Select Committee on Science and Technology Minutes of Evidence


Examination of Witnesses (Questions 680-696)

TUESDAY 18 MARCH 2003

MR SHAUN BROGAN, MR ROBERT NAYLOR AND DR MARTYN WAKE

Lord Turnberg

  680. The question relates to whether the current arrangements are satisfactory and the sense I am getting is that we are not entirely unhappy with what we are doing and more money here and there might ease things. It does make me wonder why we are so anxious about communicable disease at the moment, if everything is okay. Is it that you are describing particularly good examples of what is going on? We recognise that perhaps you were chosen because you are good people in the field. Is it just a local phenomenon or is it general? In our position we are keen to see improvements in the areas about which anxieties have been expressed to us. We are really keen to see what the key problems are and what advice we can give that would make a difference. If you are saying just arrange a bit more money here or there, that does not sound terribly entertaining to me.
  (Mr Brogan) I am not saying everything is okay. The newsletter Bandolier estimates that we could do away with 16 to 20 district general hospitals if we could get a grip of hospital acquired infection. It is said that one in every ten people in district general hospitals is there because of infection caused by the hospital itself, so everything is not okay and there is a lot to do. We need desperately to get a grip of this problem in our area, because it is one way, if we could manage to control it, of reducing our debts. We are on the case. We have a health summit next month to try to look with clinicians at all sorts of ways we can begin to save money and redesign services and improve them. That does not get away from the general thrust of my opinion which is that setting up the Health Protection Agency is right, it needs to be got righter, it needs to be improved in how it works, how it works with us and how we work with them. The general thrust is right but there is plenty to do and there is no shortage of problems to address.
  (Dr Wake) I accept what Lord Turnberg says and it is a difficult one. One would have to look at each infectious disease individually. I certainly said that I was very worried about the situation regarding blood-borne viruses. I do not think we are on top of that. People do not appreciate the size of the problem in relation to hepatitis C. When you consider that it is affecting probably around 0.4 per cent of the population that is an enormous issue and a disease which we can treat and we cannot shrink away from that. I feel that all we are doing in relation to hepatitis C is seeking to address the problem. I should like to know what more we could do. Certainly we could work with prisons, so that is one example. In sexually transmitted diseases we have a different problem because some of this relates to culture, mores, education, as well as what we can do in health. Therefore these become areas where a very wide range of partners needs to be brought in. As far as I understand it at the moment, the communicable disease side in relation to sexually transmitted diseases, is working reasonably well. I am not saying that it is successful.

  681. What about chlamydia?
  (Dr Wake) I perhaps do not know enough about chlamydia personally, but it clearly is a major problem. I do not see agreement from the experts on the way to deal with it. I have seen people challenging the idea of screening people for chlamydia, which is one thing, but my director of public health, who is an expert on screening, assures me that the science behind that is probably questionable in that you can have chlamydia more than once.

  682. It needs to be looked at.
  (Dr Wake) I come back therefore to the fact that chlamydia is a multi-factorial problem and we have a role to play, but certainly society has a role to play as well.

Chairman

  683. A group of individuals which seems to be left out of infection control is the environmental health officers and they obviously play a role in infection control at the very basic level of hygiene. Do the primary care trusts liaise with the environmental health officers at local level or is there a recognition that they have a role to play?
  (Dr Wake) I believe they do. I think there is a formal relationship with the CCDCs, who act as their proper officer. It is a good question, however, because other than that I am not sure there are good links with environmental health officers. PCTs do provide a good opportunity for us to develop those links because they are so closely related now to local authorities and indeed there is the opportunity even for budgets to be shared between local authorities and PCTs in the future. I would feel that at a personal level I do not have enough understanding of the way environmental health officers work, though I know that my director of public health would. Those links certainly need to be improved and we do have the opportunity to do so.
  (Mr Brogan) I echo those remarks. We have a very close relationship with the district councils, which have carried that responsibility in our area. We are envisaging putting this as part of our strategic partnership. It has been a little difficult in our case getting the local strategic partnership off the ground in its written formal form because the district council did not want it. We have now persuaded them that we should have one and we are bringing various things together into that, including the environmental health officers' area of responsibility. There is a very close link between our CCDC and the environmental health officers anyway, so the two things are reasonably well under control in that area.

