Select Committee on Science and Technology Minutes of Evidence


  Examination of Witnesses (Questions 340-359)

TUESDAY 28 JANUARY 2003

DR GERRY BRYANT, SIR KENNETH CALMAN AND MR PALLAB GHOSH

Baroness Finlay of Llandaff  

340. May I pick up on the sexually transmitted diseases, because it seems to me that there is a catastrophic problem when you look at chlamydia. There is—despite a new editor—`Page 3 News' and yet nobody is saying, But this woman has chlamydia." If, week after week, day after day, there were these nudes with, above them, Chlamydia positive", Gonococcal positive" perhaps you might begin to get the message across. But the pressure out there is to have unprotected sex and have Page 3.

(Dr Bryant) The other thing is the product of the negative test, as well. Speaking to our local genito-urinary colleagues, there are many people from sub-Saharan Africa who enter this country, have an HIV test and it is negative, and, subsequently, within the space of one or two years, present with HIV positive as a consequence of infection in this country. We are a low-incidence country and yet we are transmitting HIV within a country of preventable disease.

Lord Lewis of Newnham

341. In the question communicating risk effectively" comes in. I know this is a point that Sir Kenneth will be wanting to discuss at some stage but it is this conception of how you can express some of these problems to the public at large. I am reminded that Sir Richard Southwood, when looking at the BSE problem, made the remark that the probability of getting BSE was about as great as being hit by lightning. Statistically that is not a bad figure but it is just one that is not being appreciated because it was taken to mean that there was no probability of this particular thing happening. I do worry at times at the way we express some of these things and the assumptions that we build into that. Is there any sort of mechanism whereby, when you are looking at the publication of these things, you do ask the question, or, should I say scientific question, of a non-scientist? Because scientists have a way of thinking in theirown dimension, in their own particular way, and probability in particular, which is very much associated with risk, is one of the features, of course, that is very much a part of their way of thinking but is not necessarily the way that the average public thinks about these things.

(Sir Kenneth Calman) The public—and I include myself in that—overestimate low risk and underestimate major risk. The fact that 25 per cent of the population in this country continue to smoke cigarettes when all the evidence and all the publicity is so clear, suggests that it is important enough for them to say, I'm prepared to take the risk that it won't happen to me." Some of the publications I sent down try to look at that language of risk and how you change that language. There is not an easy way to do it. People still—although it is perhaps changing—put money on the Lottery. The chances of winning that are extraordinarily small but they are prepared to do it because it might just happen. Put it the other way round: in terms of a nuclear power station blowing up, they are not prepared to accept that risk because of the consequences. So it is a very complicated issue. You can also change that by what in scientific terms I think is called framing. You can frame the comment or the question. It is quite an interesting exercise to get medical students to do this, to present something to patients in three different ways: The chances of getting an infection after an appendicectomy for you, my dear, are not very high; the chances are actually one in 20; you could be one of those who get that infection. You can change the presentation very easily to change the way in which that is perceived. Somehow we have to get better at doing that too.

Lord Rea

342. To go back to the question Lord Turnberg spoke about, the MMR/autism furore, in fact how could the Department of Health have handled that better? The take-up is still diminished. Where did things go wrong there?

(Mr Ghosh) I think that in the public's mind were still memories of BSE, where there was a minority view that was being snowballed and steamrollered by big Government, and here you had Andrew Wakefield, this scientist who was concerned about children, at odds with the medical establishment. Answering the more general question about how to present risks, certainly in the broadcast media it is about presentation and it is about trust. I think BSE had a hugely damaging effect in losing the public's trust from the scientific community and also from Government. I think that is something that is slowly being built up. I think there are a lot of lessons to be learned from the way in which the Food Standards Agency has operated, where it has been seen to be neutral or on the side of the consumer rather than representing MAFF (as it was then) or the DEFRA interests. Neutrality is important but I also think presentational skills are important. The way you come across is as important as the wording of your message in the broadcast media, which I do thinkis more important in particularly breaking news stories. I would suggest that you take a look at some of the star performers. John Pattison during the BSE crisis; Sir William Stewart over the case of mobile phones; and, increasingly, Sir David King in instances. I think in the public's mind these people come across as: We are not too sure about that, but they are good blokes, they have not served us badly in the past, and we are prepared to take on board what they are prepared to say." I do think there is a case for better training in presentation. There are a lot of training courses around but quite often it is half a day on How to smile while talking" and Take out the jargon," and really it is a far more complex and difficult process than that, not just for the performance but for the people within organisations who are trying to deal with crises. There might be a case for identifying star performers within organisations and giving them more extensive training. I think those are the points I would make.

