Select Committee on Science and Technology Minutes of Evidence


Examination of witnesses (Question 700-719)

THURSDAY 20 MARCH 2003

DR MARTIN DONAGHY, DR ROLAND SALMON AND DR BRIAN SMYTH

  700. We all recognise that communicable disease infection control does not recognise borders or boundaries. What are the major points, or is there a major point that makes you want to be devolved in this, and not part of the whole HPA? Do you think that you can handle your communicable disease situation better at a devolved level than at a national level through the HPA?
  (Dr Salmon) If I can step in first, the answer to that question probably revolves around what exactly is the communicable disease problem. We have always had a system in the United Kingdom where different levels of administration have been appropriate for different kinds of problems. For example, it would be perfectly appropriate for a health authority in the past and its local authority to deal with a localised outbreak of salmonellosis from a food outlet for example. There are a number of communicable disease problems that are efficiently dealt with at the devolved administration/regional level. I quite accept that there will be problems that will be too large for us to deal with, which may be UK wide. Indeed, this is surely why the HPA is to be a UK-wide organisation. In relation to diversity, I think that responsibly applied diversity in arrangements, as we see in States of the US, can foster innovation. I would hope that that would be the case here in the United Kingdom as well.

  701. The point about the States of the US is well made.
  (Dr Smyth) I think that the current UK approach to the severe acute respiratory syndrome, which has been in the news in the last couple of days, has shown that despite health being a devolved matter, there has been a very good co-ordinated UK approach. The potential for surveillance and approaches to communicable disease control to diversify was recognised several years ago. A way to mitigate those potential problems led to Professor Nicoll, Director of CDSC Colindale, setting up what is known as the Five Nations Group. This group involves the directors of the Communicable Disease Surveillance Centres in England, Wales, Scotland, Northern Ireland and the Republic of Ireland. We meet every three to four months. The group has shared information. We have looked to see who is developing new guidelines; and whether they could be harmonised within the five countries. We are meeting next month, not only with the five surveillance centres but with our colleagues from the various health departments. This has proved a very useful information-sharing forum, and is facilitating co-ordination.
  (Dr Donaghy) From a Scottish point of view, the administrative arrangements for communicable disease control have never been on a UK-wide basis; they have always been operated mainly in Scotland, through Scottish-wide arrangements. What was devolved was political control for that, and that has been the change. In terms of retaining that, to reiterate what my colleagues have said, it is really horses for courses. Ninety per cent of communicable disease problems are dealt with by local arrangements operating in towns and cities of rural areas. The way we organise that service and the way that they are controlled and accountable are different in Scotland from other parts of the UK. However, there are problems which are best approached through a UK-wide process. Recently in the Health Protection Agency consultation, which we have been doing in Scotland—I know that it is outwith communicable disease control, but there is no logic in handling radiological protection on a Scotland-wide basis; that must be through the UK. As Brian has said, there are other communicable disease problems that are best done through a UK-wide network. If I could just use the example of Severe Acute Respiratory Syndrome, this is an international problem. We are feeding in to WHO at Geneva. Certain problems need a response outwith the UK. What is important is that it is meshed together, with other appropriate step-ups to deal with certain problems in certain ways at an appropriate level.

Lord Turnberg

  702. I want to follow up one point about the decisions to be taken in the Scottish Parliament by Ministers. Do you have a timescale for that? Do you know when it is likely?
  (Dr Donaghy) We understand that it is likely to be in June. As I said, there is an election in Scotland in May, and a lot will depend on the priorities of the incoming administration. The consultation on the future of the HPA has now finished. The Executive Health Department is taking the results of that consultation and analysing it. It will then look at the best options for Scotland, and will then make recommendations to Ministers. The process of analysing the response and then looking at options is underway. My understanding is that there has been contact between the Executive and their English counterparts because, obviously, with the new HPA starting in April, we will need to know what it is likely we will have to do on a UK-wide basis. My understanding is that early communication has indicated that the chemical side will be retained as a UK-wide function with Scotland being a regional provider. These discussions are ongoing.

