Examination of Witnesses (140-159)|
TUESDAY 26 NOVEMBER 2002
140. So in terms of prioritising, do you think
that the NHS diagnosis side would take precedence over the public
health aspect? That is the key thing people are concerned about.
(Dr Kelsey) The point I was really trying to make
is that surveillance you bolt on to good diagnostic work, and
that once you have created the diagnosis, the surveillance is
really something which comes quite easily. It is your inability
to diagnose, because you have not got the breadth of investigations
or you do not have the manpower and money to fully investigate
an outbreak of diarrhoea, or even an individual case of diarrhoea,
because you do not have the breadth of studies available to you.
This is greatly seen if you go back to look at the E coli 0157
scares, when these became prominent, and the PHLS regional laboratories,
I believe, were instructed that they should look for E coli 0157
on every stool sample, whether it appeared to be clinically indicated
or not, which was probably a good strategy, but NHS laboratories
were not funded for this, and therefore had to do additional work
within their funding, and a lot of them said, "We will only
look on children" or where you have a haemorrhagic or there
is haemolytic-uraemia syndrome already established. I think those
are the sorts of problems. The view is amongst NHS laboratories
they do not feel that they have been as well funded historically
with doing complete investigations as they would like to have
done, so the belief is, whether it is true or not, that the PHLS
region network have better funding.
141. So is there going to be a problem in terms
of timescale, bearing in mind the April 2003 introduction?
(Dr Kelsey) I think the situation as it exists now
in recent years is that the NHS was responsible for more surveillance
data on microbial diseases going into CDSC than the PHLS regional
network. Those figures have been established. So I do not think
there is going to be any less surveillance data going in; I think
that will continue.
(Dr Spencer) I think all laboratories, whether they
are NHS or PHLS, do surveillance, and surveillance can best be
summed up as information for action. I think most medical microbiologists
running a decent lab will collect information and act on it, hopefully
in a timely manner. I think it is not beyond the wit of man that
you could incorporate in the discussions when PHLS laboratories,
other than those designated HPA, go back into the trusts to have
some form of service level agreement that surveillance data will
be supplied, and I think there is a role for local surveillance.
I think it has to be at the coal-face. There is then a role for
the regional epidemiologists, who are already recruiting regional
infection control nurses to facilitate this, which is then fed
back for national figures as well. I think it is the way the change-over
occurs. But of course, the one underlying problem is IT. Many
hospitals have different IT systems. Do they talk to one another?
What are we going to do about information technology and surveillance
in the community? What are the roles of the CCDCs and the health
protection units, who will now be part of the field forces of
the HPA? It will be different, but I do not see why surveillance
should cease or be any worse than it is at the moment.
(Dr Crook) We went through a PHL withdrawal, so in
a sense three years ago we went through what the laboratories
are going to go through at the moment. I am confident that passive
surveillance, as it is provided for at the moment, will continue
unabated and very well. There will be some minor transitional
issues around that, and I think one can be very secure about.
I think our reporting will continue. The PHL have withdrawn from
other laboratories, and that reporting has occurred, and I am
sure Professor Griffin would support that as being the case from
St George's. There were studies commissioned by CDSC, and I think
Paul Farrington, who was the person who did it, demonstrated that
the NHS reported passively to a very high standard, so I will
not be concerned about that. There are financial issues that impinged
very heavily on the Oxford lab, and that needs careful thought
and costing and needs to be unpicked. We receive a sum of money
of approximately £0.75 million per annum from the PHL through
the core funding that went to support the laboratory. It was poorly
defined and when they withdrew, that money was removed, and through
a vigorous process ofif I can use the jargonre-engineering
in the laboratory, which depended very heavily on my infectious
disease colleagues going so far as refusing tests for clinicians,
we were able to substantially reduce the costs of running the
laboratory, may I say at no risk to the passive surveillance;
we looked into that very carefully at the time. So these are going
to be transitional arrangements that may incur extra cost to proceed
through the transition; that will create some degree of uncertainty,
and that uncertainty I would estimate will affect mostly that
part of the PHL work that relates to doing what is being euphemistically
referred to as food and water and environmental work. That is
capturing that bit of workand it is not a large bit of
work but it is work which is very important to environmental health
officers, to district councils and other organisations of that
nature, where they investigate outbreaks, and that needs careful
planning to make sure that that is attended to through the transition.
