Examination of Witnesses (Questions 880-896)|
BLEARS MP, DR
TUESDAY 8 APRIL 2003
880. Perhaps I could just explore a little more
about standards. I am interested to hear about the Regional Microbiologists
and the Inspector. How are we going to ensure that standards are
levelled up rather than down? Are we going to have a sort of Ofsted
for microbiology? How is it going to be done?
(Ms Blears) We are not going to have an Ofsted because
we have already got at the moment the Commission for Health Improvement
and following our legislation we are going to have the Commission
for Health Audit and Inspection. So the Inspector of Microbiology
I think initially is going to start off in public health and then
he is going to go across, or is planned to go across, to the new
Commission for Audit and Inspection. So we will have very much
an inspection role within that existing framework.
881. I understand that in the past there were
NHS Trusts that did not report to public health and the laboratory
service. What will the Department of Health do if there is a Trust
that does not report in this way in the future?
(Ms Blears) I understand that the vast
majority of laboratories actually did report through the system.
I am not aware of what the proportion was. I do not know if your
Lordship has had any figures around the proportion. My information
is that the vast majority did.
(Dr Wight) I think the current figures were around
90% of laboratories currently report. Those are the latest data
that we have and that is in consultation with the HPA I got those
(Ms Blears) But the Regional Microbiologists will
be working with all the laboratories and that I think will probably
be quite a big issue for their agenda; how do you get all the
laboratories up to the same standards? And they will be on the
ground in those regions working with the Regional Directors of
Public Health to try and make sure that we do draw in as many
as we can.
Baroness Finlay of Llandaff
882. If I can just carry this on a little bit
because the laboratory is dependent on the quality of specimens
and the appropriate specimens that come to it. So no matter what
standards or levers you have on the laboratory, it is actually
dependent on the clinicians. I am not clear where the joined up
answerability comes in and at what level it is going to come with
the Regional Microbiologists, on the hand, responsible for the
laboratory side and monitoring that perhaps and auditing that
with the problem that occurs now on wards where patients do not
necessarily get their temperatures taken regularly, or they do
it with these ridiculous little blue ear things which are sometimes
incredibly inaccurate and you cannot find an old fashioned mercury
thermometer anywhere in the hospital, even though it is actually
quite an accurate way to measure temperatures. And unless you
have got that very sensitive and important clinical pointer to
systemic infection, you are not going to get the right specimens
at the right time from the patient to inform the whole process
and that has to be the early warning system where new organisms,
particularly resistant organisms, are emerging.
(Ms Blears) I think the collections at
local level are going to be very much the responsibility of Directors
of Public Health in Primary Care Trusts working in their networks
with their Regional Directors of Public Health as well, because
these are the people who are actually on the ground at local level
working with the primary care teams, not just inside Trusts but
in primary care as well in terms of GP referrals. So I think the
system does have connections both across the laboratory side through
the Regional Microbiologists, and then if you like through the
public health clinical side, through the Regional Directors of
Public Health, the Directors of Public Health in Primary Care
Trusts and their relationships with their NHS Trusts. And increasingly
the NHS Trusts will be performance managed by the Strategic Health
Authorities as well. So they will be keeping a very close eye
on what their performance measures are like. But again, you can
have those mechanical levers in terms of the connection, but what
we have to make sure is that the people who are out on those wards
and the GPs and the primary care professionals really feel that
what they are doing is making a contribution to reducing infection
and promoting good health because if they feel that that is what
is happening, the samples will be better, they will be sent properly
and you will get good proper data coming forward. Therefore I
think it is quite an education and teamworking role to try and
make sure that all of those clinicians are brought into why they
are doing it. If you just have a top down system that says "You
must do this" then my experience is that people do not respond
to that kind of management organisation. It has got to be why
you are doing it and what contribution that you are making.
(Dr Bickler) What you could add to that, as part of
what you are describing, is the issues that underpin clinical
governance really, the details of what individuals do and how
well they do it and I think we will be looking to those clinical
governance processes to also be contributing to that quality improvement
883. Just go back to the question I asked about
NHS Trusts reporting to PHLS, and I think it was Dr Wight who
(Ms Blears) Ninety per cent.
(Ms Blears) Ninety. Nine O.
885. Nine O. What happens to the other 10% that
do not? What would you do with those?