  703. Do you feel there is a problem with the hiatus between the HPA being set up at the end of this month and taking things forward, given for example that the threat of bio-terrorism seems to have emerged rather more forcibly recently?
  (Dr Donaghy) In terms of Scotland, I think the hiatus is a problem, but I must say that in terms of bio-terrorism, both at a departmental level and through the networking that is currently ongoing, particularly in recent weeks through the smallpox plan, we are co-ordinating our response. To be fair to Scotland, I do not think that the timing of the HPA development was meshed in with events in Scotland. Where you have different political systems, it is quite difficult for reasons outwith communicable disease control issues to mesh that together. Although there is a hiatus, in terms of bio-terrorism, I do not think that that hiatus has a major impact on the arrangements that have been set up to deal with that.

  704. I have to declare my recent interest as the ex-chairman of the board of the Public Health Laboratory Service. I suspect that you may have known that, but I say it for the record. This question relates to the fact that we have seemingly two different systems of providing the services that are required. You have both explained how functionally there is not very much difference. The new Welsh system will have under its aegis all the laboratories, whereas in Scotland few, if any, will be directly under it. These two obviously work, because they have worked before, but do you see advantages and disadvantages in the two systems; and which would you recommend?
  (Dr Salmon) In Wales, we have made a conscious decision via the Assembly government to retain the existing public health laboratory service network. That is based on the fact that we think that is a successful exposition of a successful concept. In practice, it is a managed clinical network, and in many other settings we are being told how desirable managed clinical networks are for a variety of health services. It allows a degree of rationalisation of service provision; it is an efficient mechanism for arriving at standardisation and standardised operating procedures. I am not saying it is the only mechanism, but it is administratively a very simple way of doing that. It provides a ready surge capacity, which means that I can say broadly that we have been able to manage in-house the bulk of work on infectious disease outbreaks and problems within Wales over the last ten or twelve years. I think that it is a helpful mechanism, though not a necessary one, for facilitating surveillance. It does have disadvantages. You are perforce forced into the management of what is a quite complex industrial process, producing results on specimens to time and to quality, and with an important health and safety component. That does take up management time and energy and can, I suppose, be a distraction from the public health task. That said, those tasks will have to be addressed somewhere in the administrative system, so it is not as though if you have the laboratories elsewhere those tasks are in some sense going to go away.
  (Dr Donaghy) In Scotland, the situation is that our basic diagnostic laboratories are based in NHS trusts, as are our reference laboratories, but they are nationally commissioned. In the recent health protection consultation, the issues of a national system, bringing in all the laboratories into a national system, versus retaining the primary responsibility for these laboratories in NHS trusts, was a major feature of debate. I must say that views were put forward quite strongly, particularly from the microbiology community, on behalf of both points of view. One of the advantages of a national system is a standardised approach to standardised operating procedures; and there is, therefore, a degree of confidence that the results you are getting from the laboratory are comparable to the results from another laboratory. Currently we do not have SOPs in Scotland, and that is a weakness in our system. The second one is in the whole area of data quality and quality assurance. It is easier to have that if there is a national system rather than having, as we have, sixteen trusts running it separately. The third is that there are competing priorities on microbiologists. Obviously, their prime function is a diagnostic and clinical function; and we also have a laboratory maintenance/infection control/ public health function. They have to juggle these balls, and at times we have found in Scotland that the public health function suffers a little, in comparison to the pressing priorities from the clinical side. A national system would help retain and boost the public health priorities. However, there are downsides. One is coming back to the whole issue of local responsiveness, in terms of joint working with physicians and clinicians, which may be impeded through a national system. The second is that microbiology depends on a network outwith the NHS, and again there are good reasons for retaining that locally. One of the key issues in Scotland was a feeling in the NHS of cost and upheaval, of reorganisation and reorganisation, and organisational locus. SCIEH proposed in the consultation that the reference laboratories should come more into the national centre being commissioned by the national centre so that they are tied in to the public health network. The second area was entering into formalised agreements with all the healthcare providers to ensure that there was a public health focus, that the quality of the data was appropriate, and that there were SOPs being developed certainly for all the key organisms.
  (Dr Smyth) For the record, in Northern Ireland we have never had any PHLS laboratories; all our diagnostic laboratories are based in acute NHS trusts. There has always been a very strong tradition in Northern Ireland of those laboratories reporting organisms centrally for surveillance. One of the laboratories, as well as providing that clinical diagnostic service, undertakes food, water and environmental microbiological analysis on behalf of the Province. As I say, this arrangement works generally well, despite many of the laboratories being run single-handedly by a microbiologist. My microbiological colleagues do use the PHLS standard operating procedures, though I am not aware of any regional audit as to the extent of compliance. There has been recent guidance from the Department of Health in Belfast, as to the future pattern of acute hospital services in Northern Ireland, and this may help change laboratory provision and perhaps lead to a more clinical network approach, because at the moment laboratories can be under severe pressures, and a networked pattern of service would deal with some of these surge pressures.