I do not think a longer or shorter transition alters that. It
is the quality of the planning that goes into that transition
that will ensure it, and I believe with good CCDCs and good advice
through CCDCs, who are going to be part of the Health Protection
Agency, as planned in Getting Ahead of the Curve, will capture
that satisfactorily, if it is carefully thought through.
142. With respect to the present situation,
do all NHS microbiology labs currently report centrally to the
Public Health Laboratory Service?
(Dr Crook) I cannot be sure of that. That could be
provided by a CDSC, but the vast majority do report.
(Dr Kelsey) I think the answer is no, not all laboratories
report, and there are reasons for not reporting. Initially, and
it still is to some extent, it was a paper-based system. It takes
time to fill out forms. The workload on NHS diagnostic laboratories
has gone up and up. Staffing levels have not gone up particularly
in line. We have made cuts in methodology, etc, to try and keep
up with the work. One of the things which does fall off is the
paperwork, so I think fewer labs report now than did 20 years
ago. I would also make the point that the PHLS was not terribly
helpful when it came down to information technology. They provided
a system which was called Coserve, which was meant to electronically
capture information, feed that in via the regional epidemiology
network into CDSC. As an NHS laboratory that wanted to help them,
we tried to implement it, and it was not a very user-friendly
system. One of the reasons it was not user-friendly was that you
had to manually enter data. Even what you could capture from your
own laboratory information system was not enough; they wanted
more information. One of the problems we have had with laboratory
information systems in surveillance is there is no standardisation
of what an epidemiological data set should be: what it should
be for a stool, what it should be for urine, what it should be
for a blood culture. If we are going to look seriously at surveillance
in the future, given that there is no obvious end to the manpower
shortage or the funding problems that we have, then we are going
to have to capture data electronically. That means capturing it
on our laboratory information systems, which means that we are
going to have to have standardised systems of data capture. I
do not think the problems of forwarding from those systems are
that difficult, because there are large amounts of middleware
software systems which can take data from almost any output and
convert it to almost any other output. I would say that the PHLS
were told on many occasions that their system was unfriendly and
probably unuseable, and which may explain why it was not taken
up more widely by the NHS. Of course, the PHLS regional systems
were mandated to use it.
143. So there is a substantial lacuna there.
(Dr Kelsey) Yes.
144. But from what you are saying, it could
be remedied with not too much difficulty?
(Dr Kelsey) It could be remedied with forward planning.
There are a limited number of suppliers of laboratory information
systems. We have national guidelines from the NHS Executive in
Leeds about our IT systems. How much effort would it take to actually
get the Leeds NHS Executive to write a system of structures of
software which would capture the data we need to capture? In the
next few years we are mandated to going over to what we call "order
comps," which are basically that a GP or a hospital doctor
or anyone will have to order whatever request or out-patient appointment
or operating list through a computer system. This gives us a tremendous
opportunity for actually screening the work that comes in, having
to go through all the base systems for saying a test is appropriate.
If it is for a stool, for example, you ask the question "Has
there been recent travel overseas? Is there a food source suspected?
Is this part of a family outbreak?" There are very simple
questions which can be asked at the point of entry by the doctor
who has seen the patient, and this will then go into any laboratory
information system and be forwarded to any surveillance system.
So there are opportunities, but somebody has to make the decision
that they write the standards.
Lord McColl of Dulwich
145. Do you think the NHS Executive IT people
in Leeds are capable of doing what you suggest?
(Dr Kelsey) My infrequent trips to Leeds have not
been very sensible, but not necessarily based around IT. I really
could not answer that.
146. My question is about collaboration, and
what you have just described makes me worried that the thing that
might fall off the cliff might be collaboration, and that this
might be one of the transitional issues which Dr Crook mentioned.
We have heard a lot of evidence that says it is very important
to have collaboration between different kinds of surveillance
systems, so how do you anticipate that the interface between clinical
microbiology and food, water, environment and veterinary microbiology
might work under the new system?