(Dr Wight) I think it is very much building on the
exactly the approach that the Minister has just outlined and I
think the regional teams, the Regional Microbiologists or Public
Health Microbiologists and the Regional Epidemiologists are going
to have a crucial role although they will be HPA employees, they
will be the interface, if you like, between the HPA systems and
the NHS. And there will be local Public Health Microbiologists
as well, around 30 or so, scattered around the country. And I
think putting together the local and regional public health microbiology
function that is really provided through the HPA will be absolutely
crucial in winning hearts and minds. I think it is very much about
this culture change and dialogue with the local clinicians and
giving feedback as well from the centre, from the seat, from the
HPA back to the local teams so that they know what the outcomes
are, what the impact is going to be.
(Ms Blears) I think what I would want to know as well
is why do they not do that now and what are the hurdles, what
are the obstacles, what are the reasons and then
886. You took the question from my mouth.
(Ms Blears) to pursue with them what we can
put in place to encourage them to be part of the system. I would
want to know why they are not.
887. Because you are funding them.
(Ms Blears) Indeed. That would be my
answer. That is after the culture change.
888. It seems to be a very substantial part
of surveillance in any case. For 10% not to be participating is
not really acceptable.
(Ms Blears) Indeed.
Chairman: Can we go on to question nine? Lord Rea?
889. This concerns the issue of targets to encourage
desirable aims and activity. I am sure that you are now quite
wary of targets because they can sometimes be more of an incumbent
than a spur. How do you feel that they apply to raising the profile
of communicable disease control and setting priorities in primary
care and hospital trusts in that area?
(Ms Blears) Targets in general I am a
supporter of because I do think that you need to stretch the system
to get results. I think the most disappointing part about targets
is when people perhaps miss a target by one or 2% and their perception
is that they have failed completely. There is nothing that annoys
me more than when staff work incredibly hard and get 73% as opposed
to 75% and there is no recognition for the tremendous progress
that they have made. So I think targets are useful but the way
that we seem to interpret them in the public sector is that you
have to meet them in their entirety. Whereas in the private sector
they are something to aim for by which you can measure your progress.
So I just think that we use targets in a slightly odd way, or
the perception in the public sector is not always helpful. I think
target setting is useful but it is not the sole tool of performance
management and again it is about what I was trying to explain
that you can have targets, which is a bit of a top down approach,
but you have got to get buy-in in order to get those targets to
mean anything at local level. We already use targets in this field
quite a bit and it has helped to kind of raise the profile, focus
minds, focus people's attention in these areas but again I think
targets have to be in an area where you have got some control.
It is pointless setting a target over which you have got no levers
so you cannot do anything in order to meet it. All you succeed
in doing then is disempowering people because they know it is
a completely unrealistic target. So from the areas for targets
around here are around screening for specific diseases and immunisation
coverage levels, because we can do something about that and people
can work hard to try and achieve those. We have got a couple of
examples which we are already using around the HIV testing for
pregnant women where we brought in the idea of having a universal
test for all pregnant women. That was a bit controversial at the
time because in places where HIV prevalence was quite low, people
questioned was it really realistic, was it needed, was it necessary?
And our target there was to increase the uptake of it, first of
all, to 90% and try and identify 80% of HIV infected pregnant
women during ante-natal care in order to offer them advice and
treatment. I understand the 80% target has been met in London
two years in advance of when it was supposed to be and my latest
figures for the rest of country indicate that it is already met
there as well. Which is fantastic news because the number of babies
who are now being born as HIV positive has gone down dramatically
because once we identify people, then we can use appropriate treatments
and appropriate methods to ensure that the children are safe when
they are born. And that is a real positive outcome, I think, for
anybody involved in that particular area. So that is where a target
has had a real effect and what it has done is it has mainstreamed
the public health agenda because it is now a mainstream ante-natal
service that people are offered the test. In terms of the sexual
health and HIV strategy generally that we have just published
and that I gave evidence on to the Commons Select Committee, there
is quite a lot of targets in that strategy where again the rise
in sexually transmitted infections is something which I think
worries all of us enormously around chlamydia, gonorrhea, syphilis,
all of those diseases now re-emerging in quite horrifying numbers.
So we have got targets in there to achieve a 25% reduction in
the number of newly acquired HIV infections and gonorrhea infections
by 2007 and to reduce the prevalence of undiagnosed HIV and STIs.