Baroness Finlay of Llandaff

  705. I have to declare an interest because I am employed in the NHS trust that manages the cancer trials network in Wales. Having said that, I would be interested to have your comments on three particular areas. One is the point at which the gap occurs from the laboratories in Scotland into the surveillance system, which is obviously quite different to where it is occurring in Wales or Northern Ireland. That may be a point of weakness, and I wondered if you had comments on that. The other point is on the cost efficacy of supplies to laboratories as well as standardised procedures, and the third point is over the threat of the new commissioning arrangements to the laboratory services. If the commissioners decide to decrease from the primary care level of commissioning, and they decrease the amount they are purchasing for microbiological services, how much of that impairs the public health functions, particularly in the front-line hospital laboratories? I am thinking about all the different models, not only in the Scottish model where it is a bit more evident, but also in Wales in the new commissioning arrangements.
  (Dr Donaghy) On linkages with the United Kingdom, technically we do not see any great problem in ensuring that the data, once received by a surveillance centre, is shared within the UK. One area that has been helpful to us has been the European Union developments in trying to reach standard definitions and coding for key micro-organisms. Where we would like to see an arrangement similar to the English system, maybe through some form of alternative organisational arrangement, is ensuring that the quality of the data from the local laboratories is as good as possible. That is through standard operating procedures and from some data quality checks, and consistency and accuracy in reporting labs. Again, this is something that we think we can learn from in Scotland from the current PHLS system. It is something that we would like to see retained in the new arrangements. We do not think that, once the data is in and analysed, there are any major difficulties in terms of sharing it across UK-wide borders. The second area is a very valid one, and that is cost efficacy. It is particularly to do with the development of new diagnostic methodologies around biotechnology, DNA and the genome, et cetera. There is a risk for local diagnostic laboratories that in the competing pressures these technologies will not be extended as rapidly as possible. One of the arguments we put forward for bringing the reference laboratories into a national commissioning set-up was to try and get a better prioritisation and investment programme in these areas. At times, there is duplication of different DNA type platforms; at times, skills and expertise are not shared within Scotland in different laboratories. Certainly, within that area, in terms of new investment and new skills, a national approach is needed. Some of the technologies for a population of 5 million are just not deliverable in Scotland, and we need to liaise to a greater extent. We do have liaison currently with the PHLS on certain key organisms, but with the new technologies coming in, this will be a key issue of interface between Scotland and the rest of the UK about what tests are better done on a UK-wide basis or in Scotland, et cetera. That will be a common question for the regions of England. On your third area, the situation in Scotland just now is in a state of flux. The White Paper on Health in Scotland, which has just been issued, will lead to the abolishment of NHS trusts. We do have primary care trusts in Scotland, but they are different from the primary care trusts in England. Currently, general practitioner services come together in local healthcare co-operatives. It is seen that the NHS boards will act almost as a ringmaster for commissioning arrangements to be devolved out to local healthcare co-operatives, and I think there is some concern that microbiology could lose out on that, because it is often a hidden service to GPs, compared to the more up-front clinical services. That is something that we have got to engage in with our partners in the NHS boards. We see a strength in the situation where, if we have a retention of the basic tier of communicable disease control in NHS boards, that will give us an "in" to try and influence some of these commissioning decisions locally.
  (Dr Salmon) I understood you, Baroness Finlay, when you were talking about the gap, to be talking about the gap between the local laboratory and the surveillance centre at regional level, and whether the network might confer some advantages there. I think it does, but I am not sure that is always where people imagine it to be. The Public Health Laboratory Service always tended to think that it was very important to have laboratories because of the formal aspects of surveillance, because the data would flow better. That is true, but one of the very important aspects, which perhaps was always under-appreciated, was just having human intelligence in terms of having skilled microbiological personnel distributed around the area you were looking after. I think that a network does facilitate that kind of informal exchange between doctors, which leads to problems being alerted possibly even before the surveillance systems have sufficient sensitivity to have identified them. Cost efficacy and cost efficiency: with a network, you can procure the things that you need cheaper. The PHLS managed that very successfully latterly in terms of diagnostic reagents, the media which it manufactured and things like that; so I think there are real economic advantages to be had there. There is the opportunity to have the necessary scale to purchase some of the newer technologies, the capital cost of which does not come cheaply. On the threats or otherwise from commissioning, clearly the laboratory reporting element of surveillance requires that someone wants to do the test, and threats can come to that from the introduction of various economic devices to introduce efficiency; or indeed because of technological change. Equally, if there is a move towards more testing carried out by the attending physician nearer the patient, that of itself may impede the flow of information. Frankly, we have just got to address these issues almost in a reactive way. I suppose I feel that having a network that is part of a wider public health service gives you an administrative mechanism that will just make that a little bit easier to do.

