Examination of Witnesses (Questions 100-119)
MAVIS MCDONALD CB, PROFESSOR RON AMANN, DR DAVID SALISBURY CB AND MR STEPHEN CROWNE
MONDAY 21 JANUARY 2002
100. The reason I ask the question is I am told you have just changed the policy on these vaccinations and introduced them for 20-24 year olds. I have the document here which was sent out by Professor Liam Donaldson which is actually dated 4 January this year and refers to the policy being changed from the beginning of the year, so it was actually sent out after the policy was changed. This does not seem to give the GPs very much time to introduce it.
(Dr Salisbury) In this case there really was very little they had to do because I think you will find in that letter that it does ask them to immunise during January on an opportunistic basis; so that when they had people who were coming for other reasons to see them aged up to 25, then they would have vaccine supplies available to use. And the supplies were there in the surgeries. They also had got all of the health promotion materials ready to give to those individuals. These had been distributed to them before the new year.
101. But only some of them were due to have the vaccination, given that some almost certainly had already had this Men. C vaccine and others would have had a different vaccine which I understand was only a short-term vaccine so they would have been due to have the Men. C vaccine as well. The GPs would have needed to know who needed to have it and who did not of the ones who came into their surgeries and my understanding is given the age group a lot of them will be at university and very often the notes may be with the home GP when the university GP gets somebody coming into their surgery or vice versa. There would have been some work involved in trying to find out who was due to have it and who was not. It seems to me that if you implement a policy with a document sent out on the fourth implemented from the beginning of the year that is not much time given the work involved.
(Dr Salisbury) One would hope that young people who are at university would have remembered that they had had a meningitis vaccination.
102. Which? A lot of them would not know which.
(Dr Salisbury) It is clear in the letter that it did not matter which. Had they had either of the vaccines they did not require a further dose now.
103. What the letter says is, "It is recommended that the vaccine should be given to anyone in the age group who has not received conjugate group C vaccine previously. If an individual"
(Dr Salisbury) That would be plain polysaccharide.
104. Right. They should now receive the meningitis C.
(Dr Salisbury) I think it goes on to say "provided three years"
105. "Provided three years have elapsed".
(Dr Salisbury) That means that it should be none of the university students who had either conjugate vaccine before they went to university or plain vaccine when they started university.
106. I understand they were given the vaccine dated before the end of January.
(Dr Salisbury) Yes, that is correct.
107. GPs were told they had to use it all up by the end of January?
(Dr Salisbury) The supplies they have at present, yes.
108. A lot more was given than most of them thought they could possibly use by the end of January?
(Dr Salisbury) I think that is debatable. We issued 600,000 doses of vaccine at the beginning of January and their usual requirement for their infant programme, which uses the same vaccine, is 180,000 doses, so they had a surplus of 420,000 doses, that is less than 20 doses per GP. The target population to be immunised between 1 January and the end of March is of the order of three million. The maximum target is three million and we issued 420,000 extra doses in January, and there is more vaccine available on request throughout February and March for any extras that they require. Yes, the vaccine they had was relatively short dated. Managing a new vaccine for a campaign where the shelf life is relatively shorter than usual poses new problems but we believe that it was better that they should have a vaccine, even if they had more than they could use, than should they not have had enough.
109. I know a lot of the GPs concerned were angered by the fact that they were given such short notice and they were told it was all going to be easy, when they did not think it was, sorting out who had which vaccine and whether they needed it or not. They thought a potential waste of money was being landed on their doorstep by being given a lot of vaccines which they would not have a chance to use by the end of January. One of the medical groups concerned has written to their practice managers to say, "Just to let you know, I chased up why you were all sent such short dated stock, basically the stock existed and the Department of Health had paid for it, so they decided to send it out on the off chance you could use some of it up. I know this will be a small comfort in the face of the inconvenience you and every practice in the country have been placed under". That sounds to me as if there is an awful lot of angry GPs out there with the way that this policy is being implemented. Are you happy with the way you have implemented it?
(Dr Salisbury) That is an opinion that clearly somebody has expressed. The fact was we had vaccine, we paid for it, because we pay for all of the vaccine, GPs never pay for the vaccine.