And we set a national standard that all GU services should offer
an HIV test to clinic attendees on their first appointment so
that we are trying to make sure that people get the test on their
first appointment and also that we get waiting times down because
the waiting times in GU services are now too long. So we have
got to get people seen quickly and urgently. We have also got
quite good surveillance systems to monitor how well we are doing.
The unlinked anonymous surveys that we do in relation to HIV are
a good way of seeing whether or not we are making progress because
again it is no use setting targets unless you are prepared to
measure what you are doing. And I think in the Hepatitis B area
we have set some targets again for people to be offered immunisation,
to get immunisation uptake to 90% by the end of 2006 and we have
commissioned a survey to monitor progress in increasing the uptake
of the Hepatitis B vaccine. In the longer term we want GU clinics
to collect this data as a matter of routine so we that will have
an ongoing way of measuring how the Hepatitis B immunisation programme
is going. So in the areas of screening and immunisation uptake,
I think targets are appropriate and we are certainly keen to move
on that level. But again, people have got to know why the targets,
what they are designed to achieve, what can I do to help them
become a reality and how can I make a contribution? So it is top
down and bottom up.
890. Do you think that targets would be appropriate
to in fact encourage the improvement of surveillance of communicable
diseases in general? That is one of the aim of this Committee
to try and put the case for improving this.
(Ms Blears) I think targets for improvement are quite
important, as well as absolute targets, because I think that there
has to be recognition that different people are at different stages
or they are dealing with different circumstances. And that is
why the score on MRSA hospital acquired infection is actually
an improvement score rather than an absolute target because you
have to recognise that some places, particularly tertiary centres,
will take people with more compromised immune systems and therefore
are more likely to get an infection and the circumstances in which
they are operating. So if you like, it is the added value argument;
if we can see how far people have come, I think improvement scores
are quite important because again you are not hitting people over
the head in asking them to reach something that is unrealistic,
but you are saying "I want to see you make progress".
Now in terms of surveillance, I think where we are at the moment
is that we want to strengthen the systems, which is why we are
getting the HPA and I think that will be more in terms of strengthening
words and making it more integrated rather than specific numerical
targets at this point.
891. Minister, this is going to sound like a
rather negative question, but you mentioned earlier that you were
disappointed when "certain things" but are you also
disappointed when people skew the system in order to meet the
targets? Because in this particular field that could be extremely
dangerous and it strikes me that people tend to do that when either
their personal remuneration or the money attracted to their unit
is affected by not hitting the target. How do you propose to ensure
that that does not happen in this particular case?
(Ms Blears) I would be very concerned
if people do skew their activity in order to meet targets. I think
all of us as Ministers would be because what we are interested
in is a decent health service that serves patients properly and
there is no credit in the system if the figures lose their integrity
because of certain actions that a small, a very small, minority
of people might take. We have a real vested interest in making
sure that the targets, the information that goes out to the public
is trusted and therefore we would not want to see that information
undermined in any way whatsoever. I think particularly in the
area of communicable disease, then integrity is overwhelmingly
important and that is why I am saying at this stage what we want
to do is to create a system which is an integrated system, professionals
working together feeling like they are delivering something really
important for the community and therefore I think I would be loathe
to go into the area of numerical targets when what we are really
about is building partnerships and building relationships and
getting people to have that trust together. So I think I say I
am disappointed when people interpret targets in the wrong way
because I think that acts possibly as a lever for people to feel
that they are constrained in this way. I will give you one example;
in the area of thrombolysis, which is an area I deal with in coronary
heart disease, we had a target for people to get 75% patients
seen within 30 minutes because early thrombolysis saves lives,
simple as that. We are not doing it because it is 30 minutes,
we are doing it to save lives. The staff came up from a base,
I think, of 39% up to 73%. The target was 75 and suddenly a target
was not met. Well, they had done a fantastic job and saved hundreds
of lives in doing that and therefore I think we need a more mature
debate in this country about how we use targets and what the perception
is when they are met.
Lord Lewis of Newnham: But Minister, how do you make
a decision between 75 and 73 as a target?