Lord Turnberg

  706. You have described the different systems, and from what you say they could all be made to work in one way or another. In England, we are changing from one sort of system to another sort of system of laboratory networks. What recommendations would you make to the HPA in England as to how they should organise their affairs under the new organisational arrangements which resemble more the Scottish and Northern Ireland models than the Welsh model?
  (Dr Donaghy) From a Scottish viewpoint, going back to microbiological laboratories, I think you need to engage—do you still have NHS trusts in England?

  707. Yes, this week anyway!
  (Dr Donaghy) What you must not let happen is to lose the plus points of the national system which you ran through the Public Health Laboratory Service when it is devolved to local providers. Considerable effort must go into ensuring that things like standard operating procedures, reporting systems and data quality assurance continue to be enhanced. That will lead to a degree of networking on the technical side, but it will also need some degree of networking through local people with the decision-makers in local healthcare providers, be they general managers, key clinicians or public health people. That is one recommendation that I would make.

Chairman

  708. Dr Smyth, you said that there were no public health laboratories in Northern Ireland and that the diagnostic service was in NHS trusts. Is there any case for believing that the public health aspect of this suffers because the focus may well be more on clinical diagnosis and clinical service than the broader public health side in Northern Ireland?
  (Dr Smyth) In my earlier response, my Lord, I said that there were no public health laboratory service laboratories in Northern Ireland. One of the hospital diagnostic laboratories, as well as providing a diagnostic clinical service to the hospital, undertakes food, water and environmental microbiology on behalf of the Province. It is a public health laboratory; it is not part of the formal Public Health Laboratory Service Network.

Lord Turnberg

  709. What about the other laboratories and their public health role? How do they get entrained? Is it personality-driven; is it driven by a common understanding of the problems; or is there a sense that they are inward-looking and do not balance the two elements?
  (Dr Smyth) They would provide a clinical service to the hospital and to the local GPs; so if there was a food poisoning outbreak the GPs or the environmental health officers would arrange for the faecal samples to go to the local hospital microbiology laboratory. If that laboratory had any positive results, they would be forwarded to the consultant in communicable disease control for action, and also to my unit for regional surveillance.

  710. It works.
  (Dr Smyth) It works. It is still mainly a manual system, but, as I said, we have this good voluntary tradition of central reporting, which is largely down to goodwill. It has worked well despite laboratories being under quite significant pressure.

Baroness Finlay of Llandaff

  711. Dr Donaghy, I do not want to put you under great pressure, but the next question might feel like that. The report on the Lanark outbreak of E-Coli was very critical of the hospital laboratory and made specific recommendations. The report was critical of the hospital laboratories being isolated from the public health function in a way. I wondered how confident you are that across Scotland within the trust laboratories those criticisms have been completely addressed, to avoid a re-run of the same?
  (Dr Donaghy) Can I declare an interest? I worked for Lanarkshire Health Board at the time of the outbreak and I was part of the outbreak control team. There were two criticisms made about the microbiological system in Scotland resulting from Lanarkshire. One was the clinical microbiology services, and the second was on food microbiology services. The issues were to do with surge capacity. The Lanarkshire incident was a massive incident, with two to three thousand people coming forward, with 500 cases, in a short time. That was not also on the microbiology side but on the clinical side and the public health side. It stretched us close to breaking. The key issues for the clinical side were the lack of a common approach to B-tech diagnosis; the lack of serology taken of patients. That was not a standardised approach to diagnosis and was open to interpretation by clinicians in different ways; so the meaning of the test was different. The third was the actual capacity and the ability for networking in those laboratories. They were, I would say, the three key things on the clinical side. We have improved. We have got better networking. We now have a Scottish Microbiological Forum. We have more formalised arrangements through emergency planning and outbreak planning to deal with such capacity. Coming back to the point I have already made, we still have a weakness in our system, that we do not have standardised operating procedures and common approaches. We still need to work on that. The second major area related to food microbiology. I cannot remember how many thousands of samples were taken as part of the investigation, but it was a massive number, and we face the same problems of surge capacity. Our reference laboratory was also having to take the isolates from the food side and from the clinical side, and was overwhelmed. There was a huge lag in getting the data through. We have moved further on planning, procedures and sharing. One of the key lessons we learned from the Lanarkshire outbreak was the need to ensure that we integrate environmental microbiology, be it food or water, with human microbiology. We have taken steps to develop further a reference laboratory function in that regard. I would not want to say that after an event like that we have learned the key lessons one hundred per cent, but perhaps it is eighty per cent, and we still have some way to go.

