because any population sub-group tends to pass not so infectious diseases amongst themselves rather than to the general community, the problem is now occurring within the UK and it is British Asians passing the illness on to other British Asians. It is perhaps one area, if we wanted to think deep policy about how we might control TB in the UK, where we might want to think about whether this is an area that we might ask the Department for International Development to have a look at as maybe it is rather naive to think you can control TB in Birmingham without first controlling TB in Mirpur.

248. Are there any near patient diagnostic tests for TB that are being validated at the moment?

(Dr Gelletlie) There is a new test which is about to be validated, a blood test, which is much more sensitive and specific than the current skin test. It is not near patient in the sense that you can do it on the spot, as you can do your HEAF test on the patient, but this new test which is being developed will give us a better opportunity to differentiate tuberculosis from other mycobacteria. It will also allow us better to differentiate patients who have TB rather than have responded to their BCG. There is something coming on the market which will allow us to do that. We will need to do some trials in this country that will need to be funded but there is an opportunity.

Baroness Walmsley

249. I have two questions. Whichever the three explanations that Dr Hawker outlined is the truth, what is being done in terms of public information amongst British Asians as to what the risk factors are and how they might protect themselves? The second question is something entirely different, going back to something that Dr Monk was talking about. He was referring to these highly violent, unco-operative people who are in society going round spreading TB all over the place. He also described the effective drug regime as being rather a complicated one. Many years ago people with TB were hospitalised so it was much more easy to control their treatment and their infectivity. Presumably we do not have the resources to do that these days and presumably these people would not accept it anyway. What is the situation? Are they ever offered that kind of treatment? Do we have the resources to do so? Would it work if we had?

(Dr Monk) There is lots of information. There are a number of levels. First of all, I do not believe TB is preventable. I think you can protect yourself by being sensible if there are family members who have TB, but a lot of it is about working with primary care, it is about ensuring that primary care, who look after these patients, think TB and are aware of TB. It is early diagnosis that is the main bedrock of getting TB under control in this country. The longer somebody is infectious for, every week you might infect two people, so if you are infectious for six weeks you have infected 12. If you bring that forward and say that somebody is only infectious for two weeks then the pool of infected people is only four rather than 12 and therefore if you bring their period forward that is how you control it. It is awareness generally.

250. But does that not involve the patients themselves being very aware of their own symptoms and going to get help quickly?

(Dr Monk) Yes. Locally we have done a lot of work with the Rotary Club who have worked with Asian businessmen in Leicester and we have had a lot of publicity that way. We have big Asian shopping areas and we have a lot of TB awareness publicity. There are all sorts of ways in which you can alert local populations.

Baroness Emerton

251. In terms of speeding diagnosis, which is very important, what is the current teaching in medical schools on the diagnostic processes? We read quite often that quite often it takes rather a long time for a diagnosis to be made. What is the teaching? Is it enshrined in medical school training?

(Dr Monk) It is a relatively easy diagnosis if it is pulmonary. If it is non-pulmonary it is difficult. If you have got in your bone you need a biopsy and you need it to go to the right specialist in the hospital. Pulmonary TB is difficult. There are, however, problems. Number one has been the ionising radiation regulations which make it more difficult for general practitioners to get access to X-rays. The second one is a shortage of radiologists which means that it is difficult to get the X-rays reported and then the third is around access to sufficient equipment. There are undoubted problems in the diagnosis of TB.

(Dr Gelletlie) The key point is that it is the level of suspicion in the practitioner who sees the patient. There is frequently a delay at that stage rather than in getting the diagnosis made. I believe that this new blood test when it arrives will help us to be sure of the diagnosis in some of the cases that Dr Monk was talking about.

(Dr Hawker) I want to re-emphasise something that Dr Gelletlie said that perhaps she did not make enough of. Where Dr Monk said that the diagnosis of pulmonary TB in the laboratory is relatively easy, that is true, but not all labs are equally good at it. In fact, one of the areas we really need to address is the laboratory strategy in the diagnosis of tuberculosis. The second part of it needs to be the speed of diagnosis for exactly the reasons that Dr Monk explained, and also for detecting antibiotic resistance because if you are treating somebody with the wrong drugs you are not going to render them non-infectious. Finally, you may move on to molecular epidemiology in a while, but it seems fairly likely, if we can believe the various US studies and the Dutch study, that we will be missing clusters of TB here, essentially cases that we are failing to spot and which more discriminatory tuberculosis testing may help us find. You will not be surprised if I respond to Dr Monk on BCG. I will make one more reference and then let it drop. That is that the best study that has been done on the effects of TB in the UK was exactly on giving it to neonatal British Asians and we found it to be 70 per cent effective in preventing TB, and I think that should be part of the strategy.

