Select Committee on Science and Technology Minutes of Evidence


Examination of Witnesses(Questions 280-299)

TUESDAY 17 DECEMBER 2002

Professor Brian Duerden and Professor Angus Nicoll

280. You see, this is the point I am getting at, if you talk of going back to the GP then you are right into the weekend problem. The only circumstance in which I could see the difficulty that you raise standing up is when you, as the PHLS, actually have to go direct to the patient, and if that happens then indeed this is a serious problem?

(Professor Nicoll) That is precisely what happens with the food poisoning, for example, where we find suddenly that there has been an upsurge in Salmonella. The only way you can sort that out is by interviewing patients, which is done with the permission of the GPs, but then you do have to push your way through the practice and go through a questionnaire, and with patients and with controls and see what it is that is different about the two, and then that can identify the source. This which may need very rapid action.

281. My final point is, in general, are you satisfied with the speed with which the system operates at present? You did not really comment on overall speed, but how important is speed?

(Professor Nicoll) Speed is vital, certainly, in things like food poisoning, where you can have a continuing food source that is just out there and people are getting sick, and that has been happening with the egg problem this autumn. Getting information speedily allows us to take the local public health action that potentially saves lives. The other area where more speed is needed is in the communications in relation to areas like bioterrorism, or other health alerts. We have been developing a system which works under the wing of the Chief Medical Officer's public health link, which is a way you communicate out to all the public health people, but we have been extending that now to front-line staff in Accident and Emergency Departments, ITUs and Infectious Disease departments. This is copying a system in America. We have something up on the web-site about anthrax at the moment, If you see people with this condition with a widened modiastinum on a chest x-ray, think about anthrax and if you've got any suspicion `phone the following people." Now that kind of system worked very well in the States. It is being developed here. It is not perfect, because we do not have those good links yet straight into the A&E departments. But one would like to see in the future that that kind of thing could be going to all Primary Care Trusts, and then through them immediately down to GPs. In the good Trusts it is working.

Lord Rea

282. In your evidence, you say there should be an improvement in real engagement with those at the front line" and we have had very similar comments from a number of our other witnesses. As a former front-liner myself, can you identify or clarify what you mean by engagement with those at the front line, and how surveillance can be modernised to meet the needs of the people at the front line?

(Professor Duerden) I think there has been in the past a tendency for things to come from the centre and be distributed and to say, This is the way we do it." The people who deliver the data and the people who have to take action on it are front-line clinical staff, whether it is in primary care, whether it is clinicians in hospital, or whether it is public health doctors, CCDCs, for example, and even beyond the medical side of things, with the local authorities in some of their areas, and the Food Standards Agency, with people at the front line who we expect them to provide the information, they have a right to have the answers back very quickly. And we need them to influence how all the things are set up, what the priorities are, what their priorities are, because they are what we need to deliver. And certainly in the priority-setting field, we have tried to move somewhat in that direction over recent years within the PHLS to involve a wider range of stakeholders in our advisory committees and in our overview of communicable diseases, which is the opinion survey that leads into priority-setting. I think there is still a long way to go on that to get people involved, people who are the users of the information.

283. The users often feel that they do not see the benefit of providing the information that they send to laboratories, and it comes back too late and so, very often, that acts against them sending as many samples as they might, and at the same time it deprives you and it deprives them perhaps of both the co-operation and the end result?

(Professor Duerden) Absolutely, I agree, and the surveillance depends particularly upon the laboratory results and then linking those results to the clinical data, because it is the two together that tell you what is going on with a patient. Inevitably, microbiology laboratory investigations are not as rapid as haematology and biochemistry, by their very nature they take several days to complete. What we have to do is ensure that that is kept to a minimum and that there are minimum delays at the front and the back end of this, getting the sample to the laboratory, getting the report back from the laboratory to the clinician, whether it is in general practice or a hospital practice, who has asked for it, and there are important developments there in electronic ordering and electronic reporting of data to get this back. And that then flows through into the surveillance activities, if you are then using that data, using those results as part of your surveillance, which we are, that is how we get the information about laboratory-confirmed infections. It is important that the people who provided the samples get information back in real time, I do not mean in 24 hours but at very frequent intervals, to show the pattern and the trends in their particular area, not just that the work they have done has contributed to the national picture, what they are interested in is what is happening locally in their patch. And it is getting the analyses done in a consistent way, it needs to be a consistent pattern across the country but also visible at the local level, so you can see how the local contributes to that picture. And I think we have work to do there to improve that.