Chairman: That is good news; thank you.

Lord Rea

  684. This concerns the interface between primary and secondary care. Infection moves freely between the hospital and the community and a community includes residential care homes and nursing homes whose clinical care is often provided by GPs. Could infection control services in these two arenas be better integrated? Mr Naylor touched on this already when he talked about the infection control nurses who had responsibility for both hospital and the community. Perhaps you could amplify on this.
  (Mr Brogan) I certainly agree that it can be better co-ordinated. This is why we are putting this as the main item on this health summit meeting we have next month to discuss ways in which we can re-design services for the 21st century and look particularly at items like hospital acquired infection, things like lengths of stay and day case rates and so on and any other areas we can come up with which will enable us to redesign services, thereby making them more efficient and costing us less money and improving them for the patient most of all. We will be doing that sort of work against a backdrop of trying to improve the levels of hospital acquired infection and to make sure those sorts of infections are not crossing over into the community. We do not have a very serious problem at the moment in our community hospitals; we have two in our PCT and we do not have much of an infection problem in those two hospitals. I am not trying to sound complacent. We need to keep on top of it and make sure that does not happen in the future.

  685. Sometimes hospital acquired infections must come from somewhere, possibly outside the hospitals.
  (Mr Brogan) You are straying out of the area of my competence now. I do not know where it starts.
  (Mr Naylor) Perhaps I could address that, going back to the experience we are having at the Heart Hospital to which I referred earlier. We have detected an increasing incidence of infection being brought into the hospital now that we are measuring it more accurately and in a more controlled environment. Although there has been a very substantial increase in the number of patients coming in with these infections, we have managed to maintain the level of hospital acquired infection, even though more patients are coming in. Our understanding of the situation is that there is a growing degree of infection within the community. That may be because it is growing absolutely in value terms, or it may be because we are reporting it better than we were previously. We need to commission more research to try to understand that further. Coming back to the key question, there is great merit in joint appointments and in agreements between primary care trusts and acute hospitals, particularly in major urban areas where the level of hospital acquired infection seems to be greater in cities than it is in rural environments. The highest levels of hospital acquired infection in all of our hospitals tend to be in London and tend to be in our major teaching hospitals and that is largely because patients are coming into these hospitals from all parts of the community. My trust, for example, only has 20 per cent of patients from our local community. Eighty per cent of our patients, because of the specialist nature of our hospitals, come from all over the UK and they bring infections with them. Managing that degree of infection which is brought into the hospitals and controlling it within hospitals, I think is the really big challenge. The really big improvement we can make and I really believe we do have to make, is to control the extent of hospital acquired infection. At the moment, that level of infection, as has already been referred to, is about one in nine or one in ten patients acquiring an infection whilst in hospital. Although it is not possible to manage some of those acquisitions it is possible with a proportion of them. There is an awful lot to do in the health service in terms of further investment, in cleaning procedures, in new protocols, in hospital design and building. There are some short-term gains such as hand washing, but there need to be longer-term policies as well in terms of whole hospital re-design. This is a long-term battle in which there are short-term strategies and long-term strategies and a great deal can be done. The cost of this is very considerable indeed, but the benefit is also very considerable because of the amount of resource we currently waste in treating patients who acquire hospital infection. We need to develop a new strategy for this across the health service and therefore I personally am pleased to see it being given such a high profile both in the media and by government.