(Dr Spencer) That is a good question. I think to a
large degree quite a bit of cooperation already exists between
PHLS, for instance, and local laboratories, whether they are NHS
or PHLS. If we are contacted by environmental health officers
to say "We think there is an outbreak in a particular hotel,
the specimen has arrived," we feed back in a timely manner.
Similarly with the CCDCs. I think it is opening lines of communication
that is vital. Apart from the IT problem, it is actually meeting
EHOs, meeting food standards people and also CCDCs, which most
medical microbiologists certainly do. So although we are going
to have problems with IT, and there is no doubt about it, provided
we are committed to communicating with one anotherand this
goes right across the boardI think you can go a hell of
a long way down that line.
(Dr Kelsey) May I add a number of points? I think
as far as the Health Protection Agency, the PHLS and the NHS are
concerned, the cooperation will be there. There is a tremendous
good will for all of us to work together. One of the areas, which
perhaps if we are going to look at it, is food, water, microbiology
and husbandry to some extent, and it is going to be the network
of private laboratories that perhaps serve the food industry,
that serve the veterinary industry and agriculture. They perhaps
need to be brought in, maybe through a system of reporting which
is voluntaryit may have to be compulsory. I am not sure
the food industry is going to be very keen necessarily to let
you know, unasked for, about what is going on in husbandry. That
is one area which perhaps needs to be looked at carefully.
(Dr Crook) I think this is a key question, and I cannot
see in Getting Ahead of the Curve or any of the other policy statements
that have been made that there is a mechanism for ensuring that
different agencies come together and share data in such a way
that you can make the analyses necessary to determine whether
there are outbreaks or links between outbreaks, either between
veterinary services and health or water authorities and the Health
Department. How one captures that needs thought, and I do not
think it is necessarily simple to get cross-agency support. I
am aware from my colleagues in the United States that this has
been difficult, and I am aware from colleagues in Europe that
it is difficult to get the vested interests that lie within each
one of those enterprises to share data in such a way that you
can make the necessary determinations for surveillance.
147. The system that we have at the moment,
that Dr Spencer described, is very much a needs-based collaboration.
When they need to collaborate, they do. Is that correct?
(Dr Spencer) It depends what you mean by "collaboration".
148. You mentioned that obviously they talk
to each other when they have a case that requires each other's
expertise, but is there a need for something more laid-out and
regular and routine that is not based on specific needs?
(Dr Spencer) I can only speak for Bristol, but our
CCDC sits on our laboratory management committee, which is held
monthly, so she comes along with her concerns and problems and
we have our problems, and we interface that way to try and head
off any foreseeable problems. I think if you look at the way the
HPA is starting to developand of course, the problem with
the HPA is that it is a "virtual" creation that does
not exist at the moment, although it is now going to be a special
health authority because they cannot get the RRO through in time.
If you look at the emergency response division, that will hopefully
capture what is happening in clinical microbiology, what is happening
in food and what is happening in veterinary. It could be, for
instance, if we talk about a deliberate release of an agent that
is also active against animals, it could be the vets, as with
West Nile fever, that will pick it up first, and they hopefully
could feed in that way. That is a developing theme.
(Dr Kelsey) I think there is a role for leadership
somewhere in this organisation, and it is perhaps best going to
be based in this regional microbiologist, an undefined post as
far as we can see, as is the inspector of microbiology, which
seems to be a totally undefined position. A good leader, somebody
who can inspire, somebody who can bring together disparate groups
would be more effective. One of the things that you have to do
is feed back. If you are going to get people to add information
to your system, it has got to be seen as worthwhile. There has
been talk perhaps that we should set up data warehouses, where
we enter our surveillance data coming from human practice, the
vets enter their data from veterinary practice, and from other
sources, CCDCs put it in, and that this then goes into a national
or regional data warehouse, and those who submit data can ask
questions of it. They will then get ownership and benefit from
it. There is always a problem setting up systems where there are
no benefits to those contributing. Finally, on this problem of
the disparate groups, the vets, farmers, food and human sourcesand
I am sure we will come on to talk about standardisationthere
are differences in methodology between the different groups. Veterinary
microbiology and human microbiology have moved closer; their methodologies
have become more similar. I am not sure this is true of food and
water, where what they call an E coli may not necessarily be what
we call an E coli. We have to be a little bit careful of that.
