Select Committee on Science and Technology Minutes of Evidence


Examination of Witnesses(Questions 300-319)

TUESDAY 17 DECEMBER 2002

Professor Brian Duerden and Professor Angus Nicoll

Chairman

300. Can we move on to the question of training, and you dealt with it previously, recruitment and retention of staff, but can you describe the training function of the PHLS and how it will be replaced under the HPA, and would this be an opportunity to develop a better understanding of public health, clinical infection, microbiology and epidemiology?

(Professor Duerden) I think that this is a tremendous opportunity to create really novel and important training programmes that integrate the whole health protection arena, not just the communicable diseases, which are the ones we are concerned with, but to bring in the radiological and the chemical, so it is integration across those disciplines. Also, in particular, integration between the different parts of the medical profession within that, whether it is public health people or microbiologists and virologists, and especially between the medical and the non-medical professionals within the organisation. We should be blurring those boundaries as much as possible because the training needs cross over from medics to scientists, we will be having more nurses involved, other professional groups, and within the scientists to get away from the distinction between clinical scientists and biomedical scientists; we are all professionals who need to contribute, and the training programmes can be designed in modular forms to accommodate that. So I believe there is a tremendous opportunity for these cross-boundary workings. They need to be funded. At the moment the PHLS has a very strong training programme for a range of its professional groups, we have very strong biomedical scientist training programmes, we have trainees for clinical scientists as well, so we have those two groups, and we have medical trainees. A relatively small number of public health medicine trainees are in the PHLS, it is about five posts dedicated at the moment in CDSC; we have also 31 medical microbiology trainees around the country. The PHLS, ever since its inception and since the start of this type of medical training, has been a major trainer of medical microbiologists. It is very likely that all those medical microbiology posts will actually transfer into the NHS, to be part of the more general pot, or group, of medical microbiology trainees, and they will go with their funding, with their salary funding, which is currently within the PHLS.

301. Is there a place for what you are saying in the medical curriculum, starting much earlier than the postgraduate training you are talking about?

(Professor Duerden) There is certainly a place in the medical curriculum. It is very difficult to get things into the medical curriculum at the moment, it is very overcrowded, but there are opportunities there and we must broaden the microbiology infection components there into the broader area of health protection. But at the postgraduate level, where you are really looking to train your experts, the plans are that all microbiology trainees should have more public health, health protection in their training programmes, which the HPA will be important in delivering. And this cross-over between the microbiology, the epidemiology and the scientists is vital. We do need to ensure that the HPA has enough of a training budget to be able to deliver these programmes.

Lord Lewis of Newnham

302. I am slightly amiss here. Are you implying that the undergraduate course will not contain any of this type of information? It does seem to me that these are going to be the people to whom you are going to have to appeal, the type of continuity?

(Professor Duerden) At the undergraduate level, it varies from medical school to medical school just how the courses are constructed, many of them now are systems-based and they are problem-orientated, teaching-based programmes. Now within that there are opportunities. Health protection aspects, because they cross the disciplines of public health and microbiology and epidemiology, and so on, are ideally suited for the special study module approach in the undergraduate medical curricula now, they provide excellent examples, but it depends upon having people in the medical schools who can provide those. Clearly they are only for some students, and the students do a whole range of different ones, but certainly it should be there. And all I can say is that in my own teaching responsibilities I find great material here for the special study modules in the Cardiff course.

