Examination of Witnesses(Questions 20-39)|
TUESDAY 15 OCTOBER 2002
20. Did I hear that we now have a national UK-wide
NHS information technology strategy?
(Mr Kerin) Under the arrangements for devolution,
health care is a matter for each of the four countries of the
union. Therefore, the strategy that we were talking about earlier,
in the same way as the strategy for infectious diseases, is technically
a strategy for England. Clearly, there need to be very good links
with the other countries because of the cross-border transfer
of patients and the benefits of learning from different parts
of the union. Although technically we are talking about an England
only strategy, there do need to be very close links across the
whole of the United Kingdom.
21. Do I understand that, at the moment, there
are no talks between these disparate groups about having common
protocols for exchange of information electronically?
(Mr Kerin) I would have to defer to my colleagues
on the detail of that but it would be envisaged in respect of
the Health Protection Agency, which is my particular responsibility,
that it would be closely working with the Scottish body in particular
to ensure that there are compatible protocols.
22. In relation to that, the PHLS is involved
in running services in Wales and in England. The HPA will restrict
itself to England. You talked about a special relationship with
Scotland. What special relationship will you have with Wales?
(Mr Kerin) It is proposed that the Health Protection
Agency will provide a range of country-wide services in both England
and Wales. Indeed, the recent consultation document about the
legislation was jointly issued between the Department of Health
and the Wales Office. Where the position in Wales is different
is that it is proposed that local services in Wales should be
operated organisationally in a different way from that proposed
in England. But in terms of the national services across infectious
diseases chemicals and radiation the Health Protection Agency
will be offering a service in Wales as well as in England.
23. Can we now turn to clinical services for
those who are suffering from an infectious disease? Could you
give an outline of the current provision and distribution of services
at primary care and specialist level and whether you feel that
we are in a satisfactory situation at the moment? Should the emphasis
be on increasing the number of specialists in infectious diseases
or should the emphasis be on improving the knowledge of infectious
diseases through primary care physicians and primary care teams?
Should there be centres developed where perhaps infectious disease
matters could be looked at and used as a training base for both
specialists and GPs?
(Dr Leese) The infectious disease strategy was primarily
concerned with health protection arrangements in the country and
setting priorities, but it does in chapter five have treatment
and care of people with infection and the long term sequelae of
those infections as an integral part of infection services. Alongside
the work that is being done, alongside the infectious disease
strategy, a group has now been assembled to look at clinical infection
services. We should remember that pretty well all clinical doctors
handle infection at some point. The vast majority of infections
are handled quite appropriately in primary care. Some infections
are treated in specialist disciplines apart from specifically
infectious disease disciplines. For instance, hepatologists do
quite a lot of the hepatitis related work. Gastroenterologists
see a large amount of infection related work. Respiratory physicians
on the whole treat tuberculosis but over and above that there
are these specialist infectious diseases physicians dealing with
adult and paediatric infections. To begin with, the royal colleges
had prepared a discussion document on the provision of these services
across the country and we are now working with them to take this
work forward. It will involve looking at the distribution of services
across the country, how they can best be made equitable, what
is required in a specialist centre and, as you rightly say, the
provision of training, looking for the succession planning for
the type of people who are necessary and looking at the multidisciplinary
type of work that needs to be done. That will all be part of this
24. Have you in mind the setting up of such
centres, perhaps as part of the work of the Health Protection
(Dr O'Mahony) That is still for discussion. There
are various models of provision of specialist infection services.
They might vary from place to place according to local epidemiology
of disease and according to the other specialist services that
are being provided in an area. One model is a networking arrangement
with perhaps a regionally based specialist infection service attached
to an academic unit, but with an eye to standards and the provision
of care across the field by networking out across a region. That
is one of the models being looked at, but no firm recommendations
have come yet.
25. You mentioned that the royal colleges are
doing a report on this. When are we expecting that to be published?
(Dr Leese) The colleges have already produced a discussion
document. What we are now looking for is to put their ideas into
some sort of framework for discussion. We hope to have that ready
by the end of the year.
26. Do we have enough adequately trained people
available to deliver this service?
(Dr Leese) Specialist infectious disease physicians?
It is a relatively small specialty but there are quite a lot.
A lot of them are in academic units and that is one of the things
that we need to look at: how much is in academia and how much
is in providing a clinical service.