Chairman

  686. With respect to what you have just been saying, but looking at the thing as a whole, do you have concerns over the transfer of public health laboratories to the National Health Service? Given the clinical pressures on laboratories, will they be able to dedicate the time and resources necessary to fulfil the public health requirements to which you have just referred?
  (Mr Naylor) My experience before I came to London was of a major teaching hospital in the Midlands where we had a major public health laboratory on site. The relationship there between the Public Health Laboratory Service and the hospital was very satisfactory. I have come to a hospital in London which does not have such strong relationships, though the relationships are still very good. Across the health service there have not always been good relationships between public health laboratories and NHS microbiology services. I should certainly support the move of the Public Health Laboratory Service into the Health Protection Agency, but I should also very strongly support the requirement which must be placed upon NHS microbiology departments to improve surveillance and report infection through to the new Health Protection Agency. This reporting process has been patchy in the past. It has tended to be good where there are strong public health laboratory services on the hospital site, but where there are not, it has tended to be deficient in many areas. Alongside transferring the PHLS into the HPA, it is important to impose new standards upon NHS microbiology departments to improve surveillance into the central HPA of the future.

Lord Rea

  687. Could we get back to control of infection in the community? I should very much like to hear what Dr Wake as a GP has to say about monitoring and control of infection in the community.
  (Dr Wake) A couple of small points. I should be slightly concerned if the Committee went away with the idea that community acquired infection was our biggest problem. This is multi-factorial and Mr Naylor mentioned the fact that London hospitals may have a greater degree of problem with infection. I cannot give you the evidence on this, but I think we would need to understand clearly the evidence around this. My understanding would be that in London hospitals particularly, where we tend to be working under the greatest amount of pressure, the largest throughput of patients, there is, for example, a large number of different professionals seeing patients, particularly in teaching hospitals. My understanding is that all of these things contribute to hospital acquired infection. I am not sure I have seen any strong evidence that we have major problems as yet with community acquired infection, certainly of that infection going into hospitals. In primary care and in community hospitals where procedures are done, I always understood that infection rates were generally lower and there were fewer resistant organisms. That is the sum of my knowledge on it, but I would feel it would be worth understanding all the evidence we have in relation to these problems.

Baroness Emerton

  688. May I ask to what extent there is adequate IT in hospital trust and PCT settings to allow health professionals to receive up-to-date information about best practice in communicable diseases and to allow rapid sharing of surveillance information, bearing in mind the range of staff that is employed within PCTs and within hospitals?
  (Mr Naylor) May I start in relation to hospitals? The simple answer to the question is that they are inadequate. There has been gross under-investment in IT services in the NHS for decades. The current government has recognised that and has allocated a very, very substantial increase in resources, some £2.3 billion, to improve information technology in the health service. This is a truly massive challenge for the health service. Again I can talk with some confidence from my own trust's perspective. We are building a new hospital, the hospital is going to be virtually paperless, was planned to be virtually paperless in 2005. We have just gone through the process of trying to identify IT systems which will allow that to be achieved and, to put it bluntly, there is none in the world, because we have surveyed every country's IT capability. We are going to have to develop new IT systems to manage healthcare in the 21st century, not just within our hospitals where the IT systems will be extraordinarily complicated because of the complexity of hospitals, but also across a spectrum of patient care from primary care through secondary, tertiary care and back into the community again. This is a massive challenge for government, not only to find the resources, which they have done to a significant degree, but then working with industry to provide the capability to put these IT systems across the NHS.

  689. What about the training and skills of staff to manage?
  (Mr Naylor) It is an enormous challenge. Because we do not have well-developed IT in our hospitals or across the health service as a whole, there is a massive agenda of training and development. That will have to go alongside the investment in the new technology and new software.

Lord Patel

  690. Is there any strategy about new IT coming into the NHS both in terms of investment and in terms of training?
  (Mr Naylor) Yes, there is. There has been a recent appointment of a gentleman called Richard Granger, who effectively is the IT czar. It is his responsibility to the Department of Health, to the Permanent Secretary and Chief Executive of the National Health Service, to develop a strategy for the development and improvement in information technology across the health service. He has been given the responsibility of allocating this additional £2.3 billion resource to add to the existing investment in IT healthcare which, brought together, will hopefully make a very significant change both in the architecture of IT systems and communication systems between computerised systems and also in training and development of staff.