Finally, I was always impressed by cancer doctors and their cancer
maps. There may be an opportunity to produce infection maps, where
you have the veterinary problems mapped against the human problems.
We may be able with much better information technology to reveal
things which are just not obvious.
Chairman: Can I just say that I attended a meeting
in Cardiff a couple of weeks ago organised by Stephen Palmer,
who I am sure you know, and that brought together VLA and PHLS
in a quite remarkable way. We had three days of working together
very well indeed and doing things that you say should exist but
did exist. They were swapping information very well indeed, and
it just shows that the two bodies can work together very readily
and are keen to do it, so long as there no officialdom in the
149. One of the aspects of this business which
I have been trying to get a feel for from various witnesses, but
I have not really succeeded yet, is the need for speed in carrying
out these various steps. The arrangements that one proposes and
the kind of organisation that one needs is determined at least
in part by the cost/benefit analysis of how quickly you need to
know what is happening, because at the moment one is substantially
based on pieces of paper travelling here and there with some electronics
in there. Is anybody in a position really to give an answer to
the desirable speed with which this series of processes that we
are talking about can be carried on?
(Dr Spencer) What is wrong with a telephone call?
If I have a problem that I think we have an outbreak situation,
if it is within the hospital, we do a visit; if it is outside
the hospital in the community, we get hold of the CCDC and say,
"Look, we have suddenly had a whole rush of meningitis/salmonella
food poisoning" or whatever. So I do not rely on technology.
As soon as my MLSOs come along and say, "Hey, guys"we
do a bench round every day so we pick these up for the medical
people and we act on that. I do not rely on pieces of paper or
computers anyway from that point of view. I think we have to be
careful that we do not lose the human interaction.
(Dr Kelsey) I think one of the problems we have with
surveillanceand I think this is a very fundamental problemis
that we are relying to some extent, as we said, on cases that
appear at a hospital or samples that come in from the community,
and there are some areas which cause us quite considerable difficulties,
such as winter vomiting disease, which at least two of us on this
table have got beds shut because of the problem, yet there is
no community surveillance of that. If we had good surveillanceand
it may well be because we do not actually have the technology
for good surveillancethis is not something you can diagnose
with good methodology easily and quicklywe would be forewarned,
because you would be able to watch the build-up of the number
of cases, and to some extent we do this with RSV, which is a very
predictable disease in children, but we perhaps need to start
looking at the technologies and the way we do surveillance in
the community, just as we do for influenza with spotter practices.
It may well be that we are going to need to have microbiology
spotter practices, and we are going to have to put some sort of
research initiative into the areas such as winter vomiting disease
where we need good technology, such as influenza, where we need
good diagnostic technology before we can use the newer drugs that
are becoming available. So I think timeliness is a matter of forethought
and planning so that you are not hit by these nasty shocks. Of
course, this would not happen with bio-terrorism, because it would
be a nasty shock when it happened.
150. I think I should express my interest as
ex-Chairman of the Public Health Laboratory Service. The question
I have relates to the transition between what we have now and
what we will have come April next year, the new HPA. There are
a number of issues, of course, with any transition, but one is
that the Department of Health is suggesting that this can be achieved
with no additional funding. You have hinted at this before. I
just wondered if you would like to enlarge on your response.
(Dr Spencer) You could say, "They would say that,
wouldn't they?" There is a need to increase community surveillance,
and the way we practise modern medicine now is that if you want
to look at the incidence of post-operative wound infections, you
cannot restrict it to hospitals, because whereas 20 years ago
people having a cholecystectomy had seven days in hospital and
then they went to a nice little cottage hospital and had another
seven days, it is a couple of days or a day case and out, and
you talk to GPs, and I say, "I haven't got any infections
in my hospital," and they say, "No, it's all in my patch,
isn't it?" So there is a need to increase community surveillance.
There is great disparity between the numbers of infection control
nurses in the community, ranging from nought to four per 100,000
head of population, and of course, you have to talk about standardisation
of surveillance. I know the government likes league tablesand
that is why we get the MRSA bacteraemia league table, whatever
that means; if we do not include things like risk factors, it
is meaningless. If we are going to standardise surveillance, invest
in IT, if we are going to increase our community surveillance,
then we need cash.