27. It is not quantified yet?
(Dr Leese) We know the total numbers but you have
to equate that against what is the workload of infectious disease
physicians. Quite a lot of their work is giving advice to other
people as well as clinical care for patients who need specialist
28. My question was about the rapid response
to serious infections that may arise. How do you think your changes
will improve this?
(Dr Leese) There are two aspects of that. One is the
expertise and the other is the facilities with which to care for
people with very infectious diseases. This work that we are doing
with the colleges is mostly to do with resources but we will have
to look at the facilities to back that up. In a major emergencythis
is slightly outside my fieldbut quite a lot of work has
been done on the way we would house people if we suddenly had
to deal with a lot of people who were very ill or very infectious.
29. The work you have done already will help
to improve this. Is that correct?
(Dr Leese) Certainly, yes.
30. We have the evidence of that?
(Dr Leese) I do not know whether Dr O'Mahony wants
to talk more about the surge capacity.
(Dr O'Mahony) What we are doing is linking with our
colleagues in infectious diseases teams. We have had a number
of meetings with colleagues in the infectious disease world asking
how would we best respond to a major problem with infectious disease.
What would be the best way of caring for patients? What would
be the best way of having public health control measures? These
are plans in evolution. What we are doing very much is making
sure that we strengthen our services on infection. We really want
to bring together those who work in infectious disease in the
clinical, microbiology and the public health worlds so that we
have a very coordinated approach to the control of diseases, including
31. Can I go back to the question of supply
of people? In the antibiotics resistance committee we did identify
a great shortage of academic, medical microbiologists to take
posts in the academic field. Has that improved, not only in microbiology
but right across the infectious disease spectrum, in recent years?
Are there people coming forward to take academic positions in
medical schools and elsewhere?
(Dr Leese) There are people coming forward taking
posts in infectious diseases academic posts. I do not have numbers
but I believe there is still a shortage of people coming into
microbiology services. The profession, I know, has been looking
at the way that services might be reorganised in order to cope
with that. That is microbiology, including virology, which is
one of the specialities where there are small numbers.
(Dr O'Mahony) You asked about academic posts. We are
still in the process of addressing that. We are also trying to
make sure that we gather more people in training who are interested
in infection so that they have the opportunity to move across
a range of infectious disease specialities. I know the College
of Physicians and the Royal College of Pathologists and the PHLS
have put forward some very innovative programmes for joint training
between infectious diseases and microbiology, as well as public
health. Thus, in the years to come, there will be a cadre of people
with a good understanding of infection in the round, who would
be able to specialise in different fields and, who we would hope
and indeed anticipate would be the future holders of the academic
posts that we so need in this country.
32. My question is about public information
and public confidence. What will be the role of the new Health
Protection Agency in informing and consulting the general public
about the control of infectious diseases and how does it expect
to be able to win and maintain public confidence? How would it
be using the primary care services to get involved in that? Could
there be a difficulty with the perceived independence of the organisation
and to what extent will the HPA be allowed to publish independently?
I am picking up a point, Dr O'Mahony, that you mentioned in your
introduction earlier on. You mentioned the inspector of microbiological
services. It occurred to me, for example, will there be an annual
report from that inspectorate? Will it be published?
(Dr O'Mahony) I will ask Mr Kerin to pick up some
of those points about the Health Protection Agency.
(Mr Kerin) We need to bear in mind that what we are
talking about is a body for which legislation needs to be passed
to bring it into effect. Some of these issues are covered in the
consultation document, and in particular paragraph 4.33 flags
up the issues around openness and whether legislation creating
the agency should give it the right to publish its advice. The
proposal in the document is a power akin to that of the Food Standards
Agency. These are matters where the Department is currently considering
the responses that have been received and will obviously be making
legislative proposals in due course. It is certainly a crucial
aspect of the proposals for the agency set out in Getting Ahead
of the Curve and the subsequent documentation, that it has
a major role in public information as well as information for
professionals. These proposed statutory powers would be an important
part of that, but it is also important how the agency will go
about engaging with the public at both national and local level
in order to win confidence. While it is too early to say specific
measures, I think it is important to see how the public are engaged
alongside other stakeholders in the formal committee structure
and approaches of the agency. The communication strategy of the
agency which we are starting to make preparations for needs to
have a strong component of engagement with rather than talking
to the public and I think that is important. Some of the existing
organisations which will be coming into the Health Protection
Agency are already giving attention to effective communication
of what are, after all, quite complicated scientific concepts,
looking at web based and other ways of explaining the issues in
a way that will be understood and in which the public can engage,
either through feedback off the website or in other ways. Although
I cannot give you particular examples because of the provisional
nature of the agency at the moment, this is an important facet
at national level. At local level, the Health Protection Agency
will be most obvious through the teams of people who work in the
agency. Many of them already in their role as communicable disease
experts, both doctors and nurses, have an important role to play
both in explaining local issues through the local media experts
in their area; but also working closely with the primary care
trusts and the NHS as fellow professionals to ensure that the
key issues are understood and that, in those bodies communicating
with their public, they understand the health protection issues
as well. I think you were right to ask a question with a number
of facets because it is an issue where the answer will require
a number of facets. I do not think there is any one step that
is there other than that the agency will need to give careful
attention to how, as an independent, national body which may not
appear visible to the public on day one, it engages at both national
and local level to ensure that the issues are debated and understood.