Baroness Emerton

  691. Could we hear about the primary healthcare side in terms of the IT there and the links with the hospital services as well?
  (Dr Wake) I can be a little bit more upbeat about the development of IT systems in primary care in that we have been investing in IT to a reasonable level for at least ten years. Again, I do not want to sound complacent, because IT development is advancing all the time. I am sure my own trust is one of the leading trusts for the development of IT nationally, so I probably speak from a slightly different perspective. I am sure levels of investment vary throughout the country. Nevertheless, it is true to say that all GPs at the moment would have access to the NHS net: I am afraid there might be one or two GPs who do not turn their systems on. Broadly, they do have access to the NHS net and in my own PCT the great majority would use that kind of access regularly for information. One of the key areas of importance for me, is that I practice in a paperless practice. You have to develop paperless systems yourselves, but it is much easier to develop paperless systems in a small business environment, which is what general practice is like, than in a large hospital trust. We are in control and it is a small enterprise. In a paperless system like mine, I can now do a blood test in the morning and have the result on my screen in the evening. That is not true so much for infection because there is a lead time in getting results for infectious diseases. I can now get a simple urine test back within a maximum of three days from having done it and it is on my screen and it is in the patient's record. That is a very different world from the world we knew a few years ago. It is possible to speed a lot of these things up and I do hope that we will be able to do that through working with our laboratories. That is important. The other aspect of the use of IT is around information and the cascade system that we have for reporting on disease outbreaks, national concerns. We receive a lot of these. At the moment, even in my own PCT, these cascades are received mainly by fax rather than via e-mail, although that e-mail facility is there. It will all be e-mail very soon. The only problem we have in our systems locally is that they are still a little bit slow, so there is another step of investment. We have a clear investment strategy for IT and, for example, you would see PCTs moving in a few years to servers, which are centrally held at PCT offices, improving issues around maintenance, confidentiality, security, etcetera, with just online access from each individual site, which could be a GP service, a dentist service or could be a district nurse's centre. There is a great opportunity for integration and development there at the moment and I would say fairly good access to information at the moment.
  (Mr Brogan) We are not quite as advanced as that, but we have made progress. We have electronic referrals to hospital and we are starting electronic referrals to physiotherapy and so on. We do have two distinct, different GP systems; some of our GPs use one system, some use another, other PCTs have lots of systems. It is a bit of a muddle. There have been attempts over a number of years to bring them together using a special standardised way of migrating the systems towards similar functionality if not the same sort of system. We have a pretty poor computer system in our community trust covering our community hospitals and all our physiotherapists and therapists generally, district nurses, health visitors, speech therapists and so on. That system is very poor, it does not work properly and does not give us good information. We have pretty poor systems in the local hospitals at the moment which are due to change and develop new electronic patient records systems, but investment is massive and the objectives are very ambitious. There is much to be done. In relation to control of infectious diseases, we have pretty bog-standard systems; we are not using any special system at the moment. We are not e-mailing, we are still faxing the cascade information down. That is not too bad, but it could be better and will be, I am sure, when the Health Protection Agency gets a grip of it. This is all going to take a bit of time. As far as investing in primary care systems is concerned, given that the requirement is to put in acute hospital systems first with the new electronic patient records in acute hospitals first, it is going to take some time before we get community and GP systems sorted out.

Lord Turnberg

  692. Dr Wake talked about the receipt of information in order to help the practice. What about transmission of information? Some of these data you collect on infection which make up such a large proportion of the practice, might well be useful for surveillance purposes. Do you transmit as well as receive?
  (Dr Wake) We do not, but I believe those systems are better developed in Scotland and there is a great deal of use of primary care information in an integrated way. The new GP contract will start to collect certain information which will then be able to be aggregated and help us in health needs assessment and health planning, but very little of that directed towards infection control.

  693. Do you think it would be useful to do that?
  (Dr Wake) I think it will be useful and particularly once we have information on a single server for an area. Programmes are already in existence which allow you to extract relevant information, although again it is going to depend on accuracy of diagnosis, good diagnostics and being sure we are all coding things correctly, as ever, the quality of information we put in.