(Dr Monk) I totally disagree. I thought he said I don't think we're disagreeing on that", but P.M. will doubtless comment.

Chairman: We could go on about TB, I think, for quite some time. If there are any points that you have not covered with questions and answers perhaps you could let us have some notes on that.

Lord Haskel

252. My question is about costs and benefits. Inthe evidence from Public Health Medicine Environmental Group, you suggest that there should be a properly resourced national surveillance strategy where the cost of the individual programmes is balanced with the benefit they bring. I wonder if you have got any information available to enable us to judge this cost benefit.

(Dr Gelletlie) No. I am a bit of a hostage to fortune. In hindsight I would not have used the term cost benefit" which has a specific meaning in economic terms, and I should have used a slightly more general term. The point I was trying to make was relative to what Dr Monk and others have talked about. Frequently the burden of collecting the information for surveillance rests with the front line staff. The benefits of the surveillance data and their analysis etc are not often immediately obvious at the front line. As you so rightly described, around `flu it is very easy to see how the general practitioners and front line staff benefit. If it is something which is rarer it is more difficult as then the level at which the data begin to make sense is higher. My point is really that the burden often falls on the laboratories, on the front line clinicians and on the front line GPs and the benefits are often at a different level, for example, at national policy level, at health authority level, at regional level. I do think we need to get better at making our arguments for collecting all the data that we do collect. I do not have data; I am sorry.

253. Perhaps one can express these cost benefits better in terms of social costs and social benefits rather than putting it in numbers. Would you agree with that?

(Dr Gelletlie) I certainly think that the general public must understand the importance of surveillance programmes. I think we are gravely threatened by the suggestion that individuals' health data is their concern and the concern of their clinician only and that the public health benefit which can be derived from using those data in a suitably anonymised manner must be made clear to the general public. The social benefits of surveillance programmes, the purposes for which we do these programmes, must be made clear to the general public. That is a useful way of looking at it, yes. New programmes are introduced without a consideration of how, for example, laboratories are going to collect all these data, how the front line practitioners are going to find the time to collect all the information that needs to go into the enhanced data set, and resources do not generally flow down to the front line where these demands are made.

254. Dr Monk, do you have a comment?

(Dr Monk) No.

Baroness Emerton

255. Much of the evidence that we as a Committee have received identifies the importance of updating the public health legislation, not least the discussion we have had this morning with yourselves. It is a very complex issue. We are very interested to know which aspects of the legislation need revising and why does the current legislation cause difficulties. You have already outlined some of those this morning, but we need to know what your views are in ensuring proper resourcing and accountability with control of communicable diseases.

(Mr Emery) One of the first questions to be resolved is what is meant by public health" in definitional terms. Public health to an environmental health officer is probably something different from what it is to a medical officer, and it is probably something different again from what it is to the general public. Certainly as far as I am concerned public health is where my role derives from back in the mid-19th century and the legislation that was put into place then is largely still with us. We still have the 1936 Public Health Act, cleansing of verminous articles, persons and premises, for example. In the Public Health (Control of Diseases) Act 1984, which is the current main Act, we have a re-enactment of many of the elements of the 1936 Act and previous Acts. We still have terms such as public washhouses" referred to, for example, in the 1984 Act, cleansing stations, and so on. It talks about library books as infectious articles. It does not mention DVDs or CD ROMs to my knowledge, so it is well out of date there. We can prohibit outwork in people's homes where there is an identifiable disease on the premises for things like garments, and the Secretary of State has given power to add other articles to the list. To my knowledge nothing was ever added, so again that is a hole. We can exclude people from work where they have a specific food-borne disease or food poisoning. We cannot exclude people from work if they are suffering from an infectious disease which is not food poisoning or food-borne. We have the strange lists of notifiable diseases. There are five main identifiable diseases. Then there are the others we have added on. I do not know what is in the list now, about 20 or 21, and different powers can accord to separate diseases depending on which section of the regulations you read. We have a situation where the local authority, as I said before, appoints the proper officer who does not work for the local authority usually, although there may still be proper officers who are chief environmental health officers, if chief environmental health officers still exist, although I doubt it due to local government reorganisations. They generally have become directors or managers of environmental services. That is a strange situation whereby the medical expert does not actually work for the empowering authority. Indeed, the CCDC in law is supposed to follow the policies and guidelines of the local authority and one wonders sometimes whether some CCDCs may be putting themselves in queer street because they are not legally in accord with the elements of the main Act. Then we have things like the Public Health (Ships) Regulations and the Trains Regulations 1994 because of the Eurotunnel. They have more swingeing powers than, for example, the main 1984 Act. For example, we can insist on a patient being examined or put into hospital under those regulations which you cannot insist on without a court order under the Control of Disease Act. So it goes on. It really does need looking at. The other thing I would like to say about resourcing is that money to environmental health departments in local authorities is not ring-fenced so we have to get what money we can for the environmental health budget from the full contents of the purse that the local authority has and that has always been a very difficult exercise. We may be successful, we may not, but communicable disease may not figure highly on the list as far as local treasuries are concerned, although obviously environmental health managers do their best to make strong arguments. It is something which as far as I am concerned causes an awful lot of confusion and needs updating.