Lord Turnberg

343. The question of communicating uncertainty is one in which I am interested. In most instances it is very difficult to get black and white views. How do you get that across? It is not very appealing to the press, it seems to me, to have uncertainty in there.

(Mr Ghosh) Sir William Stewart did it quite well in his mobile phone report. I still remember that in the first paragraph the first line was The balance of evidence suggests that there is no risk to human health from mobile phone radiation." He said, However there are some anomalous results and further research is required, so we should adopt a precautionary approach and the public are advised to make sure their children do not excessively use mobile phones." That was something that conveyed uncertainty. It also gave the public a choice, which I think was one of the issues with MMR, and it let the public make their own minds up. People smoke because they enjoy it and it is their choice. I think it is about being straight and coming across as being straight with people and letting people make their own minds up rather than building up some view that the Government is hiding something. Gradually that is changing.

344. Jeremy Paxman always says things like, Come off the fence." Is it so or is it not so?"—that is to politicians, of course, so they can stomach that—but by and large scientists are not very good at being pushed in that sort of way. The press do have something here, as well as those who are presenting to the press, do they not?

(Mr Ghosh) Jeremy's job, which he does extremely well, is to put people in positions of influence under pressure. So it is not the kind of work-a-day scientist, it is people who deserve to be put under that kind of pressure. But there is an answer to that question: Jeremy, I honestly wish I could answer that question." It is also about showing that you are a human being, rather than being evasive.

Lord Lewis or Newnham

345. Whenever one considers the whole concept of risk from variations of this particular type, there really are two categories: those over which you have control and choice yourself, and those which are imposed upon you and over which you have no choice. I would argue that MMR would probably fall in the latter class, whereas many other things, such as mobile phones, fall into the former class. I think, realistically speaking, those are very important aspects in any presentation of risk as a whole. You have to recognise which of these two categories you are talking about and how you are then going to present them.

(Mr Ghosh) I think what you are talking about is empowerment. At the end of the day, all you can do is provide information with whatever form of media you are dealing with as honestly and as clearly as you can because the alternative is worse.

(Sir Kenneth Calman) One of the things which it is interesting to compare is the communication of risk between the patient and the doctor and the communication of risk between the public and some other figure. I think we have come a long way in the first category in terms of openness, and it has not in any sense destroyed the medial profession—in fact, I think it has strengthened it greatly. But, under these circumstances, you build up a relationship in which you can say, I'm not sure," and it is easy to say that, And if you are not happy with that go and see Dr X down the corridor." In the public sense, it is more difficult to do that. I think, in spite of Pallab's nice reflections on some of his colleagues, they do want you to give an answer. Particularly if you are a particular type of person, they want an answer. You know,"You must know because you are in that position. What is the answer?" and uncertainty is more difficult. I think part of that is the public beginning to understand the concepts of uncertainty. If I look back over the last 10 years, there has been a very significant shift that way—which, of course, I think is a good thing—in that we do not have all the answers and we might not have all the answers and you have to be prepared to wait a little bit until we get the answers. That I think is easier to say now than it was 10 years ago. I think our journalist colleagues have helped greatly with that.

Baroness Finlay of Llandaff

346. May I pick up on Pallab Ghosh's comment that Jeremy Paxman is doing a good job, because the problem is that the people who may represent, as Sir Kenneth has said, a balanced view are not going to go on that programme. Nobody in their right mind would go on that programme. It is for those who want to be lamb slaughtered. If you have suicidal inclinations, then it is fine. But you are not goingto get the balanced view. So it becomes self-perpetuating, because the sort of person who tries honestly to present the uncertainty is just going to be made to look a fool, because they are outwitted by Jeremy Paxman who is doing that all the time. That is his job. Their job is scientifically to assess whatever processes they are going to be presenting to the media. So I am not sure that you can say that it is good. Perhaps it is very irresponsible not to have a haven of reasonableness within a programme like that.

(Mr Ghosh) I think, if you see the way in which Newsnight is currently covering the Iraq crisis, Jeremy is quite capable of actually bringing out some of the major points. It is only a weapon that he uses occasionally where he feels it is appropriate. I would encourage as many people as possible to go on Newsnight because it is a very influential and important programme.

Lord Lewis of Newnham

347. There is an important point, which simply is that science can only be disprove something, it cannot prove anything.

(Dr Bryant) Particularly a negative.