151. Can I pursue that response a bit further?
What you say is, in order to improve the services and do what
everyone wants, we need to inject money. What I was really referring
to was simply the process of changing from one system to another.
Do we need money for that?
(Dr Spencer) I think we have already alluded to Dr
Crook's experience with PHLS withdrawing out of Oxford. It is
always a question about what we are going to do with so-called
core funding. Where is that going to go?
152. Is it not said to be coming from the primary
care trusts? Is that creating any anxieties amongst the microbiological
(Dr Spencer) It is a question of where primary care
trusts see their priorities. What is important to them may not
be what we think is important. They may think it is to do with
cardiac disease, cancer, infection control.
153. They will have a lot of priorities to satisfy.
(Dr Spencer) Yes, indeed.
154. We recognise that we do need more resources
to do all the things that you have said should be done. We recognise
that we need more resources to do new things in Getting Ahead
of the Curve. The Government has said health has to be cost-neutral.
The question was whether the transfer of responsibility is going
to cost more, without the extra resources necessary to do all
the newer things.
(Dr Crook) I think the transfer is cost-neutral based
upon a couple of assumptions. If there is a very substantial investment
by the PHL in their management, and that money is released, which
it may be, it is said that they spend 15 per cent of their total
budget in management, whereas an NHS hospital typically spends
about 5 per cent. If they went down to the 5 per cent level, that
would liberate the funds.
155. I think that is erroneous actually.
(Dr Crook) But say that that was true, and there was
a release of funds that would be able to fund the transitional
arrangements. If the money is not there, as you imply, it is not
there and there will not be the resource to fund the transitional
arrangements. It is clear to me that a component of the core funding
that goes to laboratories was never used for the public health
function that it was said to be; it was used to support the laboratories
in the work that they did, and even though the PHL, if I may suggest,
argued very strongly, it was all done that way, but looked at
under the cold, harsh light of day, that money was actually used
to underpin NHS functions, and there is no doubt about that, and
there is no escape from that. In that sense, to maintain the status
quo, the money that goes to laboratories will need to be funded
and our NHS trust had to find a scarce resource and under competing
cost pressures, to fund and maintain a reduced level of microbiology
over that that the PHL laboratories are used to. I must say PHL
laboratories could get used to a far lower level of funding, but
that transitional arrangement is costly in many different ways,
including in pounds, shillings and pence, and in addition to that
in terms of people's morale and ability to cope under those sorts
156. Evidence from the Association of Medical
Microbiologists argued that it is fundamental for laboratories
to use accepted standard methods and to diagnose a standard range
of pathogens. Perhaps you could expand on this and say why it
is important that there be a standard range of pathogens and whether
NHS labs will be able to work to these standard operating protocols
currently used by the PHLS.
(Dr Kelsey) I think there are a number of areas here.
First, I do not think that the United Kingdom and Ireland live
in a separate universe. We have to communicate with other countries.
If we look at the history of MRSA, it probably came from Australia
and came this way. If you look at penicillin resistant gonococci,
etc, probably in the Far East. So I think we have to be prepared
to communicate with the rest of the world. We need to know that
such things as antibiotic-sensitivity testing reach if not the
same standard, that they are believable by other people in the
world, and that when we say something is resistant, the rest of
the world says something is resistant. So I think we are operating
on a global stage, so our standards have to be internationally
acceptable. I referred earlier to the problem of E coli 0157.