Baroness Finlay of Llandaff
892. My question relates, Minister, to the previous
question about targets because another concern, quite apart from
the one already alluded to where there may be deliberate misinterpretation,
is just sloppy practice. Namely that you are below the target
in MRSA detection and whereas septicaemia is a classic where if
you are really rigorous and take really good blood samples you
are likely to correct it. So if you have got very sloppy practice
and you do not even think of it, you will not take the right blood
cultures to detect it. So a unit may be falsely low because the
process of this target setting and the true measurement actually
has not been audited or checked and I wondered what you are doing
to make the target setting more sophisticated in terms of better
reflecting the clinical process rather than being something for
the newspapers to use as a headline because it makes a great banner,
does it not, on a newspaper.
(Ms Blears) Yes, it does.
893. But it is not an accurate headline necessarily.
(Ms Blears) I think it is quite a complex area in
terms of trying to compare like with like and making sure that
you have got the same kind of data about different places. When
you are at an early stagefor MRSA, I think we are only
just beginning to get the data coming through. It is the first
time that we have ever kind of measured anything and that is why
we want to go to improvement scores because this is quite fragile
data and there needs to be an encouragement to people to report
and then we can see what kind of progress they are making rather
than setting absolute targets. I think also the Commission for
Health Audit and Inspection increasingly will have a role in this,
as CHI has through its clinical governance inspections as well.
So increasingly in the system we have now got some responsibility
for making sure that when we do audit, when we do inspect we are
drilling down into what their data systems are like and what they
are collecting. I say it is an imperfect science, it always is
going to be in terms of performance indicators and performance
management, but it is a lot more rigorous than it ever was and
that is why I am a defender of targets, if they are used appropriately.
Because otherwise we have no way of measuring often what is going
on in different organisations. If you think about the NHS, I think
every Member of the Committee will know that places vary and they
vary dramatically, even with the NHS in this country, from organisation
to organisation. So trying to get some national framework in,
whether it is NICE, whether it is CHI, whether it is National
Service Frameworks, you have got some sense that there is a national
framework here. Before 1997 we did not have any national standards
in the NHS. So it is a very new approach to say that you get your
national framework, then you can have your local devolution, but
without that national framework people do not have the security
that they have got national standards wherever they should be.
894. Thank you very much indeed, Minister. We
have come to the end of the questions that you are aware of. We
have one further one. I wonder, if you were to go through the
process again of establishing the HPA, what would you do differently?
Maybe you should come back in a year's time.
(Ms Blears) As I did not go through the
process personally because I have only held this post since June
of last year, so clearly the Chief Medical Officer's strategy
was published before I was in this post, I have to say, having
read the strategy closely, I think it is one of the best strategies
that we have produced in the Department in terms of its focus
and its clarity. So certainly I think I would have responded to
that strategy probably in the way that we have. I think the establishment
of the Health Protection Agency, from all of my discussions with
them, is going to be a positive development for this country in
terms of bringing together people from a whole range of professional
disciplines, giving them the chance to work together, share good
practice and really raise the profile of health protection and
infection control in this country. So I have got great hopes for
it and, as you rightly say, Lord Chairman, perhaps if we come
back in a year's time and have a look whether those hopes have
been fulfilled, that would be the best way to see.
895. Because there are other things on the horizon.
In The Independent this morning "European Union launches
centre to tackle epidemics" and you no doubt will be aware
of this. How will this impinge on HPA and your Department? Would
you have an input into their planning in Brussels? Or maybe you
are already concerned with that.
(Ms Blears) I think increasingly issues of this nature
will be Pan-European, they are global. Infection, there are no
national boundaries. So inevitably there will be an increasing
need to collaborate. I would say that I think that our agencies,
the previous organisations, PHLS, CAMR, all of those, had an incredible
international reputation for the very, very high standard of their
work. I have no doubt that that places us in an extremely advantageous
position to be a major player in whatever European and indeed
global institutions emerge in this field.
896. Let us hope they draw advice from your
Department. Minister, thank you very much indeed for coming along.
We have had a longish but very detailed session. It is very good
of you and may I thank your colleagues too for coming too. If
there are any further thoughts, and there are two questions which
you are going to respond to, but in addition to those if there
are any other points that you feel have not been explored sufficiently
and you would like to explore them further, we would welcome an
input from you. You will get the transcript, of course, and be
able to make factual corrections, if any. But that just remains
for me again to thank you very much indeed. It has been very productive.
(Ms Blears) Thank you, I have enjoyed it too.