Lord Haskel

  712. We have heard about the position in Scotland and Northern Ireland, and I wondered whether in Wales there are any problems resulting from regionalisation.
  (Dr Salmon) I think the short answer is "no", in fairness. Clearly, we have identified some of the things that will require more effort under the new arrangements than were required previously in responding to some of the earlier questions. Dr Smith has outlined some of the administrative mechanisms we are putting in place via things like the Five Nations Group, to try and address those, and to ensure that the various constituent parts of the United Kingdom stay in place. I might observe that this is not simply an issue for devolution and the devolved administrations, but if the intention is that more health responsibilities are passed to regional offices of government in England, then this will become, in every sense, a UK-wide issue.

Chairman

  713. During our inquiry we received a number of suggestions that it is important to have collaboration between the different levels of surveillance, from the EHOs, right up through to the Public Health Laboratory Service. To what extent is the interface between clinical/medical microbiology and food, water, environmental and veterinary microbiology, adequate in your respective regions?
  (Dr Smyth) My Lord Chairman, this is a very real issue. We would all agree that to have comprehensive communicable disease surveillance we need to draw upon microbiological information on food, water and environmental specimens as well as veterinary microbiology. In Northern Ireland, we have a population of 1.7 million people, and approximately the same number of cattle, so we are very aware that what happens as regards animal health may have a bearing on our human health. The classic example of that at the minute is that we have had a resurgence of brucellosis in the cattle population; and we have had approximately 70 human cases of brucellosis in the last two years compared to less than ten in the whole of Great Britain, so we are very conscious of this issue. However, it is difficult to integrate this data. On the human side, the specimens are generated, by and large, from symptomatic individuals who have sought care from their GP or hospital. The public health laboratory would be receiving samples from environmental health officers. These samples may arise out of a structured survey that has been undertaken in Northern Ireland, or perhaps out of an FSA UK-wide survey, or indeed as part of an outbreak investigation. It may be that the environmental health officer, as part of his routine visit to a catering establishment will lift some samples at random. In Northern Ireland, to ensure the smooth running of the laboratory, and to ensure that they are not overwhelmed with samples, each district council environmental health department is given a quota of samples, so that on a given day they can supply a maximum number of food and other environmental samples to the laboratory. Therefore, if you are extracting the data from the public health laboratory on food samples, they come from a range of sources. The food may be imported, or it may originate from within the UK or Northern Ireland. It is difficult to link this. On the veterinary side, there have been problems in interpreting the data and trends post foot-and-mouth; and, obviously, the economic conditions in the farming community have influenced sampling. Nevertheless, in Northern Ireland we have tried to address this. There is a forum which is chaired now by the Food Standards Agency, where the microbiologists from the clinical, veterinary and public health laboratories come together with myself and the Food Standards Agency. We bring our respective data. We try to detect the trends and suggest a picture of how this forum has generated research ideas and instigated certain surveillance studies in food and animals. Northern Ireland is a small place geographically. We have a stable population and a relatively small number of diagnostic labs, and we have one public health laboratory and two veterinary laboratories. We should perhaps be better placed than other areas to try and pull some of this together. Indeed, with the Department of Health's strategy on anti-microbial resistance, we have started discussions with the Enteric Reference Laboratory at Colindale, where our human and animal salmonella isolates go for further identification, to see if we can get back the anti-microbial resistance profile and see how that can be linked, and compared with the patterns seen in Great Britain. It is an area that we would like to develop, but we are very conscious that it is not as straightforward as it might be made out to be.
  (Dr Donaghy) I concur with Brian's comments. Technically, it is complicated to link data from different surveillance systems, but it is an area in which we are looking to progress along similar lines. One area is anti-microbial resistance, and that is where we are undertaking work, as is done in England and Northern Ireland. Because we also handle environmental hazards, a key issue for us is the integration of health surveillance, such as cancer surveillance and congenital abnormality surveillance, with our systems. We also have an agenda where we are looking to better integrate areas such as the burden of health with our monitoring programmes. We are in a similar position: we have a Scottish food group, which brings together people from the veterinary field, the local authority field, and the human health field. On behalf of that group, SCIEH runs the food surveillance programme. Organisationally we can bring people together, and we are doing that. There are considerable technical difficulties, particularly because, going back to different techniques used in veterinary microbiology and human microbiology, there are considerable technical difficulties in this area. It is something we need to strive for.
  (Dr Salmon) I would endorse that this area is under-developed, but it is probably easier to address with the sizes of populations in Scotland, Wales or Northern Ireland; and if you look on those countries on the Continent that have been most successful, like Denmark, in integrating the animal and human health aspects of surveillance for zoonosis, they are much the same size. One of the important things is that you have a relatively small policy community, so you have the human contacts to try and take this forward. We have been quite successful with the Welsh food microbiological forum for some years now with the local authorities, which has effectively introduced Wales-wide sampling of ready-to-eat foods at the point of sale, selected at random. We were able to do that because there was sufficient personal knowledge and trust to be able to get that underway. We have even looked, with veterinary colleagues, at the possibility of developing veterinary surveillance. The reason we have not progressed it very much of late is that there are quite interesting developments going on centrally at DEFRA now with their surveillance project, which we have been feeding into. We think that this may provide a helpful platform for the whole of the United Kingdom.

