Examination of Witnesses (127-139)|
TUESDAY 26 NOVEMBER 2002
127. Thank you very much for coming along. Would
you like to introduce yourselves, and if you would like to make
any opening statement, either collectively or individually, now
is the time to make it.
(Dr Crook) I am the Clinical Director
of Clinical Microbiology at the John Radcliffe Hospital, which
is one of the hospitals of the Oxford Radcliffe NHS Trust. I was
appointed to do this to oversee the withdrawal of PHL from Oxford
some three years ago. Presently, I am in the United States as
part of a leave fellowship from the Wellcome Trust doing research
into the evolution and transmission of antibiotic resistance.
I have as other responsibilities membership of the Hospital Vaccine
Group, where I am very active with a number of other people from
Oxford. I am a member of the Tropical Medicine Steering Committee,
which oversees the multiple overseas Wellcome Trust units for
Oxford University. I am Programme Director of the Joint Training
Scheme for Microbiology and Infectious Disease, and I participate
on a number of college committees contributing to the development
of a curriculum and college exams.
(Dr Kelsey) I am Mike Kelsey. I am a Consultant Medical
Microbiologist at the Whittington Hospital, and have been for
in excess of 20 years. I am President of the Association of Medical
Microbiologists, which is a broad organisation representing more
than 400 medical microbiologists in the United Kingdom and Ireland.
(Dr Spencer) I am Bob Spencer, Consultant Medical
Microbiologist at Bristol Public Health Laboratory and also a
member of the Medical Advisory Group for CAMR at Porton Down.
I am Chairman of the Hospital Infection Society and a member of
Council for the Royal College of Pathologists and I also act as
an advisor on various microbiological subjects to various government
departments and agencies.
128. Thank you very much, gentlemen. I will
ask the first question as usual. We have had evidence that there
are relatively few infectious disease physicians in the United
Kingdom compared to the US. I wonder if you can say a little about
the role of microbiologists, what the role of microbiologists
is, and how microbiologists interact with the infectious disease
physicians and other clinicians in the United Kingdom.
(Dr Crook) I am in an unusual position because, as
you said, I did my specialist training both in general medicine
and in infectious disease in the United States, and came to the
United Kingdom following that to follow a career in microbiology.
In a sense, I am fully trained in both, and am registered with
the General Medical Council as a practitioner both in infectious
diseases and microbiology. I think around the country there is
a variation in the extent to which microbiologists and infectious
disease groups work together. In Oxford we have a coalescence
of those practitioners into a single working group, and my colleague
is here today, Professor Peto, who is the lead person in infectious
disease, and we work as one. But that contrasts with other parts
of the country. In fact, at St George's it is a bit further away
than ourselves, and the Hammersmith in a sense is closer than
ourselves. So there is a great deal of variation. ID as such is
a small sub-specialty, and its great strength has been its academic
development and prowess, and really they have carried the banner
for research and the academic development of the subject, whereas
I think the Academy of Medical Sciences recently held an investigation
into the role of academic bacteriology, and it was clearly recognised
that there had been a substantial decline in academic bacteriology,
but that has been balanced by infectious disease. In a sense,
in Oxford, the Royal Colleges, and I think Lord Patel is part
of that at STA, we are seeing through a joint training scheme,
which is an effort to redress the degree of imbalance around a
lot of the country and bring into clinical microbiology through
joint training a good deal more clinical appreciation for practice,
yet not losing competence and expertise in laboratory medicine.
(Dr Kelsey) I would just add a little to that, whilst
being in major agreement, that, of course, the function of the
medical microbiologist differs slightly from that of the ID position,
in that we are responsible for the management of the medical microbiology
labs. The laboratories in the NHS are on the whole medically managed.
We also take on the function of the control of infection, which
is a difficult function at the moment; it is fraught with problems.
So we tend to manage groups and departments. We have biomedical
scientists, scientists, nurses all working for us, and it gives
us a broader role. To some extent, we tend to confine our activities
more to the hospital, and where we consult outside the hospital
it is mostly with general practitioners. It is often telephone
consultations. We occasionally see patients, but the role of the
microbiologist I think is more confined to in-patient work and
infection control. As well as doing clinical consultation, most
microbiologists do ward rounds. I probably do more ward rounds
than most consultant physicians. I do one every day. I see 10,
15 patients a day. So we combine everything. Although there is
a move, as Dr Crook said, towards combining training for ID and
microbiology, I think there is some distinction still to be made
in the line of activity. Of course, microbiology is nationwide;
we are represented in every reasonable-sized hospital in the country,
where we provide the bulk of the infection services. It does not
mean to say we do not welcome working with ID physicians, of course.