110. You had it, apparently, in stock, and you tried to get rid of it quickly by implementing a new policy in spite of the fact by this time you were too late. Why did you not think of this earlier?
(Dr Salisbury) I do not think that is correct. The work started round the middle of last year to look at the epidemiological priorities for the different age groups, which requires analysis of the burden of disease across all of the age groups. We also had to look again at the cost effectiveness of immunising different age groups according to the different burdens of disease. That work was done through the Autumn, it went to the Joint Committee on Vaccination and Immunisation in November, we went to ministers to get their agreement that this was a right and proper thing to do and we then worked up the implementation.
111. By this time you had so much vaccine on hand that it was too late to use it all?
(Dr Salisbury) I do not believe we have so much vaccine on hand. If you look at the numbers, in January we issued 420,000 extra doses of vaccine against a total target population that is of the order of over three million. The numbers within that three million who require the vaccine would be less than that, that is the maximum.
112. You are only doing it in January on an opportunistic basis, it is only those who wander in, but 20 to 24 year-olds do not happen to wander in very frequently.
(Dr Salisbury) That is because GPs during January are working hard with influenza outbreaks and, therefore, we felt they would not have the time to call back and immunise all of the up to 25s. That is why we suggested that during January they should immunise on an opportunistic basis and during February and March they can call back at their leisure the remaining individuals in those age groups for whom we have extra vaccine.
113. The first group of vaccine you supplied already has to be used by the end of January, that is when it runs out?
(Dr Salisbury) That vaccine does have to be used.
114. They are not going to do that if they are just doing it opportunistically, they will not have that number of patients coming in.
(Dr Salisbury) They may well have that number. That number is less than 20 doses per GP.
115. The indications that I have are they have no hope of doing it and they were worried about having to pay for it in the end.
(Dr Salisbury) They know they never pay for it.
Chairman: What are the implications, Mr Rendel, for modern policy making?
116. I was just going to ask Mrs McDonald, if you are happy about the fact that so little time has been given in this particular case and so little consultation was done with frontline people and these are the sort of things that you are talking about as being necessary to implement policy properly?
(Mavis McDonald) I would not want to second guess David Salisbury on what was obviously a thorough analysis of what was needed, when and why. I do think the approach that the unit took to thinking about what you would need to do to deal with a target population is something which has proved very valuable in thinking elsewhere across Whitehall. Certainly that kind of thinking is one of the approaches to establishing a pool of knowledge that the contingency unit will draw on when setting up this new risk assessment capacity.
117. How do you ensure that best practice is always carried out by departments?
(Mavis McDonald) The Cabinet does not have the capacity to ensure that best practice is carried out by all departments. We have a number of ways in which we can find out what they are doing, we work closely with Treasury on some of those, particularly the operation of the underlying Spending Review PSA process. We do pursue particular initiatives where quite frequently we ask departments to show us what they are doing, such as we did on improved consultation when we asked departments to send in regular returns on whether they were abiding by the guidance that they should consult within 12 weeks of proper and full consultation. Ron Amann on the CMPSs, the whole programme of promoting modern policy-making is designed to transfer learning and know-how and knowledge between departments.
118. Let me take an example, if I may, confidentiality clauses, I understand that a note went out from the Treasury in 1993 to indicate that departments and the Civil Service in general should not use confidentiality clauses when people are let go for different reasons. Are departments still using them?
(Mavis McDonald) I am not sure I know what you mean by "confidentiality clauses". I am not sure I have ever seen one.
(Mr Glicksman) This is a reference to severance terms when senior staff leave their posts. I think the fundamental point is it is individual accounting officers who are responsible for the way in which they manage their departments and they are the ones who are accountable. Guidance on severance terms and confidentiality clauses was issued by the Treasury in 1993 or 1994. A lot of other guidance goes out as well.
119. What I am interested in is that in the Report it is clear that one of the things that the Civil Service is trying to concentrate on is making sure there is a good deal of thinking across departments, that good practice in one department is copied in another, and what I am interested in from Mrs McDonald is whether she is happy that good practice of that sort, where you should not have a confidentiality clause or maybe in order to use it you have to lay down certain strict rules, is copied between departments?
(Mavis McDonald) By and large what has happened over the last 10 years or so is that we actually classify very much less material and are much more open with each other in terms of exchanging material.