256. Apart from the definition which you have just mentioned and organisation, which is paramount in terms of the partnerships that need to be made, is there anything else besides the surveillance and prevention of treatment that anyone would like to see put into the revision or updating of public health?

(Dr Hawker) There are a few. One was the list of diseases which I agree get out of date very quickly but they are very out of date. The reason why they are important is probably less to do with surveillance and more to do with the fact that the Act and the Regulations give powers that you can exercise in the light of a notifiable disease so that if a disease is not notifiable you cannot use the powers. If I give you two examples of diseases that are not notifiable, one is Legionnaires' disease, and of course it has been in the news a lot this year. Legionnaires' disease is not notifiable and yet clearly needs public health action to control it. The second one is less clear because the problem with the Public Health Act is that there is no case law around it, but probably E.coli 0157 that is contracted from a farm visit or from a nursery or a swimming pool, is probably not notifiable either because it is not food poisoning and yet clearly the public would expect us, first, to know about those cases and, secondly, to do something about preventing them. There are areas around the powers which are in themselves relatively inconsistent. Mr Emery mentioned about excluding people with food poisoning. We can exclude them from work and we can exclude them from school but we probably cannot exclude them from nurseries and yet of course gastroenteritis is more easily spread in nurseries than in schools. I think the powers themselves need to be looked at. Finally, back to the point that Lord Haskel raised earlier, a lot of the problem we have with confidentiality would be solved by making something statutorily notifiable.

(Dr Monk) There are two comments I would wish to make. One is on review of the law. We can all demonstrate its outdatedness. It is important to get into perspective that we actually do very well and I think in parliamentary legislative time there have to be some serious questions asked as to the usefulness of updating that. I am not saying it should not be because it is a mess but whether that is useful I am not entirely sure. Around the partnerships we have we know about E-coli 157 and we know about Legionnaires'. We controlled the outbreak and we did it very well and we do not have any legislation to enable us to do that, which is interesting. The other comment I would make, going back to Baroness Walmsley's point about TB, is that we do not have any legal powers to treat anybody. We can put them in hospital but they can refuse—and they do—to take their medication and there is nothing that we can do about that. There are real difficulties about that. If there was one thing I would do with TB it is to think of centres to put people in because in hospital we cannot hold them in. It is not to do with resources; we just cannot. Secondly, once you have held them there it is a bit like mental health: you have got to be able to treat them. If you do not want to go there because of the Human Rights Act we then have to balance that with your right and my right not to catch TB. It is a very difficult political debate.

Baroness Walmsley

257. I have just made a note of a couple of things that you mentioned earlier on in your evidence which I think are things that perhaps would be useful in terms of changing legislation. I think it was Mr Emery who mentioned reserve powers, that somebody needs a reserve power to decide who does what if something gets done, so you might want to say a bit more about that. The second point was on the duty of partnership. I think it was Dr Gelletlie who mentioned that and again it might be worth elaborating a bit on that. Just to go back to my thing about enforced hospitalisation, there is clearly a link between users of hard drugs and TB. Currently is there any obligation to X-ray people who are picked up who are on drugs? What happens in prisons? When people go in for hard drugs offences do they get an X-ray? Do we find out even if they have got TB, and then at least have the chance of asking them will they be treated?