(Dr Spencer) There is very little for me to add. My
two colleagues have summed up the situation. I think it is worth
remembering that in the 1970s the United States Surgeon-General
said infection is dead, we do not need to do any more research,
we have got antibiotics and we have got vaccines. Of course, this
has been shown to be total nonsense, with the resurgence of antibiotic-resistant
organisms and, of course, the threat of infectious diseases in
the shape of tuberculosis, and West Nile fever, which is sweeping
the United States and also sweeping up through France, and it
is only a question of time before it lands on our doorstep. There
was a decline in infectious disease physicians following the closure
of the large fever hospitals in the 1940s-1950s. How we interact
is an interesting concept, because there are relatively few centres
in the United Kingdom that have both ID physicians and clinical
microbiologists. On the whole, I would say that they get on quite
well. Their role is somewhat different, in that ID physicians
may have beds, they have may units, they have out-patient clinics,
whereas, as Dr Kelsey said, the role of the clinical microbiologist
is that he has to run a laboratory, to make sure that results
are accurate and produced in a timely manner. They undertake surveillanceI
expect we will get on to that later. They also do rounds on in-patients,
mainly on intensive care units, and also they are the connection
between the hospital engineers with regard to decontamination
of re-usable surgical instruments, which of course has hit prominence
in England with the advent of variant CJD.
129. You mentioned West Nile virus infection,
and in the recent outbreaks of both West Nile in the USA and anthrax,
they were recognised early because of the unusual clinical syndromes
that they presented. These were identified by clinicians with
training in infectious diseases. Could we have controlled it as
rapidly as they did in the USA?
(Dr Spencer) In actual fact, if you look at the history
of the West Nile fever, it was the vets that actually found the
cause. People had already died from some bizarre neurological
disorders in New York state, and at the same time the vets found
there were these crows falling dead, and it was they who made
the connection. As regards anthrax, following 9-11 CDC increased
central observations at various A&E departments throughout
the United States, and it was really that that triggered the diagnosis
of meningitis in Mr Robert Stevens, who was the photographer down
in Florida, and when they saw the anthrax bacilli in the CSF.
Following that there was more intensive surveillance, because
if you look back, by the time Stevens had been diagnosed with
pulmonary and anthrax meningitis, there had already been at least
half a dozen cases of cutaneous anthrax seen in New York which
were unrecognised, undiagnosed. They were treated with antibiotics
that perchance happened to have activity against Bacillus anthracis.
Would we recognise it today? I have talked to A&E consultants,
and I have said, "How many cases of unusual illness would
you need to see before the penny dropped?" and it was quite
a large number, and of course, if, for instance, you carry on
with the deliberate release scenario, say, at Waterloo station
with everybody disappearing to their home in the south-east and
also in the north, and one or two cases here and there, it would
be quite difficult, but that is when, of course, surveillance
would hopefully kick in.
130. Coming from a hospital which has recently
had a rabies death, would the public be better served if all infectious
disease specialists also trained in microbiology, recognising
that some of them would then end up running microbiology labs
and doing infection surveillance?
(Dr Spencer) I think that is probably what will happen
131. Why eventually?
(Dr Spencer) It will take time because the examination
for the Royal College of Pathologists has somewhat changed. There
has been change, for instance, in the Senior House Officer grade
in pathology. When Dr Kelsey and I am sure Dr Crook came into
microbiology, we would serve a year as a resident clinical pathologist
or SHO, and go through four different departments of pathology
before you decided "I like that" or "I don't like
that." So you would be trained in that. Those have disappeared
to a large extent, so what we are getting is people that have
done a general medical training, and one of the criteria for coming
in to be an SPR in medical microbiology is possession of the MRCP.
Most of the good postgraduates who are coming into the discipline
already have MRCP. The reason they want to come into clinical
microbiology is to treat infection but they also like interacting
with patients. So I think it will probably go that way eventually,
but of course, it takes time for people to come through the system,
to be trained in both, and to become consultants, because there
is quite a few of us who were still trained in the old way.
132. So if the Royal College of Pathologists
and the Royal College of Physicians were to take the initiative
and talk together now, it might come sooner?
(Dr Spencer) They are already doing that anyway. We
have two joint training scheme placements in Bristol, and I think
there are some in Cardiff, and I know there are in Oxford. I am
sure Dr Crook can address that.
(Dr Kelsey) I was just going to make the point that
there are joint training schemes in London as well now.
(Dr Crook) If I could briefly add to that, I agree
very strongly with what Lord Patel is saying, which is that there
is great virtue in bringing a coalescence in the training between
what is essentially a physician in clinical practice, seeing and
ministering to patients, and a pathology, laboratory-based practice,
which historically has been very strong in the UK, while infectious
disease has been stronger in the United States, as was implied
earlier, and bringing in a hybridisation of those two. As you
imply, I think that would be a particular strength for the specialty
of infection in the future. How one accelerates that, which would
be very desirable, is quite difficult, in that the number of competent
individuals to train is in the order of 44-50 infectious disease
clinicians in the country. It might be as many as 70. That is
quite restricting in the extent to which one can promote joint
training. Whether there is some way through the Royal College
of Physicians to expedite that and give further support and give
greater emphasis to that scheme I do not know, but it would be
Lord McColl of Dulwich
133. Have you thought of putting the clock back
and having house jobs which are partly house physician and partly
bacteriologist, infectious disease? We used to have that, and
they worked very well.