The same problem occurred with cryptosporidium. You are told by
a letter from the Department of Health that everybody has to look
for cryptosporidium in every stool. The truth of the matter is
that not every hospital laboratory could do it because they did
not have the manpower and the resource, so it was not done. If
we are all going to operate to the same standard, so that surveillance
means the same thing in the south of England as it does in the
north of England, for example, then we need to operate to standard
operating procedures which are the same. That brings us on to
the other problem of what is the framework in which we are looking
at things. Are the same numbers of general practitioners submitting
stool samples or urine samples or high vagina swabs in different
parts of the country, different practices? That again brings us
back to the problem of should we have spotter practices looking
at particular diseases. I do not think that is mandatory and I
am not sure it will turn out to be necessary, as long as things
stay the same. It will become a problem if suddenly everybody
stops sending in high vagina swabs because the primary care trust
says "We can no longer afford to do microbiology and therefore
we are going to give less money to the microbiology in the hospital,"
in which case you say, "In which case we are not going to
do your work." There are risks like that, I think. I think
we need standardised care. Some labs will need to raise their
157. Putting this another way, are you in fact
saying that these NHS laboratories will have responsibilities
that actually go beyond their immediate authority because their
results have effectively regional or national implications; they
have a double obligation?
(Dr Spencer) You could argue that this may be one
of the roles. I understand that the job description for the regional
microbiologist is currently being arranged. It may be his role
to ensure that the non-PHLS laboratories or ex-PHLS laboratories,
ie NHS, do form standard operating protocols or it could be a
function of the CPA.
158. Will he have any levers to implement that?
(Dr Spencer) I do not know. I have not seen the job
description yet. There is one concern, in that of course, at the
moment the PHLS is subsidised in its medium production, and the
statement about ten days ago explaining the creation of the special
health authority also said that the PHLS for the next 12 months
will stay in operation, and one of its main if not only functions
will be concern over medium production. This has produced a very
substantially subsidised rate so we can afford to do more than
an NHS laboratory which buys it commercially. The question is,
at the end of 12 months, if the medium production departments
close, and we are therefore prey to market forces, are we going
to have to pay more? I think the answer is yes, in which case
we are going to have to say, "Hang on a minute, maybe we
don't need to do this or do that." That is an interesting
problem that we are going to face 12 months down the line from
(Dr Crook) If I may say a few words about this, the
first is that the variation in reporting between laboratories
has less to do with methodology within the laboratory and more
to do with the case definition that is used by clinicians in deciding
to send samples or not. The greater variation, vastly greater
variation, depends on how, when and under what circumstances a
clinician decides to do a test. So the laboratory is entirely
the victim, as it were, of the circumstances of who it is and
when samples are sent. If you want to get a comparable standard
of surveillance across the country, you need clinicians to have
the means of agreeing with one another how and when to send samples.
Microbiology is pretty mature around the world; irrespective of
the nuances in methodologies that microbiologists are getting
excited about, the degree of variation that that causes is tiny,
and there has been, I think, an over-emphasis on that. It would
be far better were the effort put into deciding which cases to
send the samples on and to allow clinical judgment to determine
that, and to move away from this obsession. I think it is ducking
the question where it is allowing surveillance to be much weaker
than it necessarily ought to be. Furthermore, if many NHS laboratories
went the route of PHL standards, it is going to cost more, and
there is absolutely no question about it. We (Oxford) had to move
away from PHL standards to come within budget. Were we to have
to return to that (PHL operating procedures), we would need another
quarter of a million pounds to satisfy the need to do that.
(Dr Kelsey) I would not disagree with what Dr Crook
says. I am not an obsessive microbiologist, and most of my colleagues
are not, but there is an area where we will be facing perhaps
a lowering of microbiological diagnostic standards. Point of care
testing, where the test is done in the primary care setting, or
in the Accident & Emergency Department to diagnose a microbial
disease is going to be with us fairly soon and some technology
has been aroundnot highly taken up, but as technology does
go forward, it is going to be much easier to do these tests. There
are two problems we face. One is capturing that information, because
you are going to have to capture it from primary care or accident
and emergency departments, and the other problem is going to be
around quality assurance. We know that there are very good point
of care tests which when done by a biomedical scientist give you
a sensitivity and a specificity in the 90s, but the moment these
tests move out of the controlled environment into primary care,
specificity tends to drop quite severely. So there is going to
be a large role for quality assurance at point of care testing
that is going to be done, and we have not looked at that in terms
of how we will cope with that.