(Professor Nicoll) I can go on about training for a long time. I will try to restrain myself, because really it is the Faculty of Public Health Medicine's responsibility and I was meeting with Sia®n Griffiths yesterday, and I am quite enthused by some of the approaches that they are co-ordinating, and the lead Dean, Graham Winyard, in particular, is doing some interesting work. I am very optimistic at the moment, because speaking last night with the person who deals with all the public health medical trainees in London, she was reviewing them, they go through a thing called RITA panels, and she asked, Well, what are you doing to do?" and she said nine out of ten wanted to do health protection. It is very attractive for them, these are young people and we are going to need them, for two reasons, one is for anything new you need some bright young people into it, and secondly there is a cohort effect because the Consultants in Communicable Disease Control, many of whom were appointed after Sir Donald Acheson's report in 1988, many of those are now nearing retirement. There are other issues. There needs to be funding for those posts, there needs to be more imagination; we find that in some parts of the country the Deans are very imaginative, and they will say, Okay, I want my people to come and spend three months in Colindale or in one of the regional centres," and there is nothing that is better for the people in the short term, because they just see such a lot in that short period of time, they see everything that is going on locally and nationally that comes to us. And it is also very good for future arrangements, and relationships, because it is so much easier when the chips down if you are speaking to somebody that you have worked with, or they are speaking with somebody in a place they have been to and they do not regard them as some far off place but it is a place that is full of human beings like yourself. I worry in the future whether the HPA will have the money to support those trainees. It is all very well saying, Go spend six months in Colindale," but you have actually got to have the people there who can spend a bit of time devoted to training, and we have shaved that money away, to meet service needs in the past few years. But that is the medics. Then I worry about the scientists, because we tend to use them rather poorly, to be honest, I think, this is in CDSC, obviously I am not speaking in the labs, which I do not know so well. Though the scientists come in and do an excellent piece of work, but they have no career structure, and they will work on one topic for three years, and then when an opportunity arises in another part of the organisation they will go off and do another job, and there is no sort of tailoring of it to a career which says I am a public health scientist." They often feel that they ought to have a higher degree. We get a fair number through MScs but then they have got this fascination that they ought to get a doctorate, and the universities in this country are not imaginative in these. Professor Weinberg and I have talked about this in the past, he is on my side with this one. But when you look at the universities in The Netherlands and the Nordic countries, they will do higher degrees, PhDs, they may be not so good as the classical PhD but they are much more related to the needs of the scientists in service organisations like ours. They can be doing a particular area of work, they can work for three or four years, produce three or four good reports, peer review papers, put them together, give them a top and a tail, and you produce something that, if you pass an oral examination, then will give you a doctorate. And I so wish that we had some of our better universities in this country, well let us say the established universities, that would actually do that, because at the moment I am saying to people, Well, I really want to register you for Nijmegen, or somewhere in Sweden, rather than you registering with the University of London," and that is a shame.

(Professor Duerden) Please do not suggest that those degrees are of any less value. I have the highest regard for those Scandinavian degrees, there are some very high quality ones.

(Professor Nicoll) And they are read by more than five or six people, which is the problem with the classical degrees usually.

Chairman: Let us move on to the question of Research and Development in the PHLS on public health issues.

Baroness Walmsley

303. My question is about the significant amount of research and development relevant to public health and infection which is being done by the PHLS, and I am aware that you have partly answered the question, I think, in answer to Baroness Warwick's question earlier on, but do you wish to say anything more about how you think this R&D will be carried forward once the HPA is established? And I noticed that Professor Duerden used the word hope" in his answer to Baroness Warwick earlier on, and in fact has used the word hope" a number of times this morning. Would you like to flesh that out at all?