  714. You may remember a meeting in Cardiff on zoonosis, which I found extraordinarily well arranged and very successful. It brought together several areas—medical, veterinary, environmental health officers. Our conclusion was that it certainly should be repeated on a regular basis because it got everyone talking, along the very lines that you gentlemen said should be happening. That was a very good indication that at ground level people could get on together and communicate very well indeed.
  (Dr Smyth) Within each part of the UK there is a zoonosis committee, which is multi-disciplinary and multi-agency. By definition, this will be facilitating sharing of this sort of information.

  715. At this point, I should declare an interest as a member of SACAR, the Scientific Advisory Committee on Antibiotic Resistance, which brings in zoonosis and animal-to-human problems and human problems.

Baroness Emerton

  716. For the background, my record is nursing and nurse education; and I am chairman of a healthcare trust. I do not think we have had one committee where we have not had information technology on the agenda; so the question is this: how is information technology used to best support communicable disease surveillance and control in Scotland, Wales and Northern Ireland? To what extent will the English system be integrated with these systems?
  (Dr Donaghy) From Scotland, we currently have two priorities. One is to develop electronic information exchange systems to facilitate the rapid and more accurate exchange of information. We have two key areas: one is microbiological laboratories and the second is NHS boards and public health departments. We are advancing on the first area through a system called ECOSSE, which is French for "Scotland". It is the equivalent of CoSurve, the system which is adopted in England. We are rolling out that programme. We have had considerable difficulties because each NHS laboratory works in a different way. They have their own laboratory systems, so there are technical issues with interfacing. It is a priority and we are making that happen. We are developing discussions with the NHS boards' public health departments on general public health surveillance, and in that area we are defining common data sets. The second priority for us with regard to information technology is to move our systems on to the new web-based technologies. A key advantage in that is that currently we take the data; we analyse it, interpret it and present it, and then feed it back. Often, the way we feed it back to the people who give it to us does not make sense for the particular questions that they have to deal with. Web-based technologies offer us an opportunity to have more interaction, once the data is placed on the Web, to enable local interpretation analysis. That has opened up a third issue for us, which is our third priority, and that is how we at the centre can facilitate local units with microbiology and public health in developing the skills and technology, and being updated. We have outposts of staff working in the main units that deal with HIV patients in Scotland; and we have seen great benefits in the quality and relevance of the information in the HIV field by having our staff working with local staff. That is something, resources permitting, that we would like to develop.

  717. You have mentioned the magic word "resources"; is there an issue about resources in terms of central allocation, or not?
  (Dr Donaghy) There is always an issue with resources.

Chairman: We have a division.

The Committee suspended from 11.38 to 11.50 for a division in the House.