(Dr Crook) I want to enlarge on what Dr Kelsey said,
that there are areas which are new to microbiology where standards
are absolutely critical, and when I refer to microbiology as mature,
I am referring to methods based on culture essentially. If you
start to go towards new technology such as measuring the presence
of nucleic acids and manipulating that to determine diagnostically
what is going on with people, they are in their infancy; they
need to be validated, yet at this stage they are already being
used and presented as though validated, and it is in that area
that there needs to be a very substantial improvement in the standardisation
and understanding of the performance of those tests, lest we be
misled, and it could easily be the case that if those data were
early captured into surveillance, that we could be misled into
believing there was an outbreak perhaps. There is also the potential
for the loss of data through point of care testing, which means
a general practitioner doing it right by the side of a patient
in a sense, and if that data is not captured into the entire data
set, you lose, and you might, for instance, have a delay in identification
of a disease process. New technologies are bringing the means
of doing that at the bedside, so for instance, there may be a
case where you could do a salmonella test at the bedside in a
general practice, and that is lost to the data set for the national
surveillance. So those areas clearly need standardisation.
159. The situation you described, Dr Crook,
was where the laboratory is very reactive to the clinical decisions
of the clinicians to send the samples in for testing, so in that
situation how on earth do you stick to a budget? If you have problems,
does the primary care trust have to make decisions that certain
kinds of work will not be done, in the way Dr Kelsey was just
hinting at earlier on? Which decisions are they going to make?
Are they going to make decisions based on how their performance
(Dr Crook) I think your point is very well made, and
there are going to be major issues around what ought to be passive
surveillance, in other words, which of those elements that you
capture because samples course through laboratories and you get
results, and you have IT systems that capture that data that allow
people to peruse it and make a decision whether there is a departure
from the endemic or normal rate of that particular organism or
syndrome or whatever it is, versus circumstances where you wish
to determine in a structured manner the burden of disease in a
population. That, I have to suggest, is separate; it needs to
be designed differently, and in a sense we might be getting confused
between capturing data that is coming from laboratories and is
referred to usually as passive surveillance, versus that component
of surveillance which is specifically designed and has as its
aim and end point understanding the burden of disease, knowing
the organism that you are going for, and measuring that, and I
would suggest much of what we do today could be done that way.
It does not mean you have to go to every laboratory. You can carefully
devise those studies to occur in a restricted area and you could
make it fit very well with improved evidence-based testing, which
decreased the pressure of testing on laboratories, which is a
major cost pressure for laboratories, the growth of testing, much
of which is not necessary.
(Dr Spencer) I have to say that the majority of GPs
already practise a kind of syndromic approach, which is in question
7. If you go and see your GP with symptoms of a urinary tract
infection, he will reach for the trimethoprim and send you on
your way, but he may test your urine if you come back and your
symptoms have not alleviated. Similarly with chest infections.
They think, "Yes, I will give you Amoxil" and it is
rare that we get any sputum samples from GPs unless they are complicated
with longstanding chronic disease. So I think GPs are already
practising this syndromic approach. In hospital it is a bit different
because the junior doctors are very stressed with their European
time directive, they are looking after far more patients, and
they tend to screen for everything. They ask for every biochemical
marker known to mansimilarly with microbiologyjust
in case the great man comes round the next day and says, "What
is the serum rhubarb?" "It is 2.3." "You are
very impressive, aren't you?" So that is a problem. Now that,
of course, is tied into teaching of undergraduates and you find
that microbiology teaching for undergraduates is getting less
and less, and I understand that in the newly created Peninsular
Medical School there is no time set aside for teaching microbiology
so we have these junior doctors who have qualified with no microbiological
education at all, and we have to educate them on what specimens
to take, what antibiotics to use, etc, so it is a problem.
(Dr Kelsey) Really, to go on to say a little more
about Baroness Walmsley's question, surge capacity was what we
were referring to which was the ability to take on additional
work because of an incident or an outbreak. This was something
which the PHS used to provide us with. I can remember many years
ago handling outbreaks of diarrheal disease, which used to occur
in hospitals more frequently than now, and you could not cope.
So we used to lay off the work to the local PHS laboratory who
would assist us. That may be something which needs to be covered
under the new arrangements, and I see this as something to do
with networking and modernisation of pathology which I am sure
we will go on to consider. So there is a need to take on surge
capacity; we must think ahead for the outbreaks; we may be hit
by a major food poisoning scarewe just do not know.