(Professor Duerden) Yes. I will probably use the word `hope' again, because the first thing to say is it is essential to maintain a strong R&D activity within the new Health Protection Agency, and without the research and development, and particularly the big D element of this, the development aspects, an organisation such as this will become fossilised so quickly, it has to have a development programme, it has to do research, it is not an optional extra. PHLS has a strong R&D record, and has had for a long time. About half of that R&D is funded from external sources, it is funded by money won in open competition, grants from outside bodies, and I am sure that that will continue in a strong organisation, as I am sure the HPA will be, with the forward-looking and the outward-looking attitudes, it should be as successful or more successful in gaining external funding. And that tends to fund, in many cases, what we call the big R element, the research, as against the development element you can fund from outside sources. What I am more concerned about is the development aspects, which is funded by internal resources at the moment. You need internal strategic investment in development in order to keep all the activities, whether it is laboratory-based, whether it is surveillance-based, they are all developing, they need people to do the development, they need equipment, they need consumable materials, so there is an element there. Our concern is that most of this big D, development, work is funded from internal sources, and a significant part of that in the declared spend on this, just by the way you have to account for this, relates to people who are on the staff, permanent members of staff, senior members of staff, who are crucial to delivering the reference or the surveillance function. Their main job is to be a major component in a reference laboratory or in one of the CDSC divisions. As part of that job, quite rightly, they may be doing 5 per cent, 10 per cent, 20 per cent, whatever the figure is, of development work, and the suggestion for the Health Protection Agency, the indication is that the R&D monies that are identified from within the existing bodies will be transferred to the NHS R&D Directorate to form a health protection development fund, or R&D fund, to be used in a strategic way for development. Now that is fine, except when it affects the salary components of individuals who are key individuals there, regardless of their R&D work, they are essential to the Service, and you cannot then strip out the proportion of their salaries to put into a separate pot for open bids, because it is not transferrable money, it is linked with that individual, because you need them to do their 80 per cent job, and without the 20 per cent you cannot pay them. I hope that is not too complex.

Lord Lewis of Newnham

304. How far are you actually dependent upon external monies in order to employ some of these people, and do you have people who are, in point of fact, on temporary contracts, in order to do some of this research?

(Professor Duerden) We do not depend specifically upon external money for the employment of our key permanent staff. We do have staff on short-term contracts on research monies, and that is like any academic establishment, if you get a grant which is for two, three or five years you employ people on that grant on time-limited contracts to do that work. What I have been talking about previously is the internally-funded R&D work which is carried out to some extent by people who are on permanent, established contracts.

305. What percentage of your staffing is in this temporary and permanent category now?

(Professor Duerden) Of our R&D monies, about half of the R&D is funded externally. I cannot tell you the number of staff who are on temporary contracts, but they are within that package of work. If I can give you an idea, the total PHLS R&D declared spend is around £8 million, perhaps a little over, half of that is external funding, and as a rough estimate usually about 60 per cent of the funding that comes in that way is for staff, but that is against a background of an organisation with an overall turnover of about £140 million.

Baroness Walmsley

306. May I just come back to this 80/20 situation that you outlined just now. Do you fear that that 20 per cent of work simply will not be able to be done by those people, or are you suggesting that they would have to apply to a different pot of money in order to do it, which sounds to me like a bureaucratic nightmare and a bit of a nonsense?

(Professor Duerden) My concerns are two, one that you have just described, that they have to apply to another pot for that, but of course it is part of their basic salary, the risk is that you strip out from the salary costs of the reference laboratory or the surveillance division elements that are crucial to delivering the normal service, but it happens to be the development part of that. So to my mind any organisation like this needs within its own financial responsibility an element that supports the development work done by its established staff members.

307. Do we simply not know what is going to happen yet, in terms of that financial arrangement?

(Professor Duerden) We have made that case and it is still being deliberated upon by the R&D workstream of the Health Protection Agency.

(Professor Nicoll) I also want to respond to Lord Lewis' question. We have one specific area where we have hit problems in the past three or four years because of a setting up of another agency, in that the Food Standards Agency was set up a few years back, and the Department of Health said, That's quite right we hand over the food area to you." And one of our big areas between both the microbiology and the public health side is doing work for the FSA, in terms of monitoring levels of infections and responding to outbreaks. And because of the existence of the FSA, which is very welcome, the work in that area has gone up, but we cannot actually find where to get money to do that, because the Department of Health says, Well, it's not us, because food is with FSA," and the FSA says, Oh, it's not us, because your sponsor department is the Department of Health." And the only way we have been able to survive is by us encouraging our very able people to go out and compete for research funding, some of it from the FSA, and they are good people, they have done well in getting this, but then to use some of those new people coming in to perform some of the core functions, and that feels wrong, to my mind. It is not saying those people should not be doing research, but it is just a bit dangerous eventually if you are relying on people with short-term funding to be doing some of your core work. But it is the only way that I can actually retain the senior staff because they were getting pretty upset with the workload going on and us not being able to find additional funds because it just was not a development area for the Department, because it is the FSA's.