284. There are some practices, including mine (after I left it actually) who have developed very good communications with their local microbiology and other pathological divisions, and that has encouraged people to ask for laboratory confirmation of their diagnosis, so it is a two-way traffic, and really good computer links are important.

(Professor Duerden) Professor Nicoll mentioned the developments of web-linked systems so that people can see how their local information, what is happening in their practice, fits with the regional and the national pattern.

(Professor Nicoll) I also wanted to pick up from Lord Rea the whole issue about how you explain to people why it is important what they are doing; so many of the times that you supply information it is a negative or it does not seem that important. I think there has been a failure to communicate back to suppliers of information and we are responsible for this. But I think it is a broader responsibility within the NHS to explain what are the outcomes and the outputs of the kind of work that an individual GP is doing. Like, thinking back to confidentiality, the fact that you make a diagnosis of autism in a child and also you fill in a vaccination record (you do not make a diagnosis, you refer a child up which may end up with a diagnosis of autism) but eventually that information can be put together by people like us to show how safe the MMR vaccine is. I do not think that kind of result has been communicated back to people, how essential they are to the system working. There is a whole communications strategy on this that I know the Department of Health is wanting to do, but as yet it has not been given priority. I would ask who is in the front line? There are a variety of people, primary care is in the front line, but there are also the front-line people who are responsible for health protection and in public health so they also need to be involved. What my colleague, Dr Mike Catchpole, who leads CDSC's surveillance has been doing is starting to convene stakeholder groups, which are both horizontal and vertical, so you get people from the front line who can contribute to those, and getting more of a feel from them as to what they see as their priorities than perhaps we have had in the past. We are also trying to get people to work together at a local level, and I think this will be crucial to the strategy, and it is getting back to the idea that the strategy is bigger than the Agency, because that is only one part of 14 developments of the strategy, and that you are going to need these front-line people to form together into local Health Protection Partnerships. We see those as a kind of a table with four legs, which have got the health protection specialists who are co-ordinating it, the Primary Care Trusts which have primary care and the directors of public health, the Acute Trusts with the microbiology and other pathology services and the local authorities. Now really those are all the people in the front line there, and we need to be getting those groups together to get a better voice as to what their needs are for surveillance. But they also have to appreciate that some of the needs for surveillance do not look very big when you are looking at them from a local level, but they become national issues. They are rare events but are very important, like we could never answer the MMR issue by looking at just one locality, that has to be approached as a much bigger picture.

Chairman: Somewhat related to this last question is the next one by Baroness Warwick.

Baroness Warwick of Undercliffe

285. In answer to one of our questions on the policy intervention that would have the greatest impact on preventing outbreaks of infectious disease, your evidence stresses the importance of a secure evidence base to inform future policy priorities. You are critical of the lack of analysis in Getting Ahead of the Curve, and in what you have said today I think you have emphasised the importance of strategy. Is there a strategic programme to put this evidence base in place and to identify and fill some of the gaps that you identify in your written evidence?

(Professor Duerden) I hope that there will be, in the Health Protection Agency and in its relationship with the Department of Health. The development of the evidence base and how we develop our priorities has developed as a process over the past decade. Within the PHLS we have had a system called the overview of communicable diseases, which has been an opinion survey of people. Initially it was the experts in infection, so the first time round it was mostly PHLS, and then we extended to other colleagues in infection, and the last time we were able to include an opinion survey of some general practitioners. That needs to be developed, it needs better analysis of the quality of the evidence base and the feed-in of other evidence from expert advisory committees, and beyond that the hard facts, the evidence that comes from surveillance data, from laboratory data, from research and development work, both within the Service and externally. It was a system we were developing and progressing and I hope that that will continue. We need to apply a much more stringent analysis to the quality of the evidence in order to inform strategy. We also need to be able to link better the Department of Health's priority-setting exercises and those of the new Agency; that does not mean to say we have not talked to each other in the past, we have, and there have been very good links in many areas. But I think that perhaps will be due for review in the new era, as to at what level the Department has its own input from its expert committees and where then it interacts with the expertise of the Health Protection Agency, and the two come together to generate the best package of evidence for developing a national strategy. So I think there is work to be done on analysing the evidence base and really being more secure about it.

286. Could I just follow that up by asking are you confident that there is going to be a drive to do that and that there will be someone responsible for ensuring that that drive takes place?