Baroness Walmsley

  694. My question is about feedback. Do PCTs and hospital trusts receive enough information from the surveillance system and about best treatment practice in order to improve their decision making and implement strategies to prevent and treat infection and also perhaps to encourage them to input information? Could you say something about how that information would be most usefully received by the PCTs and hospital trusts?
  (Mr Brogan) The information would be best received electronically, I am sure of that. Most GPs would prefer to get e-mails rather than paper documents. We are a little way away from that, as we have discussed in answer to earlier questions. Public health and GPs do get quite a lot of information already on communicable diseases so there is quite a lot of that sort of information passing already. I would expect the Health Protection Agency would improve that over the next year or two years as they begin to get a grip with their new responsibilities. I am moderately optimistic about how that would proceed. There is plenty to be done. I am not being complacent. We are on track.
  (Dr Wake) In terms of best practice we would already have on our desktops access at a keystroke to information about a particular disease we are faced with in front of us. That is already there, depending on which company you get your IT from. Certainly there are plans to have access to NHS agreed systems of work. Initially there was a system called Prodigy, although I think that has gone a bit quiet at the moment. I am not quite sure where that is going. I am quite confident we would have that. As far as information goes—and I speak from my local experience—we would always be notified of a particular outbreak in order to be alerted to particular diseases. I know that we have had an alert this week about this international virus problem, we have had an alert locally about an outbreak of syphilis and wherever we get a notification like that, we would be informed what to watch for, because you do not see it terribly often in primary care, how to treat it, where to refer them to, etcetera. Again I sound complacent, but those structures are there and I am assuming they work as well in every area.

  695. Do you think the information about smallpox that you are getting at the moment is adequate?
  (Dr Wake) We understand where we are about smallpox. If I were honest, for a GP on the ground, while I feel they are clear that they are not able to provide the immunisation, I do not feel they will be entirely clear about the degree of the threat. It is a good point to make that while the health protection units are completely aware of what government is thinking and planning around the control of an outbreak like that, I am not convinced that emergency plans are uppermost in the minds of people practising on the ground. That is certainly true in primary care. I am not sure whether that is true in hospital. It may be slightly different in hospital settings.
  (Mr Naylor) In relation to hospitals, I would say that the receipt of electronic information about surveillance systems is excellent, certainly greatly improved over what it has been in the past. I agree with my colleagues here, that electronic information around best treatment practice is very easily available, what we call integrated care protocols. That is greatly improved in recent years, but I guess the area where I would have concern would be in the transmission of information about infections which are being identified within hospital pathology laboratories, to which I referred earlier. Where it is good it has been good, but there are many areas where there are big holes in the transmission of information. I would hope that is something the new Health Protection Agency would pick up and improve the flow of information about infections in hospital environments and in primary care so that we collect a greater proportion of the total available information which can then be sent back to those people out in the field who need to know.

Chairman: Finally, still connected with this area, designing surveillance systems.

Lord Lewis of Newnham

  696. To what extent do PCTs and hospital trusts have input into designing the surveillance system in order to ensure that it delivers the sort of appropriate information for your needs? I know you have been telling us a lot about receiving it, but what actual input do you have in designing the systems themselves?
  (Mr Brogan) At the moment our CCDC is working with our director of public health and has been—not the same individuals—working together for years. There is good communication, mutual trust, mutual respect and a very good working relationship. The creation of the HPA will change things, not necessarily for the worse, in fact I do not think it will be for the worse at all, but it will change things and will take a while to settle down and consolidate itself. As long as that process is well led and well managed, in the next year or two we shall see an improvement in this area.
  (Mr Naylor) I would simply endorse what Mr Brogan has just said. There is not direct involvement in the majority of NHS trusts in development of these systems and the systems have historically been developed through the public health network and, through the arrangements which we have described and hope to see developed, through the HPA in the future.

Chairman: Any further points? If not, gentlemen, thank you very much for coming along. If there is any issue which you feel we have not touched upon and should have touched upon, or any issue we have dealt with rather peremptorily and should have followed it further, if you would like to submit any information to us, we shall gladly receive it. You will get a copy of the transcript which you will have an opportunity to correct factually in due course. Thank you very much indeed.

Lord Turnberg: If the witnesses come up with any ideas that they would like to see in our recommendations for change which would make a difference to their work, can they perhaps write in?

Chairman: Thank you very much.





 
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