348. I think that is an important concept which is not appreciated by many people, including many scientists.

(Sir Kenneth Calman) Yes. I have just a brief comment. I have always said that when I grow up I would quite like to be a TV producer. I would have a weekly programme, I would pick a disease, any disease; I would find patients who are dissatisfied; I would find a professor somewhere who had a cure; I would find a dark room and put a senior doctor in it who was confused. You could do that on a weekly basis. We have talked really about the press and the serious media but there is a lot of that kind of journalism around too, which I really do not think helps those who happen to have particular illnesses.


Chairman: We must move on. Lady Emerton.

Baroness Emerton

349. We talked about the communication skills of health professionals earlier this morning. Could we just move on to think about the health professionals' knowledge base. Do you think that health professionals are sufficiently aware of the issues around the risk of contracting infectious disease and the risk of being vaccinated, in order to provide effective advice to the public?

(Dr Bryant) It depends on what we mean by sufficiently.

350. Do you feel health professionals have adequate training?

(Dr Bryant) We can look at this on two scores. One is the professional dealing with the individual and the second is the professional dealing with the public. If we look at it from the personal physician or personal nurse perspective, then I think there is fairly recent evidence—and I hate to go back to MMR—relating to MMR that the people trying to encourage and advise patients as to what is likely to be the best course of action are not fully versed with all the information relating to the subject that there is. On the other hand, can we expect that? There is a huge amount of information; we are an information overloaded society. I think the important thing is for those individuals to acknowledge that they may not have all the answers at their fingertips—and this, again, is the honesty: Okay, I don't have that information now but I will find out and we will have a discussion about it again in the future." I think there is a tendency for people to feel they have to have all of the answers at their fingertips and if they do not then they are failing. I think acknowledging that we need to find out more is important. I think whenever we are about to speak on a particular subject, it is important that we do our homework, because we cannot remember all the latest and I think we cannot retain and hold all of that information. I think, again, we have to acknowledge that and do our immediate homework before talking in public about an issue.

(Sir Kenneth Calman) I agree very much with that. I think the key point that Dr Bryant has made is that when you do not know the answer you should be able to get it. This is the issue of briefing notes. The technology is now available to get that quite quickly. If something new turns up—and this was Pallab's point right at the beginning—the ability to get into the Internet or whatever way you wish to get some information quite quickly should be available. All of us will see things that we do not know enough about. If that is the case, we should be able to find that out and find it out very quickly.

351. Do you feel that is built into the official training of medical students and health professionals generally or not?

(Sir Kenneth Calman) I think it increasingly is—I mean, increasingly in terms of the evidence base and where you go for it and how you get it. I think that should be there. But in terms of the continuing professional development of professionals, that has to be seen as something you will do. If I may return to the cancer issue: testicular cancer, I used to see lots of them. It is an extraordinarily rare thing. If you were a general practitioner, you would see one every 30 years. How do you expect to know about it? You cannot. But when you see it, you should be able to go directly to where you get the evidence, what happens, and to get a specialist who can help. That is a key for any professional, to be able to use that information.

(Dr Bryant) It is as much about information management as holding all of the knowledge.


Baroness Emerton: Yes, and I think the experience of being able to say, I don't know but I will go and look." That calls for considerable experience and maturity.


Chairman: Lady Finlay.

Baroness Finlay of Llandaff

352. Why do you feel we have such appalling antibiotic prescribing for things which are probably viral infections? The classic is the number of antibiotics given out in general practice for upper respiratory tract infections still without any evidence that they are going to be antibiotic sensitive. There the health care professionals have been taught, have been told, but their behaviours have not changed at all.

(Dr Bryant) I think there are several answersor possible reasons for that, one of which is uncertainty—fear of uncertainty and fear of getting it wrong: If this is not a viral infection, I have got it wrong and there is going to be a problem for the patient and me." I think that is a very real fear. Lack of time: it is unfortunately for many people still quicker to reach for the prescription pad, coupled with that doubt. The final point is that if we actually look, particularly, around a sore throat or ear infection in children, the evidence is that, yes, antibiotics may overall reduce symptoms by one day. For that individual, in that situation, that one day may be important and may be worthwhile. I do not think we should definitely dismiss all antibiotic prescribing in those situations as being a problem, so the `convenience prescription'. The other problem is patient expectation. There are many strategies that can actually be used to overcome that. I think it is, again, this feeling by the patient: You are refusing me. You are just preventing me having this." Negotiation is what comes in there. It is negotiation around, Okay, I do not think antibiotics are needed in this case. I do not want you in my surgery tomorrow morning and the next day and the next day, though, so let us temporise on this. If you are no better within 48 hours, then perhaps a prescription may be of some help to you. You can, by phoning, obtain a prescription at that point, unless you need to see me if you are worse." It is a matter of time and negotiation and I think time, particularly in general practice, is one of the key factors as well.