(Professor Duerden) I am confident that that will happen. It was included in Getting Ahead of the Curve as a requirement, and in discussions with Department of Health colleagues and with Sir William Stewart there is a clear recognition that there needs to be a review of this interface between what the Department does and what the Agency does, but coupled with that a very clear understanding that the Agency will need to have a way of getting the expert advice and feeding in the evidence from a wide range of inputs, not just from within the Agency. It needs to be the focal point because it will be the organisation that has to pull it together, but it will need advisory committees in various key areas that bring in people from NHS, from academia, from the broader healthcare services and public health activities to input to it, and then you analyse and come up with the priority recommendations.

(Professor Nicoll) Further answering your question, whoever does that (Leading on R & D in the agency) is going to have to have a very broad overview of different disciplines. When you look at the sorts of things that we have had to know about, and it is more development than research, in the past few years. Suddenly we needed to know something about how powders get distributed around buildings because of the anthrax problem, so you need building engineers, you need behavioural scientists to be informing your behavioural surveillance, and also simple things like how you ask people about what they have eaten over the `phone without giving them leading questions. You need to have veterinary people and some experts who are interested in mosquitos in England. And then particularly modellers and mathematicians we found useful recently, and we have now formed a unit, which does health economics and modelling and statistics together, so getting in health economists to be involved in that. So you need to have all those people, some of them in the organisation, many of them are outside but on tap, so whoever has the overview needs to be familiar with all of those fields. I think the other thing we have discovered is you need to be nimble on your feet, economically, with resource behind it. I would not say we were caught unawares, but when the West Nile virus concerns came up it took a while for us all to get going, to be starting to discover the research gaps that there are, to discover that the only person who knows something about mosquitos in this country is now aged X and that no proper surveys have been done outside of Sheppey for N years, and yet suddenly we were facing the issue could this virus be coming in through birds and mosquitos. There needs to be a mechanism that does not involve the traditional, Well, put in a submission to the MRC and it'll come back some time," that says, Right, this is something that needs to be done quickly," somebody has a budget, can pull it together and just pull in appropriate people. Obviously, there has to be scientific overview of that, to make sure it is of high standards, but it has got to be quick.

Lord Turnberg

287. You have talked about the development strategy needing this evidence base, which you have spoken about, the needs that a strategy would have to have in order to start itself going. Have you seen any evidence that a strategy is being developed or has been developed for the new Agency?

(Professor Duerden) The strategy is now being developed. I cannot say much about it, but Sir William Stewart has convened his interim Advisory Board and has convened several small expert groups in different areas to start to build up the basis for a corporate strategy for the new organisation.

288. But one has not been published yet?

(Professor Duerden) One has not been published, no.

(Professor Nicoll) I have seen the draft R&D workstream report, which is good for what it is, it is very laboratory-based at the moment, and I think now needs to bring in some more of the other areas. Another worry I have got about the Agency is that potentially it might rather drive the public health and laboratory sides apart if we are pushed into different silos inside the organisation. On a personal level I do not see that happening in the short term, but as time moves on and institutional arrangements start, I think at least we have to put down a marker of saying we want to make sure that the essential relationships that we have at the moment between people who are doing the eg HIV microbiology work and the public health work, those kinds of things, have to stay together in the future. I think that is a way we are very superior over many other countries.

(Professor Duerden) And that applies at both the strategic level and very much at the operational level as well, of integrating across the various component parts of the new Agency.

289. Is that at risk, that bringing them together?

(Professor Duerden) The structure that has been published for the Agency has component parts, chemicals and radiological in due course are distinct divisions. The communicable diseases components that are currently within the PHLS and outside with the CCDCs in Primary Care Trusts are to go into several different divisions within the new Agency, CDSC division, a specialist laboratory division and a field services division.

290. So it is at risk?

(Professor Duerden) And the risk is not co-ordinating between those. What we have certainly recommended is that there needs to be a way of co-ordinating these activities that ensures that you do not have the silo effect within those individual divisions.

Lord Lewis of Newnham

291. Are these individual divisions funded separately, is there an operational procedure whereby to stay on your own becomes an advantage?

