Select Committee on Science and Technology Minutes of Evidence


Examination of witnesses (Question 720-730)

THURSDAY 20 MARCH 2003

DR MARTIN DONAGHY, DR ROLAND SALMON AND DR BRIAN SMYTH

  720. Is your system able to communicate with other systems?
  (Dr Salmon) The short answer to that is "yes". Currently, our team are working on a system called the Microbiology Data Store, which does what it says; it stores data from microbiology laboratories in open-access architecture (that is just jargon to me, but may mean more to others) in such a way that you can bolt on to it other pieces of software, other surveillance systems as necessary. What the teams tell me is that the integration of systems at the technical level is not a problem at all; you can build interfaces relatively easily and move information from one database to the other. Far more problematic, and which we are not scheduled to discuss today, are the increasing institutional and cultural barriers to the sharing of information, particularly between different organisations in the public sector. That is a very real concern because this could serve to undermine the technology that we all regard as being an advantage.
  (Dr Donaghy) I would say that there is a technology side, but as an addendum to that, I would say that in terms of the important issues around information-sharing, confidentiality, data protection and straightening out that area, is more now of a priority than simply computer hardware and software.

Baroness Finlay of Llandaff

  721. You have half answered the next question, which relates to the problem of confidentiality and your views on consent. It has been suggested that we should have a system whereby patients opt out of their data being collected; in other words, there is an implicit consent that in the nature of the specimen being collected, that data will be logged and that the consent should be the other way round. What are your views on that?
  (Dr Salmon) I suppose I would have to declare that I would be sympathetic to that as a way of proceeding. I find these questions a little difficult to answer generically because it seems to me that within the practice of healthcare there is a great deal of information, some of which people feel particularly sensitive about, but some of it not. It gets caught up in the same legislation although people do not actually mind very much when you talk to them informally. In a sense I would like to feel that there was a system that exhibited that degree of differentiation. Also, I would like to feel that just as, for example, for the purposes of law enforcement there are clauses that override this right, for severe instances where public well-being is endangered, that these could be applied. I would have thought that a potential mechanism for this might be via the promised new Public Health Acts. In the shorter term, much could be done to simplify the Health and Social Care Act to make the sharing of information for individuals ultimately for their individual benefit rather easier than it is currently.
  (Dr Donaghy) In Scotland we have three legislative areas which govern this. One is data protection, the second is the General Medical Council interpretation, what is ethical or not, and the third is the European Convention on Human Rights—which, in Scotland, we were ahead of the rest of the UK because of our separate legislative system in bringing into legislation—and the ECHR does provide a public health rider which overrides confidentiality. However, the interpretation of that into law is a key issue, and in Scotland we are looking to take forward legislation on that. In terms of the specifics of an opt-in or opt-out, I would prefer, unless somebody explicitly says no, then consent is given. However, we are finding that increasing numbers of people are wanting to get access to information held by us for reasons of litigation and making that practicable is something that we have to be a lot more specific on.

Chairman: Can we turn to manpower now. Lord Turnberg?

Lord Turnberg

  722. I think the answer to this is fairly predictable, but I will ask it anyway. Do you consider that the numbers of microbiologists and clinical risk measures are adequate to run an effective programme in Scotland, Wales and Northern Ireland? You can be brief if you want.
  (Dr Donaghy) Certainly. They are not adequate. I think the adequacy and the effectiveness always comes to light when the system is tested. If I could then just say what the two current tests are in our system. Firstly, healthcare associate and infection, is a priority in Scotland. Microbiologists, as well as providing diagnostic function, they are often infection-control doctors and recent work has outlined that we are short of microbiological expertise. We have an aging cohort of microbiologists, and there is worry that there is a dissonance between the number of trainees coming in and the number of people going out. Certainly, we are probably—in terms of WTEs and in terms of posts which require filling—about 10 per cent short currently and that situation can only get worse. In terms of infectious disease physicians, I think, in comparison to the rest of the UK, we are comparatively well endowed. Recently with bio-terrorism and the smallpox plan, we have been looking at ID physicians' rotas about availability of the skills of ID physicians, particularly in differentiating rashes, areas such as that. We cannot cover the requisites of the smallpox plan and mesh that with rotas in terms of having sufficient ID physicians on call to do that. With ID physicians, of course, there has been a considerable move for infectious disease physicians in Scotland to have general medical duties in terms of admissions. Also, there have been changes in the role of adult ID physicians caring for children, and we only have one paediatric ID physician in Scotland and, again, that is an area that needs strengthening.
  (Dr Salmon) I substantially agree. In terms of just what skills are lacking, I think the biggest problems in Wales are we really do not have enough ID physicians. We have three and they are all in South Wales and they all have general medical duties as well. So that is one key area. The second key area is medical laboratory scientific officers, which is an area where it is proving both difficult to recruit and to retain, and they still remain, in the current level of technology, a particular key element in the efficient running of the laboratory.
  (Dr Smyth) In Northern Ireland, my Lord, we have a particular acute problem in that we have two adult ID physicians, one whom is about to retire, and one paediatric ID physician. As my colleagues have said, trying to operationalise the UK smallpox plan is causing considerable difficulties, and the Department of Health in Belfast is looking at how best ID manpower should be addressed. I would fully concur with the remarks my colleagues made. Regarding microbiology, we have several vacant consultant microbiology posts, and I understand there is a national shortage of such consultants, and some of our other microbiologists are on long-term sick leave. So really we are very stressed at the minute and if we had a major communicable disease problem, that would severely stress the system.