Lord Lewis of Newnham

308. Does the FSA have its own research facility grouping?

(Professor Nicoll) It does, but you all apply for it competitively.

309. I am sorry, they have a fund, but do they have a laboratory which they could use?

(Professor Nicoll) No.

310. So, in point of fact, they are totally dependent upon your particular laboratory facilities?

(Professor Nicoll) Us and other people who can provide that kind of thing, there are other laboratories who can do testing, but I would defend our laboratories as being the national experts.

(Professor Duerden) And it is not just the laboratory facilities, it is the surveys, it is all the back-up, it is not just the testing capacity but the epidemiological and analytical capacity as well.

(Professor Nicoll) So when we have got something like the egg problem at the moment, that we can actually say, Right, drop everything for a short time to sort out this egg thing, and then get back to the research work." I should not say that.

311. No, you should say that.

(Professor Nicoll) I can just see them saying, Well, what are you doing with this research money?" and you are doing Service work on it. But it is a way of surviving and keeping our senior staff not feeling that they have been let down by senior managers, like me, who have been unsuccessful in getting additional resources in for them doing Service work.

312. But it does strike me that this is a fundamental problem that you have got, and that is the differentiation between research and development, and that in point of fact it is rather equivalent in the old university system to dual funding, where the non-research element was maintained very much by the dual-funding system, and it is sort of generic, I think, within this particular type of approach to the system as a whole?

(Professor Duerden) It is a generic need that you have to have a sound base of the infrastructure and the ongoing development that keeps your services up to a standard where they can win the external grants to do the big R.

313. Forgive me, but you give me the impression that you very much have to be responsive in certain instances to certain types of problem that occur, and you cannot predict that, it occurs and it has to be dealt with, and then, having dealt with that, you can then change your staffing direction in another way, but you must have a responsive mode?

(Professor Duerden) Oh, yes.

(Professor Nicoll) I think that the food one is a particular anomaly that I am acutely aware of at the moment. There are other areas where it has been identified as a priority, like CJD, like TB, where under Shifting The Balance Of Power the Department has been pushing out functions, but with it some resource. The work is odd, in that I have found that the burden on both our side and the microbiology side has been going up but we cannot find anybody who can actually say, If you're going to do more work for us, here is the money for it," unless you bid for research funds and hope that you are successful.

Lord Rea

314. I wonder if I can follow up that point a little bit and take, for example, the Food Standards Agency. They commission research from various laboratories and other institutions around the country; does that sort of research come the way of the PHLS often, and other requirements, from other bodies as well, perhaps?

(Professor Duerden) We have been successful in several instances in winning grants from the Food Standards Agency to do their work. We are one of their major providers.

315. After the change to the HPA, will that be affected in any way?

(Professor Duerden) It should not be, because the HPA will continue to have both the responsibilities and the facilities in that area that the PHLS currently has. In the food area, it has been agreed that the Health Protection Agency will continue to be responsible for the network of food, water and environmental laboratories; even where laboratories transfer to their NHS Trusts the HPA will have a direct line of responsibility for ensuring the FWE work is done and funded.

Chairman: Can we move on to a question on public confidence.

Lord Lewis of Newnham

316. I think really this touches in part on what we have been talking about a little earlier, but of course you are very much in the public eye, if anything does happen immediately you are expected to be able to respond and give critical and accurate surveys of it. How far is there a danger here of loss of confidence in the public? We have been given two examples, of whooping cough and MMR vaccination as recent examples, which I think have really accentuated your problems. How do you feel that one can deal with this particular situation?