Baroness Emerton

  718. I had just posed the question about resources.
  (Dr Donaghy) Resources is always a problem—resources tied to priorities. I think on the communicable disease side—somebody mentioned the Lanarkshire outbreak; food and outbreak control became a big issue and resources went into that. The current two priorities we have in Scotland just now are healthcare associated infection and, linked to that, the potential transmission for VCGD through surgical instruments. We have expanded our involvement in that area, and I must say that the Executive Health Department is investing in that area. The second major issue is bio-terrorism and deliberate release. We are not getting as much investment in that area as we are getting in HAI, but we are getting some investment. We are upgrading our surveillance and we have been in discussions with the Executive Health Department, so we can strengthen things further. There is a cross-over: although we get investment for specific issues, you can upgrade your general systems in these areas, and often for ourselves it is making sure that these issues are raised with the Executive and that we are fully engaged in decision-making about them, as appropriate.
  (Dr Salmon) The English system is substantially a CoSurve system, and I should point out that it was built in Wales in 1992 by the IT team that we still have as part of the Public Health Laboratory Service in Wales. It was built on time, despite its eleven-year longevity, and for a very modest sum denominated in tens of thousands of pounds rather than anything else; and that team has gone on to build three other highly successful information technology projects for infection control. If you think of the generally sorry story of IT procurement in the public sector, I am very happy to put on record that that is a considerable achievement, and I would hope that the Committee would agree. One of the reasons it has been successful is that its manager is an engineer and builds it according to engineering principles of working out the specification of what people want, and then having a continuing dialogue with clients. That, in a sense, caused me to think, when I read this question, whether you were expecting me to answer it technically and say that we should have a system of distributed databases, or a system of centralised databases; or perhaps more generically to say what information technology strives to contribute to communicable disease control. It might be worth dwelling on the latter for a second because much quotidian disease surveillance is a rather mundane, dare I say dull activity. What information technology has permitted is a degree of automation and efficiency in the collection and collation of the data. It also permits rather more sophisticated analyses, if they are appropriate and you want to do them, than was the case before we had this. The other important aspect that we are only just getting round to addressing is that mediums like the Internet allow much greater accessibility to the information and results than was even the case ten and twelve years ago. The curious, of a faintly scientific inclination, can get very up-to-date information from very authoritative sites about the situation in Wales, Scotland, Northern Ireland, the United Kingdom and the world. All this has been made available by intelligent application of IT in the area.
  (Dr Smyth) One benefit of CDSC in Northern Ireland being part of the PHLS infrastructure is that we have been able to reap the benefits of their IT developments so that we are rolling out to our laboratories and health boards in Northern Ireland the IT reporting systems such as CoSurve. Therefore, we did not have any developmental costs. Later this year, software is being rolled out in England to facilitate the capture of anti-microbial resistance data; and, again, we would be taking that for use in Northern Ireland. Because of our size, it is unlikely that we would have the resources or skills to develop a communicable disease IT system that would be unique to Northern Ireland. It would be much more sensible to take what works elsewhere in Great Britain. The other point I would like to make is that it is not just a matter of having hardware and software; it also requires the skills to use it. There is a very great need to have these skills in a hospital, in a health board, working with, for example, infection control teams, with the consultant in communicable disease control, so that there is somebody there who can extract and manipulate the data under instruction, to give the information to the infection control teams, to say, "here are the trends in this ward/department; it has doubled over the last two or three weeks and perhaps you should look at this". We need analytical and IT skills built in to each acute trust and health board. This will be particularly important when there is a big outbreak because then small departments can very easily be overwhelmed. Similarly, the work of an infection control nurse is very much paper-based, keeping notes of the patients with MRSA in the hospital and so on. They need some standardised, validated statistical package, such as they are developing in Wales, to allow them to quickly track infectious patients in their hospital so they can update what the injection control precautions are and have a much more reactive accessible system, rather than making notes here and there which get lost.

Lord Haskel

  719. I was interested in your comment that you got an engineer to do your IT system. The reason why it can be done cheaply, I presume, is because it was not given to IT consultants, who would just add the noughts on.
  (Dr Salmon) We have had an in-house team for 16 years now, which has been built round the original member, who is head of informatics now, and who is an engineer by background. We have found that invaluable because not only do they have an appreciation of the technical aspects of the information technology, but they have developed an in-depth understanding of the business that they are trying to build for. It does not seem to me that you can usefully extensively substitute consultants for that. It is fair to say that we sometimes outsource discrete bits of work, but we do that in the knowledge that we have people who can superintend those contracts properly.


 
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