Chairman: You echo what we have heard previously about England and its general problem. Any other comment? Can we move on to question 7. Baroness Emerton?

Baroness Emerton

  723. Thank you, my Lord Chairman. Could I just ask to what extent the training of health professionals in your view is adequate to support infectious disease prevention and control in each of your areas, Scotland, Wales and Northern Ireland, and perhaps to add to that, the support staff as well and ancillary staff?
  (Dr Donaghy) Thank you, my Lord Chairman. I will lead for Scotland. If I could first deal with professionals working in the public health field involved in communicable disease control. One particular worry for us is a dwindling of numbers of environmental health officers in local authorities in Scotland and we are now down to just one training course. As we deal in SCIEH both with infection and environmental hazards, that is a concern for us in Scotland. Also, in Scotland we are concerned to ensure that public health professionals not working in communicable disease control—that is not specialising in that area—have sufficient skills to be able to man on-call rotas. We have had problems in that area with the quality of decision-making in recent incidents in Scotland, and that is a priority for us to improve that situation. Moving on then to health professionals who do not work in the public health field, or whose main job is not public health. Our current priority is related, again, to infection in hospitals, and that is improving training and hygiene, in particular in hospitals for all levels of staff. There is in Scotland a ministerial task force, led by the chief medical officer, taking forward a wide-ranging programme on HAI and it will be introducing mandatory induction training and, if we can, mandatory CPD around hygiene and infection control. I must say one particular group that we always have difficulty with in this regard is the medical profession. So there is that area and that is a priority for us. The second area we have—looking at our priorities around the bio-terrorism side—is the recognition of unusual illnesses, or illnesses which present in unusual ways. Recently in Scotland we had the experience of the first case of rabies for 100 years. There are issues about diagnostic and the sensitivity and the level of in-depth suspicion that there is in clinicians around unusual illnesses, which could be of an infectious nature, so that is the second area. The third area is really making sure that everybody working in health and, particularly I would say, not just health professionals and clinicians, but people like managers and people on boards, are aware of the importance of public health surveillance, public health intervention and sharing information. Going back to the previous point about information sharing, people can be quite territorial, and that can impede effective intervention.

Chairman

  724. Dr Salmon?
  (Dr Salmon) Just one related comment. I see a strong case for a wider dissemination of the more general skills of field epidemiology. That does not mean I think there needs to be more epidemiologists and, indeed, that might be quite self-defeating. It seems to me a number of the professional groups, who encounter infection problems, would function better if they had a better understanding of a relatively modest level of attainment in that area. For example, I do not think we teach enough epidemiology to our infection control nurses, bearing in mind that this is essentially a population problem that they are dealing with when they have to contain infection within a hospital. For example, our health visitors would make a better job of explaining the rationale behind immunisation if they had a better grasp sometimes of the principles on which those decisions were based. I think, microbiology training—although it is improving—could usefully introduce a greater epidemiological component. Two relative success stories, one on a Welsh basis, one more nationally. We have been successful in introducing it more widely into the undergraduate medical curriculum and I think that has been beneficial. It is now a much bigger part of the culture than it used to be. At the University of Wales Institute of Cardiff they have successfully introduced it into the environmental health curriculum and we have reaped the benefits of that over several years.