(Professor Duerden) Clearly, there is a risk of loss of confidence in these sorts of areas, and it is an important role for PHLS presently, and will be for the HPA, to provide an authoritative, evidence-based approach to this, but actually it also sets it in the lay context that it provides information in a way that is accessible to the general public, and through the media to the general public, based on hard evidence of work that we have done. You cannot go into that if you are not secure in your background knowledge and information, but I have always regarded it as an essential part of the PHLS service to take the material that we have, the information, to put it into the public domain in a way that the public can use and can understand, and can be interpreted by the press and media, to get the message across.

(Professor Nicoll) I think the contrast here is quite interesting, because the whooping cough was a disaster, even though there was not an orchestrated campaign against the vaccine in the way there has been with the MMR, and I think, in some ways, to my mind, with the MMR vaccine uptake it has been remarkable how well it has held up; it has not been good enough but, when you look at all of the forces that are ranged against it, it has done well. Why is that? One reason, there is a good infrastructure, there is pretty good data that helps people to see how they are doing at the local level. I think we could have been doing a better job sometimes with treating the public as adults and really explaining the details to them. But the key thing was that, back in the mid and early 1990s, when the first indications came up that this plausible link was forming in the minds of parents who have got children with disabilities, and I remembered Dr Gillian Baird, from Guys, drawing this to our attention, that people started taking it seriously. Probably we should have taken it seriously a bit earlier, but that is easy to say with hindsight. But the result was that a fair amount of research was done pretty quickly so that you could look into and investigate scientifically, by an independent body, which is what the PHLS is, with other researchers, whether there was credibility to what was a plausible link, something that you could imagine that there could be an association between MMR and autism. So that when things really got motoring, much of the research had already been done. And that is a huge contrast to the whooping cough experience which I remember, down in St George's, back in the early seventies there, when those epidemics were taking place, where it was almost ten years from the initial idea in 1974, that there might be a link, before the final evidence, as it came out, saying, Well, it doesn't look as though there is a link." So the trick is to have in place long antennae to pick up these potential associations and to investigate them as quickly as you can and as scientifically as you can, so that when there is the media interest in it one is able to say to the front-line practitioners, and the real battle is in the front line of the GPs, that they can say, Well, you can have confidence in this vaccine because this has been done and here are the papers." Where I think that we are not so good still is in providing the training for the front-line staff. I recall very well, when I was in Nottingham dealing with the whooping cough problem one of the things that worked there was to come up with simple training modules for the GPs and the health visitors, so that they had confidence in talking with the mothers. Because you are not going to win this battle with the Daily Express or the Daily Mail, the battle can only be won, I think, in the consulting room, because at the end of the day the public do put a lot of trust in their own doctors, to whom they still have to take their children when they are sick.

317. But the media is a problem, quite clearly so, and particularly a thing like MMR, which has really hit the headlines as a whole there. But do you not have the secondary point, I agree with you totally, you have got to persuade, first of all, your clinicians that in fact this is a safe operation, but then of course they have got to take the next step on, and it really does become somewhat difficult when you have got these two groups vying one against the other for the attention of the public?

(Professor Nicoll) I do not know exactly what you do with the media when clearly they are selling newspapers. I just want also to state that we have to recognise that there are real side effects of vaccines. And I am quite proud of the people in the Service, they have come up with two associations of MMR, one with a now disused vaccine and one a real one, where they looked at it, they found it, they publicised it. Action was taken on the first one. For the second one, JCVI, who makes the final recommendation, said, Well, this isn't one that's big enough to warrant changing the vaccine." And it does need some ongoing investment to make sure you have got those systems in place. And it comes back to the confidentiality issues, because the sort of research that has been done, we are taking all the children on a population basis with autism and comparing them with the real vaccination records, not what the parents have come to believe happened with the vaccination but what really happened, and matching those two together, and you cannot do that except by names.

Chairman

318. A rhetorical question for you, that you are confident that HPA can maintain an independent stance against political charges brought against it?

(Professor Duerden) It will be essential that it does.

319. The question is, do you think it can?

(Professor Duerden) My experience, from the PHLS end, has to say yes.


 
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