(Dr Monk) Dealing with the last one first, prisoners are very difficult. They all have a health questionnaire. In most remand centres you have about one minute per inmate. They come from the courts and most prisons are taking so many people that the fast movement of prisoners means that you have not got time to screen them. Even if you decide you need to screen them there is a real problem because you have to take them to a hospital which involves at least two prison officers and it is an incredibly complex process for them to do. There is some very interesting innovative work being done from Rotterdam where they have got a digital imaging system which is much more flexible and much easier to use and that has just been trialled in Pentonville Prison a couple of weeks ago. That might be one of the ways forward but there really are substantial problems with this group of people. There are also substantial problems about holding them in custody suites. One of our patients who was arrested and I thought, This is my dream come true", was released because the medical officer who advises the police and the police surgeon decided that the infectious risk he posed was too great for him to be interviewed by a solicitor and therefore the police had to release him without charging him for manslaughter, which is what he was arrested for. It is very complex.

Baroness Finlay of Llandaff

258. I would like to go back to the earlier discussion related to funding issues and ask whether you think the development of the primary care trusts as the budget holders will threaten infectious disease surveillance activities in the face of competing priorities such as cancer or coronary heart disease targets which are set.

(Dr Gelletlie) When I put that point in I actually said that the development of PCTs as budget holders could and would threaten the whole gamut of control of communicable disease. I was thinking more there of the money PCTs need to put into TB services, to put into immunisation programmes. That was the end I was thinking of rather than surveillance per se being threatened. I think surveillance programmes, possibly because they are not overtly funded, would probably be less threatened. We are going to need money for GU services. We have a problem with sexually transmitted infections at the moment; there is no doubt about that. There is a need for investment there. There is a need for investment in tuberculosis programmes which has to come out of the pot which the primary care trusts use for the health services for all the population for all aspects of health and because infectious diseases generally are rarer than things like cancer the priority of some of these other services will be higher and the ability of the PCTs to get money for infectious disease programmes will be less. The national and local priorities will not necessarily be the same. Ring-fencing is no longer something which is done within the Health Service. We used to have money which was ring-fenced for particular programmes, ie, HIV, for example. When the money first came out for HIV it was very clearly ring-fenced and you were only allowed to use it on HIV and you had to report that to Parliament annually on how you used your money. That is not currently how health services function but it may be necessary to consider that for some of these diseases which present grave threats to public health but which may be within a local patch a relatively low priority.

(Dr Hawker) The other side of the resources argument is the performance management argument. Primary Care Trusts would be much more closely monitored by Strategic Health Authorities on things like cancer and coronary heart disease than they will be on infectious disease prevention. Partly that is a difficult thing to fix. For example, not all Strategic Health Authorities yet even have a public health doctor in them, let alone someone who knows about infectious diseases. A potential weakness in Getting Ahead of the Curve, which again I have to preface by saying that I think it is a really good document, is the way that it gives clear and unambiguous responsibility to the Regional Directors of Public Health but does not appear to give them any clear or unambiguous power to influence because of course they are not part of the Strategic Health Authority or part of the performance management framework. I think it might be easier to identify problems in PCTs than to fix them.

(Mr Emery) One of my concerns with PCTs and the partnership concept, is that there is a potential for wasting money or at least spending money immoderately on all sorts of partnership schemes of an environmental or public health aspect, such as sustainable development, recycling, healthy eating. There is a whole range of issues out there that people are now talking about in relation to health and public health. My concern would be from an infectious disease point of view that there might be too much emphasis on too many resources going into those sorts of schemes rather than enough being earmarked for infectious disease control which I regard as a public health priority.

Baroness Walmsley

259. How could the adoption of modern techniques such as molecular typing be encouraged in the UK? What are the opportunities and threats that face surveillance as a result of these new diagnostic methods such as near patient testing and molecular typing? I notice that in Dr Gelletlie's evidence she suggests that perhaps we should not get too excited about things just because they are new but to ensure that public health needs are taken into consideration when new technologies are being introduced into clinical practice.