  725. Dr Smyth?
  (Dr Smyth) Yes, my Lord Chairman. This problem has been recognised by the medical school in Belfast. Recently there has been increased emphasis on infection control and related issues, and we wait to see how this extra input into the undergraduate programme will lead to changes in junior doctor practice. My colleagues have mentioned that hospital medical staff do not often seem to get regular updates on infection control, and we have recently undertaken a survey in acute trusts in Northern Ireland, which very starkly bears this out. There is plenty of training for ancillary and nursing staff, but very little structured updates for medical staff. I firmly believe that consultant colleagues can act as very important role models to the junior staff, and if a consultant is seen regularly washing his hands, the junior doctors will then do it. One point that has not been mentioned yet is that there is a great dearth of knowledge among healthcare professionals in the variety of community settings on infection control. GPs have not got a good knowledge base on infection control, nor do staff working in residential and nursing homes, many of whom are working in the private and voluntary sector. They are maybe not covered by the trust's community infection control nurses, and any support they do get from the trust is perhaps only on a reactive basis if there is an outbreak. I feel that—certainly in Northern Ireland—we do need enhanced community infection control provision, which is not just to trust facilities but to a range of day centres, private and voluntary, residential and nursing homes, because that is where many of our SRSV outbreaks occur. As we know, these organisms can very rapidly spread in these homes and there is a need for regular proactive updates on infection control. Dr Donaghy has mentioned the importance of ensuring that public health doctors, who work perhaps on an on-call rota to deal with out of hours communicable disease issues, must be kept up to date. We try and do this in Northern Ireland with at least one annual event every year where we update our colleagues. Clinical staff, as well as getting the skills to enable them to undertake personal infection control matters, also need to recognise the public health dimensions of infection control. So if they do see something untoward, they know to report it and what the public health response is likely to be. If they are aware of the chain of events which is potentially initiated by their first report, that might encourage better reporting. These issues are very much alive to us in Northern Ireland.

Chairman: Could we move on then to question number 8, more on the international scene.

Lord Haskel?

Lord Haskel

  726. Thank you, my Lord Chairman. We have had a little bit of discussion about the international scene. Dr Donaghy mentioned about his connection with the World Health Organisation and also there was a mention about EU development sharing data. To what extent does communicable disease control in Scotland, Wales and Northern Ireland link in with international infectious disease problems?
  (Dr Donaghy) From Scotland we have different types of interrelation. Firstly, professionals working in our field liaise with colleagues European-wide, and one of the key developments has been the development of the EPIET training. This is a training for epidemiologists working in communicable disease, which is a European-led development. The second area is that in Scotland we have a section which deals with travel-imported infection. We run a web-based system called Travax, which is a system that is available to general practitioners throughout the United Kingdom, which offers them access to advice to give to patients who turn up in the clinic on what precautions they should take if they are visiting a particular country. That is a UK-wide system which we run in Scotland. Through running that and gathering the information on what is happening in Borneo, or what is happening in Wandoan or wherever, we scan what is available from the WHO and we have good links with WHO personnel on that. The third area we are involved in is that at times Scotland, on a European-level, is considered the equivalent of England because their systems are slightly different and, therefore, we participate in certain networks around the sharing of surveillance data on a European-wide basis—this is beyond the European Community, this is European-wide—areas such as MRIC surveillance, enteric infections. Unfortunately, we have particular experience in Scotland on e-coli 157, which we can bring to the table. So we do have links there. The last area, which is growing, is the formal ongoing development of EU systems, the European Commission. Of course, that is a UK-wide area—it is not a devolved matter—and we link closely with our colleagues at Colindale, particularly Angus Nicoll from CDSC, who co-ordinates a UK-wide response to link with the Department of Health in negotiations with the EU and I think that is through, what has already been alluded to, the Five Nations Conference. The Five Nations mechanism is obviously the four UK countries and also, because of the close links with the Republic, they participate in these discussions. So we have a range of links internationally. We have a link with certain universities in India through the British Council, these have grown up through the years, but formally into European Commission decision-making, it is led through London and I must say they co-ordinate it and they are more than willing to take suggestions from any of us on the development policy in that area.