33. I agree with you that the public needs to
understand the issues and you have obviously thought that through
but what the public wants to know is what are the risks that it
runs. What is the risk of catching an infection and have you given
any thought as to how you will communicate that to the public
and tell people what risks they are running?
(Dr O'Mahony) Perhaps Dr Salisbury can give you some
concrete examples which we are using at the moment and which we
would like to use more of.
(Dr Salisbury) It may be slightly tangential but the
work that we do is all shared presently with the Public Health
Laboratory Service. Again, it would be an opportunity that would
be available to the Agency when that arises. We have a number
of areas in which we do a great deal of work with the public,
both finding out what they know, what they want to know and who
they want to get information from. We feed a lot of that back.
Twice a year we have 1,000 mothers of young children interviewed.
Twice a year in between we have another 500 mothers of young children
interviewed. These interviews are specifically focused on vaccinations
and vaccine preventable diseases. The purpose is to find out what
they know, where they get their information from, who they want
to get their information from, who they trust, what information
on vaccines and the matching diseases they have seen, where they
saw it, whether they were satisfied with it, whether they were
satisfied with the opportunities they had in primary care to discuss
these issues. We have a huge wealth of information. We have over
20 rounds of these interviews done now, going back over a decade.
We use this knowledge to develop our communication strategy and
how we take information back to parents. We do not use our own
prejudices on what we think people believe. We have concrete evidence
of what they want to hear, where they want to hear it and in what
form. We hear increasingly, for example, that parents want facts,
so we have dealt with increasingly providing factual information
directly to parents. We do this through NHS Direct where we have
trained NHS Direct staff so that they can answer questions that
the parents put to them and they give us regular feedback of the
questions that they are being asked about infectious diseases
from the public. We have a new "MMR: the facts" website
which I commend to you, within which there is a facility for anyone
to send us questions. They can go through the website. If they
feel that their questions are not answered, they can e-mail their
questions to us. We have an undertaking that they are all answered
within five working days. We get about 50 inquiries at present
per week and we have a facility that puts in a hierarchy of response
to deal with the different questions. We are developing skills
that are specific to what the public tell us they want to know
and we do a great deal to make sure that we provide information
in the way that the public can best use it. All of that is presently
shared with the Public Health Laboratory Service, with our counterparts
there, and I am certain that we will maintain that in the future
so that all of this information on how to communicate and what
it is the public wants to hear about to do with infectious disease
and vaccines will be a facility that can be used in the future.
34. Following what Dr Salisbury has been saying,
the Department's evidence, paragraphs 34 and 35, deals with the
issue of confidentiality and the issue of concern that clinicians
feel about reporting data without explicit patient consent. Presumably,
part of the HPA's remit in establishing the kind of confidence
which is required by the public will be helpful when negotiating
these issues of confidentiality. Is that correct?
(Dr O'Mahony) Within the health service when collecting
data on infectious diseases, it is vitally important that we get
the appropriate data. There is the key principle that all data
should be anonymised unless there is a strong reason to the contrary.