(Dr Crook) From my perspective, I am not familiar
with that particular scheme. My route of training was essentially
coming out of a house job in South Africa, going through the London
School of Tropical Medicine in the UK, to the United States, where
I trained in general medicine, the usual route in the United States.
I think that this applies here these days, as has been touched
on earlier. It is at the SHO level, where many of the people going
on to do infection are doing SHO jobs in general medicine, and
then progress to infection. Our aim should be to catch many of
the brightest and most able of those trainees at that level. I
think that was quite thoroughly addressed by the Academy of Medical
Sciences and they have reported on that. One of the points that
they raised was at an earlier stage, SHO kind of level, yet I
think there are changes in training at the moment to reorganise
medical training which would abbreviate it, and that might be
one of the changes that would be particularly attractive in invigorating
people in a career following infectious disease earlier.
(Dr Kelsey) I would just like to add something in
answer to Lord McColl's question. In fact, there are a number
of SHO training schemes that include microbiology now. There is
one at St Thomas's which is an intensive care microbiology and
other medical specialty training scheme, as well as some which
I think go through paediatrics as well. An awful lot of paediatrics
is considered to be infection-related. Can I go back and say something
about the relationship between clinical infectious disease and
microbiology and the breadth of medical microbiology? We must,
I think, be quite careful that not all jobs are the same, and
I think it is important that we allow some doctors who may be
very bright, but may not wish necessarily to take that particular
lead in clinical medicine, to go to a more laboratory-based, more
research-based career. I do not think we should exclude them by
saying every job has to be the same, every job has to be clinical
microbiology with an infectious disease element. We must not restrict
good graduates who wish to take a slightly less centre path.
(Dr Spencer) We must not lose, of course, the vision
that we need people to lead on infection control, and of course,
we need people to lead on the decontamination of surgical instruments.
If we go down the way of being very ID-focussed, we may risk losing
134. Given that we have heard quite a lot of
evidence from others, and to some extent from you, that this is
the way to go, bringing infectious disease training and microbiology
training closer togetherno-one is suggesting that there
should not be within that proposal, people who specialise one
way or the other, but that training should come closer togetheris
there resistance in the microbiology community to this?
(Dr Spencer) I have to say yes, there is, with some
of the older members.
135. Older than yourselves, presumably?
(Dr Spencer) I am quite old actually. My first technician
was a technician who worked with Alexander Fleming, so we go back
a long way. There is some resistance among the older school, but
nature being what it is, they will all drop off their perches
and be replaced by a younger generation without fixed ideas. So
I think the mood is changing somewhat.
(Dr Kelsey) May I add a little to that? I am a trainer,
as I am sure my colleagues are, and we train the future generation,
and I ask them, because ours is a microbiology-only rotation,
whether they would not have rather applied for one of the joint
training schemes, and although some say yes, an awful lot of them
still say, "I can get out of my career what I want from microbiology,
because I am not divorced from the clinical side of medicine."
I am sure it is true we will gradually move towards a joint training,
but not everyone feels that is exactly what they want.
136. I wondered if one can start, instead of
from the point of view of the individuals providing the services,
but from what the community would best be served by, then one
perhaps might come to a different conclusion.
(Dr Kelsey) Yes.
137. There has been concern expressed about
the commitment to surveillance which may be lost due to the introduction
of the Health Protection Agency and the transfer of laboratories
from the Public Health Laboratory Service to the NHS. Do you think
that this is a risk, and if it is, how can it be minimised? How
can we ensure that the NHS microbiology laboratories will fulfil
the public health duties carried out by the PHLS, as some evidence
has been given that transferring labs to the NHS will mean that
there is more focus on diagnosis than on general public health.
Do you have any comments?
(Dr Kelsey) I would say that actually, once you diagnose
the patients, your information on surveillance, of course, is
far greater. The problem arises in transferring the information
that you have gathered from your material into a surveillance
system. I am sure there are some concerns, and a lot of the concerns
of my colleagues are about the transfer of funding from the existing
PHLS regional network to the NHS laboratories, and there is some
fear that there will be retention by the Health Protection Agency
of more than is perhaps justified, and that this will leave the
NHS labs somewhat short of funds.
138. Is that an emulation of funding in relation
more to manpower availability or to the equipment and the information
(Dr Kelsey) I am sure it relates more to manpower
because you cannot function without people to do the work.
139. And there is already a shortage.
(Dr Kelsey) There is a shortage.