(Professor Duerden) That is difficult to say at the moment because the funding arrangements for the Health Protection Agency are being developed. They will be derived from the funding streams of the organisations that go into it, and the Health Protection Agency itself will then have its budget, which is this amalgam of existing budgets, and then when there is a finance system in place and a Director of Finance there will have to be an arrangement for the devolvement of components of that budget into the various divisions. But that is no different from what we have at the moment within the PHLS, that is how we operate. But we have not yet got a Director of Finance to take charge of that.

Baroness Finlay of Llandaff

292. Is there going to be any provision for budget to be transferred from one year to the other, so that you are able to hold a contingency fund for the situation that was already alluded to, where you need suddenly to contract in people, or is it going to remain with the current budgetary restraints on?

(Professor Duerden) I think that really has to be something we would have to pass to the Department of Health to answer. We have had some flexibility over recent years that has enabled us to carry over some specific funds for defined purposes, with the agreement of the Department and the Treasury, and certainly in the set-up of the Health Protection Agency in this first year arrangements are being made for certain funds from the current organisations to be carried forward, because we know there will be set-up funds needed for the new Agency. So there is a little flexibility there, it is not large, but there is some flexibility to allow that, and it is being used certainly this year to help with the set-up arrangements.

(Professor Nicoll) Can I just follow on, on that. I had a lot of concerns initially with the structure, I still have some concerns, but which was seeming to imply, Well, there is CDSC and you do surveillance, and then there is a field services division, which did the business. And I think what has been recognised now is that, if you are going to be able to bring co-ordination and national expert advice to bear on what are sometimes very local problems, there is going to need to be strong dotted lines. So that CDSC, because surveillance is only one of the six or seven things that we do, would still continue to be providing the co-ordination and marshalling the expert advice when it was needed. It would not all be going up to the head of regional services and down again, remembering that CDSC has a regional structure already. I am sure I am going to have a number of my staff moving into field services, but my understanding now is that they are going to be functionally retaining the close links with us in Colindale, not least because many of those people are national experts. It is not as though we have people sitting in Colindale who are just the national TB (tuberculosis) person and if they are not there then there is no national TB expert, we go out to our experienced REs and CCDCs, and that is what I think is the power of this network organisation in the future. But I did have some worries initially, I am now just nervous, I am not so worried.

(Professor Duerden) Very briefly, to add to that, on the laboratory side as well, there are some key national experts who will be in laboratories that are currently PHLS and will transfer to the NHS under these arrangements, and again we have to retain their input to the national Service.

Chairman: If we can move on to the next question. I think in large part it has been answered, but I am wondering if Baroness Emerton has any supplementary to put.

Baroness Emerton

293. Thank you, My Lord Chairman. The question is, are you confident that NHS laboratories will undertake the work of the type required for public health, once the PHLS laboratories are transferred to the NHS, and, as the Chairman said, we have touched on some of those things. But you also said in your evidence that there were some situations which could compromise this situation of co-ordination, in terms of handing back, we have mentioned the clinical microbiology back to the Trust, and also the funding going to the PCTs. And also, earlier on, you mentioned that you were listing the tasks that were done already by the laboratories in preparation. But are you confident that the NHS laboratories will undertake the work?

(Professor Duerden) I hope that they will and that we will be able to put in place the agreements that will ensure that they do that. There is still a lot of work to be done before I could say, Yes, I am confident it will all happen just as we would wish." Our concerns are that currently we have the direct responsibility, direct line of funding and managerial accountability; that will change, and we have to ensure that within the service level agreements that there will be with each of the laboratories that have transferred, they carry on doing the public health work, the health protection work, that is needed. And we need to be sure that that is reflected in the funding stream that they get from the Health Protection Agency, because the money that currently they get from the PHLS is going to be split into two. Some will continue to go through the Health Protection Agency for the public health function, but what has been regarded as a residual subsidy for the clinical work, which has always ensured that the PHLS had a good foothold and they could get the public health work done, that will go out through the Primary Care Trusts. We know there are concerns from colleagues in the laboratories around the country that they will not have the funds available to them that they have now, through this slightly more tortuous line of funding.

294. Is that not down to the fact that there is perhaps a lack of understanding of what is happening by NHS Trusts and the PCTs?

(Professor Duerden) In part, yes, because I do not think it has been widely explained. The document that came out last week from the Department should help with that.

