Examination of Witnesses (Questions 120-126)
TUESDAY 5 NOVEMBER 2002
Baroness Warwick of Undercliffe
120. Quite a lot of evidence that we have received
has commented on the lack of infectious disease specialists and
the difficulty of recruiting to microbiology posts. Several people
have referred to that. Equally, Professor Finch talked about the
range of expertise that ought to function in a more integrated
manner. We have just touched on the more general practitioner
having some elements of specialist knowledge and so on. I wonder
if you could say something about how you see the skill mix required
for infectious disease treatment and control evolving and how
you think the training should evolve.
(Dr Wright) I think that we could be on the verge
of a considerable improvement in relation to the possibility of
getting an infectious disease specialist into district general
hospitals. A consequence of Calmanisation was that each infectious
disease unit would usually have a registrar post and a senior
registrar post, and both of those were often converted to Calman
specialist registrars. Therefore, in training now we probably
have more infectious disease specialists than ever before. What
is less clear cut is where they will go to work. There is now
a strong academic stream in British infectious diseases, because
infectious diseases is such a fertile area for studying immune
responsethis is why we developed an immune response, to
respond to infectious agents. So I am optimistic that both the
academic provision and the clinical service provision in district
general hospitals should improve. This will require a will among
the persons describing the configuration of specialist interests
in departments of medicine in general hospitals to accept the
notion that they need somebody who is a general physician with
an interest in infection. It would be sad if the infectious disease
provision were to be left with the new breed of microbiologists
with an interest in infection. This joint training in microbiology
and infectious diseases has just started and so numbers of individuals
training are low as yet but they will certainly increase in number.
I think we have the potential, in terms of numbers of people training,
considerably the representation of infection along
with the other accepted specialties in district general hospitals.
121. Dr Wright, I am aware that you have to
leave and, if you wish to leave, please do so, but if you feel
that there is anything that you feel you would still wish to say
you could let us have it in writing.
(Dr Wright) Thank you. My clinic starts at half-past
(Dr Beeching) Just to reply with some numbers, if
I may. This is from the Royal College of Physicians' publication
looking at workforce requirements across the board. In our own
submission we recommended that the target should be a clinical
adult infectious disease specialist for every 250,000 people.
This is in comparison with Sweden, where there is one per 27,000;
Norway, one per 61,000; but, perhaps more comparable, in the Netherlands,
which has a similar kind of practice of both microbiology and
infectious diseases, just over one in a quarter of a million.
Our projected requirement for the UK would be about 200 adult
ID physicians and perhaps some extra specialists, which roughly
correlates to putting one into each district general hospital
unitthere are about 250. So two different estimates came
up with a similar answer. We currently have 85 roughly in England.
We have had a five per cent expansion historically for the last
15 years. The current workforce targets we have estimated at 200
by 2010. The current workforce target that has been set is actually
just under 130. So I think it is fair to say that the profession
would feel that there is room for considerable expansion which
will require an increasing number of specialist registrars in
Baroness Warwick of Undercliffe
122. Could you say something about infectious
disease nurses. We have talked about clinical practitioners, but
what is the role of nurses?
(Dr Beeching) There is the infection control nurse,
who has a very specific and very important role, both in the hospital
and in the community; there are clinical infectious disease nurses
who manage inpatients in a unit; and then of course there is a
district nurse, a component of health visiting and infection control.
So there are three different groups. I think the clinical practitioners
actually do not have a cohesive group in the country but they
are a very important component of health care and for educators
as well, should there be outbreaks, for other nurses.
(Professor Finch) I support what has been said by
my two colleagues but I think it is also not just about simply
increasing the number of infection specialists but it is about
how they integrate and deliver their expertise in partnership
with other professionals within the total body infection expertise.
I think this is very important. In other areas of medicine, we
have cancer centres, for example. Those of us working in larger
centres have tried to develop the concept of an integrated department
of infection that captures the diagnostic, the public health,
the sexually transmitted, the clinical infectious diseases services.
It is important. It is important not only because different types
of expertise are required but you do need critical mass which
can be used effectively to inform research and educational needs.
I think it is through the establishment of centres of excellence
built around integrated departments of infection that will bring
about real change at local and national level. It goes back to
the original question concerning surveillance. If we know more
reliably and more accurately what is the time burden of disease,
we can plan those units and staff them in a manner appropriate
to the population needs.
123. One final question relating to the Conclusion
in your paper, where you say, ". . . the effectiveness of
surveillance, links between surveillance and treatment and the
links between surveillance and strategies for preventing infectious
disease is weak." Is our teaching in medical schools either
at the undergraduate or postgraduate level up to scratch? If it
is not, how might it be improved?
(Professor Finch) I think there is wide variation
between medical schools in terms of undergraduate teaching and
exposure to infectious disease. Some have intensive and specific
courses, others perhaps do it somewhat patchily and not in a joined-up
fashion. I think there is an opportunity to look at education
at undergraduate level and ask: "What are the core components
and skills and how should they be taught and translate to professional
life and activity?" There is also the need to sustain education
and competence in managing infection which links to the issue
of postgraduate training. An example from Nottingham is that we
have included within the senior house officer training experience
in the management of infection emergencies, so they are familiar
with the management of imported fevers and endemic problems such
as meningitis, etc. Where you have a nucleus of expertise, that
can inform and influence the local training agenda.
124. Are you saying that infectious disease
teaching is not a core component of undergraduate teaching?
(Professor Finch) You may find that certain diseases
are taught but by different specialities.
125. It is not a core module.
(Professor Finch) It is not always a core module.
You may get pre-clinical teaching in microbiology, but it does
not always connect through to the clinical expression of infection
and its management.
126. So there may be medical schools where infectious
disease teaching may not module.
(Professor Finch) That is correct.
Chairman: Thank you. We have come to the end. If
there is any point you feel we have not covered, please feel free
to let us have further documentation.