On behalf of the communicable disease and infectious disease community,
CDSC provides documentation to the Patient Information Advisory
Group that was set up by the Secretary of State to deal with the
requirement for communicable disease data collection, reporting
and surveillance arrangements. It is important that we continue
with that work, so that we have public confidence, through the
agency and the Department, in the nature of the information that
we collect and that we provide in turn. This is very much an evolving
situation, depending on the wider context of the Data Protection
Act and other legal requirements for infectious diseases that
may change. I regard it as absolutely vital that we bring the
public along with us and that their input will shape some of the
way we collect data to provide information back. We have tried
over the last several years to have public input in a variety
of ways including our expert advisory committees and into the
way we collect information. We have had public meetings and for
example, we recently had a public meeting to do with matters relating
to CJD. With a whole variety of input, we hope we can arrive at
a position where the information that is collected and provided
on behalf of the Department by the agency meets with public demand
and public acceptance. This is something that we will have to
keep an eye on because requirements and expectations will change
35. Going back to the proposed agency's public
information strategy, has thought been given to rapid response
to the need for public information when that might be needed?
For example, if there was a rapid spread of a serious infection,
an academic providing the information that will help the public
to recognise the symptoms to report and providing the measures
they can take and so on? What about rapid response?
(Mr Kerin) It is certainly one of the issues under
attention with web based approaches. It is one way through NHS
Direct that will be an important way of communicating with many
people. One of the things that need to be investigated is how
do the general public get information and how far are these new
technologies appropriate or are there other ways that need to
be found as well. There will be a need for it and it is certainly
one of the things that is being considered.
36. Are there any problems associated with the
Data Protection Act, especially with very sensitive data that
may be accumulated and available? Do you envisage any problems
(Dr O'Mahony) We are working under the new requirement
about the need to be specific about data collection and about
the methods used. Those are all now being taken into account.
As far as possible, all data are anonymised unless it is a requirement
from the point of view of control measures that we have some identification.
I think Dr Salisbury has given examples where, for some diseases,
particularly those where we are approaching elimination, we need
to follow up individual reports and where we do need certain information
of an identifiable nature. For those diseases, we need to be absolutely
explicit and have agreement. For those, we would follow up individual
patients. It would be the same for outbreaks of disease where
we need to get in contact with people who have a particular infection
or who may have been exposed to a particular food source for follow-up.
There are requirements that are likely to be always there but
how we collect that information has to be checked all the time
under the new regulations that have been laid down by the Secretary
of State. Of course, we will fit into that infrastructure.
37. This is about laboratory services. In your
introduction you made, quite rightly, much of the need for integration,
co-ordination and co-operation between the various bodies which
are concerned with various aspects of public health protection
and the need for the facilities for surge capacity and rapid response,
all those things I would applaud. The question really relates
to how you feel changes in the laboratory services will assist
this process. The question that you have seen refers to the reference
microbiology services, which are largely within the PHLS and,
as I understand it, may well remain within the HPA as the central
facility. There are suggestions in the Report that these services
may in the future, at least in part, be commissioned. The question
is, how does commissioning services as against doing them yourself
help this integration process? The question also relates to the
more routine public health microbiology protective function that
PHLS laboratories do round the country, how the changes envisaged
therewhich are to ask the NHS trusts in which they currently
sit to take over that role and to provide the service to the HPA
and to the country from that positionhow will that improve
integration, co-operation and co-ordination do you think?
(Dr O'Mahony) You have put a number of questions within
that. If I may start with defining what we mean by general microbiology
services and reference services. General microbiology services
are described as those that provide the diagnostic capacity within
the health service, and are primarily clinical in orientation.
However, all microbiology laboratories do have public health functions,
indeed there are four main public health functions for all routine
microbiology services; these are the provision of information
to those with the responsibility for control at a local level
and a national level, for example giving reports of cases of diphtheria
and salmonella; a second function is that they submit the appropriate
specimens to the reference laboratories. These may be required
for national programmes, as Dr Salisbury mentioned for vaccination
programmes such as tuberculosis; they are also required to keep
a watching brief on some of the rarer organisms that are carried
in the country; the third public health function is that they
assist local teams in control and arrangements matters; finally
they give advice on local policy development and implement some
national policies. Almost all laboratories in the NHS do these,
some do it to a high standard and some do it to a variable standard.
All public health laboratories carry out these basic functions.
It is envisaged with the proposed agency that those PHLS microbiology
laboratories where most of their work is general in nature would
be transferred to the health service, where they would support
local health services, and public health functions to make sure
that this public health function has a clear focus. It is proposed
to establish public health microbiology posts in all those PHLS
laboratories that transfer so that public health microbiologists
would be in the NHS to drive that public health component of the
general microbiology service. The post would not be nominal but
would have dedicated sessions to support the public health function.