Chairman

353. In all fairness to the antibiotic resistance issue, since I chaired that Committee, the Department of Health and Sir Kenneth when he was there did an enormous amount in the medical profession. Whether one can say that in the press and in the media is a different matter. It was a very determined effort which I think was very effective in the medical profession. I think there has been a tendency to go back a little or to flatten out the effect, but the communication of the medical media on this issue I think was quite good.

(Dr Bryant) We should not knock ourselves too much because we fare far better than many of our European and other counterparts.


Chairman: May we move on? Questions 6 and 7 are rather connected. Lady Warwick.

Baroness Warwick of Undercliffe

354. We have touched on training and decided to come back to it, and I think these two questions very much concentrate on that. I remember, when this Committee looked at the public understanding of science, that one of the conclusions we drew was that scientists really needed to understand the public a bit better as well. I wonder whether you think that scientists should be trained in communicating—as I have said, we have touched on it with the public and media—and how best that can be done. You were positing the possibility of drawing out from the medical profession individuals who have particular communication skills. Do you think it is a question of general training or whether or not we really ought to be identifying individuals better?

(Mr Ghosh) I think it is down to individual organisations, because there are some organisations, like PHLS, that will be required to respond tobig emergency situations, or there are smaller universities where nothing may happen for years. I think training needs to be thought about. Quite often organisations think, Yes, we should have some media training and we will bring someone in for a day or half a day," and that is that box ticked. I think training needs to be thought about strategically. Also key performers, star performers, should be identified as people who can be put out, put in front of camera, and they should perhaps be given more intensive courses in, I suppose, the dark arts, really, about what the message is, what is required from different forms of media, who the individuals are within various organisations. One of the things I have noticed as a customer of media resources from various organisations is how undervalued the press offices are. There are so many organisations where the press office is usually the last place to hear about things—I am often the one who tells them—and they are often treated like clerks by an organisation, where everything is done and dusted and then a matter is sent to them to try to get some publicity for it. Better organisations—and I cannot think of many in this scientific field, but certainly in private industry—do have a proper director of communications at the heart of the decision-making process. Dare I mention Alistair Campbell—someone who is involved at the very basic level of policy making, can advise at that level and then can see it through in a more strategic way. I think there is an issue there which needs to be thought right from the board outwards.

355. There is a leadership issue as well, is there?

(Mr Ghosh) It is about the status of communications within organisations fundamentally.Also, getting someone with enough seniority and clout and knowledge at the highest possible level and of course paying them accordingly.

(Sir Kenneth Calman) The answer is yes, but I think there are some caveats. First of all, the point that Pallab has made and I have made already about the need for preparation and the role of the press officers. They are actually terribly important and sometimes, I think, undervalued. Secondly, in educational terms, the one-day course on media communications is likely not to be necessarily helpful in the long term but it might just sensitise people to think again. Finally, I have been involved in two courses, interestingly. One is in Scotland, where all the new PHD students come together and they discuss things like Ethics" and what the media think and what social policy is and what the Government is thinking. I thought that was really very helpful. The second was in the Netherlands, a British Council arranged meeting in which young scientists, newly post-docs had a couple of days with some very distinguished media people, trying to work through and having to present information back to their colleagues. Again, it sensitises. I do not think it answers all of the questions, but I think we could do more and the opportunities are there. It should be part of a PHD programme's training.

Lord Lewis of Newnham

356. We have touched on what happens in Scotland and Holland. Are there any countries which do this job very well indeed? If so, do they actually have courses or arrangements of some form or another? Is there anything we can learn from this sort of presentation in other countries?

(Sir Kenneth Calman) I am not sure if there are. I think there are generic issues. This is not about scientists, I think, or about medical people or whatever; it is about generic skills which we build up, I think, by experience and by watching star performers and listening to them. There needs to be perhaps a greater apprenticeship within that to do it, rather than a particular course.

Baroness Warwick of Undercliffe

357. If I may follow up on the next point, which is the question of whether there is sufficient knowledge and clear information available and whether scientists should themselves be trying to develop courses which would assist the media. You talked about the headline-writers, for example, being quite separate. We have all suffered from that, when you have had a decent discussion with a journalist, only to discover that the message has been completely distorted by the headline, and you wonder just how much is read below. Is there, in a set of complex issues which often characterise science, technology and medicine, the development of courses by the scientists themselves for the journalists?