295. And has that gone to NHS Trusts and to PCTs?

(Professor Duerden) It has gone to the NHS Trusts that are the receiving Trusts. I am not sure about the PCTs, but it will go to the PCTs. There are concerns that have been raised with us, not just to the transfer of this funding but some inevitable add-on costs that there will be in breaking up a managed network, in that currently PHLS provides corporate functions for its laboratories, such as the human resources function, the finance function, and so on. How is that going to be handled, will the Trusts be expected to pick it up or will there be a devolution of some monies for that; we do not know, as yet. Capital for major equipment, not for the building itself but for the expensive equipment, and so on, some of that comes through the PHLS now. Also there are other aspects of funding that could be retained by the HPA and felt as a loss by the individual laboratories.

296. So really what you are saying is that there is a tremendous amount of work to do in a very short space of time?

(Professor Duerden) Yes.

Baroness Walmsley

297. Do you think that the funding for the PCTs for their public health work only being guaranteed until March 2005 will affect their ability to plan?

(Professor Duerden) It is certainly affecting the laboratories that are going to transfer, in their planning and in their negotiations; it is affecting the Trusts to whom we are transferring the laboratories, they have expressed concerns, to ensure that they will continue to get these funds. They are earmarked for the first 12 months, the money will still be there beyond that but it will be part of the general allocation to the PCTs, so the potential there is for it to be in competition with other priorities. I think most of us who are involved in infection, microbiology, communicable diseases, do not believe that there is excess capacity in the microbiology service. Whether it is NHS or PHLS, the microbiology services in the country are doing a very good job and they are pretty stretched for cash, and anything that is perceived to threaten the totality of the funding for microbiology work is a concern.

Lord Oxburgh

298. You said that after 2005 it will be a matter of competition with other priorities within the Trust, if I understood you correctly, for that stream of the funding?

(Professor Duerden) After 2004. The first year it is earmarked and specifically directed. After that the money will still be there in the PCTs but in their general allocation.

299. Then from the point of view of the PCTs there is presumably a possible conflict between obligations to meet their local priorities and obligations to meet what is in a broader sense a national priority related to this public health service?

(Professor Duerden) That is certainly a possibility that we see. The principle should be that the money that is going through the PCTs is what has been identified as the amount of money that is in the PHLS that helps support the clinical services, which are the responsibility of the PCTs, and the money that is to be left with the Health Protection Agency is supposed to represent the amount of money that supports the public health or the health protection functions. It is very easy to write that down on paper, it is almost impossible actually to segregate these out in practice, because the work that is done in a laboratory all starts off with the same specimen, which is used for patient diagnosis, and the information that is gleaned and then extra work is done which supports the public health function. So when it comes down to it, it is one package of work that supports both.

(Professor Nicoll) That is why I feel it is so important that in the next year we will be forming these local health protection partnerships, because there is a real danger, and I have seen it expressed by some general public health colleagues who are working in PCTs, Well, okay, let the Agency just get on with it." And unless they can feel confident that they are part of a local partnership which is delivering a number of things, protecting their population but also populations elsewhere, then they will be saying, Why should we be spending money on that?" But money is not everything, and I think another important area is about getting it built into professional rules and regulations, and into job descriptions, that so many people deliver something on public health. And we have started, through the Faculty of Public Health Medicine, some discussions with the GMC to try to get them to pull together. They have got various little bits of guidance, but it could all very usefully be pulled together into something that is on the public health responsibilities of doctors, and that is just doctors, you could also say nurses, and suchlike. Because at the moment, when you read GMC publications they are saying, Well, you should give information about patients if you have to," but also but watch out for the confidentiality bits, and if they don't want it to go then don't give it." There is nothing positive about, It is actually a way of protecting your patients and the population," and that needs to be turned round. And I am hoping we will be able to get the GMC to take that perspective, because I think that would be very helpful and it would allow professionals in these NHS laboratories to say to their managers, Well, look, I need to do that sort of thing as a doctor." That is not a blank cheque, but it is saying, It's important that I report, `or' it's important that I follow up these patients."

(Professor Duerden) I have one point to add which perhaps we have not been absolutely clear on. I think that most laboratories, current NHS, current PHLS that will transfer, will continue to do their routine reporting for public health purposes, there is a long tradition of that now and I do not see that that is at risk. It is the extra bits, when something happens it is the extra studies, the special things, that are not just part of the routine, Yes, we've got a result," it is in the category that should be reported, we do it. It is when we go back to them and say, We need this extra work done." Perhaps flu is coming up and we want to check some extra specimens and do a bit more work on them, or the food poisoning, it is those extra things that we have to ensure are picked up in the new arrangements.


 
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