That is absolutely vital for a secure service. When we talk about
reference laboratories we are really looking at highly specialist
laboratories. These laboratory services are provided at the moment
in the large part by the Public Health Laboratory Service and
by the Centre for Applied Microbiology and Research and some academic
departments, for example at University College London and the
London School of Hygiene and Tropical Medicine. They are a source
of expert advice, with expertise on individual organisms and diseases.
They provide special functions like finger-printing organisms.
An example might be salmonella infection that will be identified
by general microbiology in the NHS laboratory but the finger-printing
of that salmonella will be done by the reference laboratories.
That service is vital for us to pick up outbreaks. For example
at the moment there is a large investigation being carried out
on an outbreak of salmonella of a particular type, the nature
of which can only be determined by reference laboratories. It
is that special nature of the reference laboratories that needs
to be preserved and developed. At the moment the reference laboratories
are managed in different organisations and in academic units.
What is proposed in the strategy is that the two main providers
of these very special laboratory services would be brought together
in the proposed agency, namely the Public Health Laboratory Services
and that they would work within a framework with other academic
units so that they would have a true national resource for the
very specialised microbiology laboratories. Lord Turnberg mentioned
commissioning. At the moment most of the services are provided
by the special agencies. It is envisaged in the future that this
approach will continue. However, there may be instances within
the National Health Service or academic units where they both
have specific expertise and the agency may wish, to use that focus
in the future. For example, if the nation requires a special laboratory
to be set up then the agency would work with that special expertise
in the NHS rather than setting up a separate, new laboratory.
It may, as the PHLS does at the moment, work with the London School
of Hygiene and Tropical Medicine and also with University College
London. I do not believe or envisage that very many reference
services side will be provided outside the agency; if anything
it would be a minority, but it may well reflect, like I said,
future expertise that may be in different parts of the health
service. I am not sure if I have picked up all your points.
38. That is very helpful about the reference
laboratories. As I understand it, most, if not all, current PHLS
and CIAMR laboratories are in the new Agency and in future, of
course, it may wish to commission other services from outside
rather than farming off existing reference laboratories. If I
can turn to the network of what you describe as routine public
health laboratories, which provide routine microbiology, the key
to this arrangement is that they work as a network, so that in
a group of laboratories in a region, for example, as you know,
each of them does not provide all the services but between them
they do, and one will do virology and one will do food and environmental
work, so they have the total resource between a group of laboratories.
If you then hand these over to individual trusts how do you envisage
that co-ordinated network approach being continued?
(Dr O'Mahony) The development of microbiology services
needs to be considered within the wider development of pathology
services. The Government has set up a strategy for the modernisation
of pathology services, in which it is envisaged that there will
be a network of pathology services broadly mirroring strategic
health authority populations, populations of around 1.5 million
people. Microbiology is seen to be an integral part of general
pathology services. It is envisaged that there would be a series
of pathology networks across the country, probably about 30, which
will have pathology serviceshistology, haematology and
microbiologywithin them. It is important to see that microbiology
will be part of that overall pathology development. However, in
discussion with colleagues in the modernisation of pathology services,
it was recognised, as Lord Turnberg says, that there is particular
expertise already developed in PHLS around networking arrangements.
We would hope that we can capitalise on the microbiology expertise
in PHLS in developing wider pathology networks within the NHS,
and maintaining as far as possible some of the work that has already
been done by the PHLS in managing what may well be a forerunner
of the pathology services, for example by distributing tests where
appropriate by doing them where there is particular expertise.
These are some of the particular areas that are being considered
at the moment by the implementation team. We are very aware that
the PHLS has developed expertise in standard operating procedures
throughout its laboratories and we would hope the PHLS will work
with the NHS in putting in good quality protocols for microbiology.
The PHLS has had a lot of expertise through its network in procurement
of good media and, again, we would hope that the NHS would benefit
from this huge expertise. I believe that the PHLS has a great
deal to give to the NHS and this is being considered as part of
the implementation work that is being carried out by the Department.
39. Could I ask a supplementary at this stage.
I think our final report will very much require figures about
manpower and woman powerthe microbiologists available,
their training, infection control nurses, training available,
possibly laboratory technicians. Some of this information, of
course, is available in the public domain already and I think
it would be quite useful for us to have all the information that
there is on this whether it is in the public domain or not to
help us with our deliberations. Do you think that a reasonable
(Dr O'Mahony) Indeed, my Lord, we would
be happy to provide any supplementary information that we can.