(Mr Ghosh) I would love to go on a half-day course on gene therapy and so forth, but I would not have the time really and I think that is the same for all my colleagues. First of all, I would say that, with issues of complex science, quite often it is a specialist that is put on to it, so we do have a bit of a background in what we are reporting. It is more important for me to get the right briefing, the right conversations, at the right time. I think emphasis should be put on thinking through those structures. I also think that for our part we need to be raising our bar a bit, to make sure that our standards of reporting are high, and we try to do that internally and also amongthe science community, the science journalism community, as well.

(Sir Kenneth Calman) There is quite a good model for this in things like Medicine for Managers, put on by a number of groups, of which the Royal Society of Medicine just happens to be one. I think there are ways in which we could help with that, but there are two issues. One is: Do I know enough about the subject? The second is: When it happens, who do I contact to know about that subject now? And I think they are both relevant.


Chairman: Dr Bryant?

(Dr Bryant) There are several strands to this. The first is that our children today are being trained and educated in presentation skills. Even at primary school, they present their work to their classmates, to their school, so I think for our future generations the situation may be looking rather more rosy than for the older ones among us. I think personal presentation is something which is going throughout our education system. If we look at the specifics relating to these lines of questioning, we have already had discussions about whether the media has a responsibility to report science and health honestly. I think we, in science and health, equally have a duty to present scientific and medical findings in a manner which is understandable by the public, and I think that is the flip side to the coin. As I have said before, that is something that takes time. As to whether there is any possibility of putting on courses specifically for the media related to science, I think there are two elements. One is the general, but most of these issues are around complex specifics, and again it is the investment in time in briefing the various portions of the media around that specific subject. That is down to the team or the units doing the work, to spend and invest that time in educating around that specific subject. Looking at media training, I had a small amount of formal media training but the vast bulk of my media training was by experience and I think the apprenticeship is important. I think we fail, in general, to use opportunities. If we look at public health medicine, it is a core competency to have some media training and media experience. For the vast majority, that is a very brief course and not a lot more. Those people who have gone through that brief training should then be being allowed, encouraged, facilitated actually to work with local media at a small level to gain experience, to put them on the next footing and the next step up, and we need to up-date and use those skills continually, otherwise they will become rusty and less useful to us. I think training is one thing but using the training is more important.

(Mr Ghosh) In reality, it is just a handful of people having a handful of conversations with a number of journalists that makes the difference. I think, as well as training, what is also necessary are relationships with some of those key people, whether at national or at regional level.

Lord Lewis of Newnham

358. How far do you find that you are able to approach the professional bodies? I am reminded of the fact that in Denmark they have an arrangement with their chemistry society that if there is any major catastrophe involving chemistry they are contacted, and they will guarantee to give you an answer of some sort or another within a limited period and the answer, if that is possible, within a larger time. Does this apply to other areas and disciplines?

(Mr Ghosh) I find it varies. I think the Royal Society has really cleaned its act up. During the GM crops debacle I tried to get a comment for the 1 o'clock news and I was told they were having a meeting and they would issue a press release the next day. Now they are much, much better, they will respond straightaway and they understand the requirements of broadcasting and media print much, much better. The research councils have undervalued and under-resourced press officers, they are regarded as clerks. At the Department of Health there are very, very good people who do not feel empowered to say anything before it is cleared and if you ask for a briefing you might get a briefing in about two or three weeks' time, which for a breaking news story is useless.

Chairman

359. As an addendum to this question some of us were in the United States last week and we visited Atlanta where the CDC, the Centre for Disease Control, existed, which is a pretty big federal organisation. In order to handle some of the press situations they are developing the concept of media fellowships so that journalists in the USA can see how CDC works and report on developments. Firstly, would such attempt in the United Kingdom be worthwhile? Secondly, would such fellowships be of interest in the media?

(Mr Ghosh) Fellowships are always interesting. A number of my colleagues have been on such things, it provides an opportunity for us to get off the treadmill and stand back. It is not so much to learn about a specific area, like health, or whatever, but to reflect on how we do our jobs. As I say, in the main there are certainly pressures on our time and to take 3 months out, or sometimes 6 months, is something that some of us do maybe once during our career. If such a thing were offered it would be useful to think about what we are trying to achieve here. There is no point in somebody being an expert on malaria, you want to be able to understand the scientific process more.


 
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