Chairman

  727. Dr Salmon?
  (Dr Salmon) You will recall, my Lord Chairman, from your meeting in Cardiff that we know a lot of people, and that has formed a very fruitful basis of the professional collaboration over the years. This weekend my colleague, Dr Meirion Evans, should be flying out to Peking as part of the WHO mission there to look into the acute respiratory syndrome. We have participated actively in EPIET—the European Programme for International Epidemiology Training—and we have hosted three trainees over the years, two from Sweden and one from the Netherlands. I would perhaps put in a special word for that scheme, because it has been a remarkably fruitful network-building scheme since its inception in 1995, which we also participated in. For example, when we had a case of meningitis in a French-exchange schoolboy and all his contacts were already on the bus somewhere between Wrexham and Calais, we were able to ring up the Institut de Veille Sanitaire and who should we find at the other end but one of the trainees who had been with Brian Smyth in Northern Ireland. So, of course, this greatly facilitated making the antibiotics available when the bus arrived. In fact, it was a very efficient demonstration that the local Me«dicin Inspecteur d'Hygiene was there to meet the bus on its return. Those kind of professional links we have used on a number of occasions and they have been used equally by other colleagues in other European Member States. We have links with the Centres for Disease Control. We have employed two epidemic intelligence service alumni over the years and we have worked with them on infectious causes, with the CDC on infectious causes of chronic disease and we have some links with Health Canada, particularly in the area of VTEC, verotoxigenic, E.coli and the spongiform encephalopathies. So, although they tend to have been built up, or have their origins as professional collaborations, nonetheless they have been sustained over a number of years to, I think, very tangible public health benefits.
  (Dr Smyth) I have little further to add to that, my Lord. Liaison, as far as Northern Ireland is concerned, with international agencies is generally through CDSC at Colindale, or the Department of Health. We are a host institute for Fellows under the EPIET programme, and several colleagues in Northern Ireland participate in the teaching of that programme but, as I say, generally everything is through London.

  728. When we were at the World Health Organisation there was some criticism of England really not participating fully in seconding people for short or even longer periods, but from what you are saying your regions are willing to do that and, in fact, do that.
  (Dr Salmon) I think, paradoxically perhaps, we may value this more than some of our counterparts in England do, simply because—as the thrust of the question identifies—we do recognise the importance of belonging to networks of knowledge that are operating at the highest level, and this is one of the mechanisms for ensuring that that is the case.

  729. I am wondering if we can go on to the last question which is basically directed to Dr Smyth. If, indeed, the division bell goes before you finish, perhaps because of the time, if you have not finished, you could let us know your answer in writing. I am sorry to ask you to do that, but we never know when it will go. What, if any, are the formal relationships with the Republic of Ireland in the area of infectious disease prevention and control?
  (Dr Smyth) There have always been very good personal relationships between communicable disease professionals on either side of the border and that was really based on close personal contacts. However, co-operation between health boards and other surveillance units, both north and south of the border, has been steadily strengthened over the years and I can illustrate this by a number of examples. At a health board level where most of the day-to-day communicable disease work is undertaken, the health boards on either side of the border are currently working on a joint cross-border outbreak plan, which will be ready this year. At a regional or national surveillance level, my staff would be in at least weekly contact with their counterparts at the National Disease Surveillance Centre in Dublin. We are both host institutes for the EPIET Programme and are currently sharing an EPIET Fellow, who has just finished a year in Belfast and is now spending a year in Dublin, as part of his two-year attachment to Ireland. Last year, for example, we had a series of one day training seminars for the scientific staff in both institutes using validated EPIET training materials. This brought together the various surveillance officers who, for example, could meet their opposite number, look at what case definitions or methodology they were using for their tuberculosis and flu surveillance. So it provided a very good opportunity for networking, and for looking at how each other did their work. As has already been mentioned, the director of the National Disease Surveillance Centre in Dublin is a member of the Five Nations Group, which I suppose would be the formal liaison mechanism. At a governmental level, the Department of Health in Belfast sits on the Republic's immunisation advisory committee, and the Department of Health in Dublin also sits on the UK joint committee on vaccination and immunisation. There is extensive liaison on the animal health side, between both Departments of Agriculture. Then under the Good Friday Agreements in 1999 a number of cross-border bodies were set up, one of which is on food safety. The Food Safety Promotion Board has surveillance functions where they take surveillance data from the north and the south and look at it on an all-Ireland perspective. They are facilitating and promoting harmonisation of surveillance systems, of food laboratories working together and have funded some useful research, such as a random population survey of the level of infectious gastro intestinal disease in the community, north and south, similar to what the FSA funded in Great Britain a number of years ago. Another example would be two or three years ago when there was a north/south study of MRSA bacteraemia. So I think, and I hope, that those examples have shown there is really quite considerable co-operation between Northern Ireland and the Republic of Ireland on a range of communicable disease issues.

  730. Thank you very much indeed for that response, which is very encouraging, of course. Gentleman, the time is moving on, and we have got to the end of our questions. May I thank you very much indeed for coming along and being so forthright with your answers to our questions, and putting up with the interregnum that we had to have a short while ago. If there is anything that you feel we have not covered and should have covered that is important, please feel free to let us know in writing. In addition, you will get a transcript of this morning's deliberations and you will be able to correct any of the factual areas and send it back to the clerk. Again, thank you very much for coming along. I hope you felt this was a useful session to you; it certainly was a very useful session for us. Thank you.
  (Dr Donaghy) Thank you, Chairman.
  (Dr Salmon) Thank you.
  (Dr Smyth) Thank you.





 
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