(Dr Gelletlie) If I can start with a concrete example, molecular typing of tuberculosis, in Bradford the majority of our tuberculosis cases are patients from the south Asian community. The key question I wanted to answer was, are they getting the tuberculosis in Bradford or are they getting it abroad? We have not got there yet but because we now are able to identify the individual strain of tuberculosis each patient has and, with, longitudinal studies we could do this over some years. We could begin to map where people are picking up their tuberculosis. That is clearly essential if we are going to get to grips with tuberculosis. I managed to do that because I had a Wellcome Foundation grant to do that with; that was not done out of health services funding, so we need to ensure that there is funding available to do this. Currently I cannot continue because I have no funding and the techniques need to be paid for. That is a concrete example of something which is a useful tool which would have to be paid for over and above the standard laboratory testing. We are slow to adopt these things within the NHS. Often research is done and somehow or other we are slow to move it from the research phase into the rolling it out phase, partly because of the resource difficulties and partly because perhaps there is not enough joined-up thinking between those who are doing the research and those who are commissioning the services. In terms of near patient testing, clearly the concern there is that, for example, the general practitioner has a patient in front of him. He does a test. It says that this patient has X disease and the ability to capture that information and then transmit it to the surveillance system might well be lost because currently those tests are usually done in the laboratory where you have got more staff, better organisation and potentially you can automatically move your data from one system to another. That is a concern that we would have on near patient testing.

(Dr Hawker) The two examples you give are very different in the sense that molecular typing is an opportunity and to some extent we need to think about how we might best use that, and near patient testing is a threat. We need to think about how we would best get around that. With molecular typing TB is the example where we have done the most work but perhaps I can give you an example of somewhere where further molecular typing would be most useful, which might be in gastro-intestinal disease. Molecular typing essentially allows you by better discriminatory microbiological testing to flag up hypotheses for looking at with epidemiological methods. For example, it might flag up cases that look like they ought to be linked so you go out and find out whether they are. If we go back to when I was CCDC in Birmingham, I might get 1,000 cases a year of campylobacter reported to me. Probably 80 per cent of them would be not differentiated further and most of the rest would be called campylobacter jejuni which I already knew because I knew what 80 per cent of the rest were. It was probably pretty useless telling me about those cases: there was not anything much I could do with them. If, however, amongst that group we had a separate test which actually was saying, And this group look like they might be linked amongst those 1,000 cases", there could actually be quite a big outbreak. It may be affecting 50 diagnosed cases and therefore 150 undiagnosed cases: I would not have spotted them on the old test but with molecular typing I might well spot it and be able to find out where it is coming from and put a stop to it. We need to look at where the great opportunities are and then undertake the research to see whether these opportunities can be realised. I know Getting Ahead of the Curve talks a lot about research and development monies but this would seem quite a good area where we might be using NHS development monies to look at real public health gains. With near patient testing it need not be seen as a big threat for 10 years' time that GPs might do a lot of diagnoses themselves in their own clinics, provided their information where they record all diagnoses is something we can access. Maybe that is done bythe fact that increasing computerisation and standardisation will allow an anonymised version of that data to reach us or maybe it is done by integrating surveillance with the new electronic patient health record. We need to bear these sorts of challenges in mind to make sure that we design systems which can meet them.

(Dr Monk) The question you asked is how do you make it get in. The answer goes back to the document which I have quoted from, the CDC American guidelines, in that surveillance ultimately has to lead to a reduction in morbidity mortality or improved health. What we have to demonstrate is that these techniques are clinically useful. The death that I have described in the TB outbreak, we only knew was associated with the outbreak because we had the Professor of Microbiology doing a molecular diagnostic technique on the sputum that we get. Without that we would never have spotted that. The classic example which has not been quoted is not quite molecular typing but it is a similar process is that of meningococcal disease. It has been a universal success that typing of the organisms of those that affect people had led to the vaccination programme. I personally use that data in the way I manage the public health. Those that are a certain type of meningitis behave more aggressively and I was much more aggressive in the chemo-prophylactic approach that I took. With TB, we seem to have a funny strain in TB which is aggressive. If I think it might be I get a 24-hour result and we will be much more aggressive in our contact tracing. If we get those sorts of messages out, that molecular typing is not some ethereal, academic, wouldn't it be nice if we knew" type exercise, it actually has an impact on the clinical coal face and it is useful, as Dr Gelletlie has said, for service planning and knowing where the organisms and the strains are coming from and, as Dr Hawker said, spotting why there are regional outbreaks. It is useful at all levels but we have got to get the message through that it is useful at the clinical coal face. I use it every single day and it affects the way I personally intervene in making clinical decisions.

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