Examination of Witnesses (Questions 380-399)|
TUESDAY 4 FEBRUARY 2003
380. You were saying you were disappointed there
was no feedback of the information. At the very local level to
whom do the practices report and what happens to that information
at the beginning of the reporting situation?
(Mrs Howard) The practices would phone into us and
tell us they were seeing a lot of patients with whatever. Or we
have an informal reporting system via the local education department
and they send in a form which tells us they have so many children
off with chicken pox or flu like symptoms. We also have other
information that is coming across directly from the microbiology
laboratory. It is possible, on occasions, to marry that information
and to have a very good idea of what is happening in a particular
part of the county (I work in a very widespread geographical area
in a particular part of the county) and then to see if there needs
to be some sort of intervention such as information sent out on
particular issues. That is how we work.
381. You mentioned the lack of feedback. Is
that a detraction for making this system as effective as it should
(Mrs Howard) I think the lack of feedback tends to
be from the surveillance perspective when specimens are sent.
Obviously there is feedback directly to the GP who is caring for
the patient to guide the management of the case, but there sometimes
tends to be a lack of feedback from the overall picture back out
to primary care. I think that probably is one of the big problems.
There is no incentive to report. The relationship with the general
practices and the CCDC team is built up by networking in a particular
382. Can I ask whether there are any privacy
issues that arise in pursuing this perfectly sensible course,
namely the information that comes back on patient samples being
distributed more widely?
(Mrs Howard) It is distributed it an anonymous way
in terms of: "We are aware of x infection and you
may possibly see cases". That is how it is distributed.
383. Continuing the surveillance theme, we have
had evidence suggesting that surveillance should be thought of
in general terms as providing information for action. But should
it better be used to identify clear objectives and targets for
disease reduction and collect information to be used for those
specific ends? I am thinking particularly of things like sexually
transmitted diseases, chlamydia, TB, food poisoning.
(Mrs Williams) I would like to say that my area of
expertise is TB. In terms of TB surveillance we have a very good
surveillance system. We have had enhanced surveillance annually
for the last 10 years now which collects information about ethnic
breakdown, travel and different aspects according to each case
in a very clinical sense which has been very helpful to show which
groups are most affected. We have also now started to collect
information about treatment outcome which is obviously very important
for measuring the quality of the service that you are giving and
making sure that people are completing treatment. We have, however,
tended to focus very much on clinical surveillance and have not
been so good at collecting data on social aspects which are obviously
very key to the group of patients that often suffer from tuberculosis.
The London TB Nurses Steering Group has already piloted one case
load profile aimed at producing a snapshot of social information
about the patients on the case load. Although the data in the
first round was not particularly rigorous, it did give us much
more information about homelessness, incomes, statistics, immigrant
status of people on the case load, which would be very useful
information in terms of planning services according to the patients'
needs in any particular area. There are issues about increasing
the levels of surveillance and changing the type of surveillance.
Feedback is a very important aspect as has already been mentioned.
If people are asked to fill in more forms and take time to provide
information it is very important that they get feedback on their
local statistics in relation to the overall pattern both in their
region and probably nationwide. What we want to do this yearif
we get the resources to do this in London at leastis to
repeat the profiling exercise with an improved pro forma so that
we can collect the social data again on a broader range of aspects.
If we then keep that cohort of patients, we can review the treatment
outcomes on those patients in the following year. We will get
an idea of what aspects are related to problems with compliance.
All of this together will give us some very useful information
in looking at the make up of services that we provide for helping
patients with TB, both to come into the services and also to remain
within the services and complete their treatment.
384. From what you say, so far as TB is concerned,
you are sold on the idea that surveillance is specifically targeted
at disease reduction in TB.
(Mrs Williams) Yes. In terms of microbiological surveillance
we do have mycobnet so that every positive culture we have is
tested for antibiotic resistance which is, in fact, the way we
found the outbreak in north London.
385. Do you have targets? Disease reduction?
(Mrs Williams) In the action plan it has been suggested
that there should be some disease reduction targets. The problem
is, if we put more resources into something like TB you are bound
to have more cases initially but they would eventually go down.
If we are looking long term it is perfectly realistic to have
these disease reduction targets. In terms of using more social
profiling, it is very important so that we can target screening
effectively in order to find our cases much sooner to prevent
delays in diagnosis and prevent infection in the community.
386. Are the health care professionals on the
ground involved in the setting of the targets with an understanding
of the resources that are going to be provided and able to pass
an opinion on whether these targets are appropriate and achievable.
(Mrs Williams) There have been a number of targets
which have been set for London over the last few years because
there has been an acknowledgment of the serious problem of TB
in London. The increase in London accounts for the increase in
the UK as a whole. We have been doing some work on London and
a lot of the concerns that have been raised by people in London
have led to certain targets being set such as the nurse ratio
should be one to forty notifications of TB. That has helped to
put quite a lot of pressure on PCT's in order to commission additional
staff. Not everybody agrees with me, but I find targets very welcome;
you can use them as levers for local commissioning. Essentially
there has been very little additional resource linked to these
targets. There seems to be some additional resource attached to
the action plan although it is very unclear. The resource that
has been made available most recently at very short notice is
not TB allocated money, which is one of the big issues. There
is no specific money allocated to TB. We have to scratch around
to try to get it very locally. It is very intensive work to try
to get local commissioners to put the right things in place to
meet the targets.
387. When statistics are collected do you distinguish
new arrivals in this countrywho presumably arrived in this
country with TBfrom indigenous occurrences? My second question
is, roughly what sort of percentage do you have of full completion
of courses of treatment?
(Mrs Williams) The answer to your first question is
yes, on the new enhanced surveillance form there is a section
which asks how long somebody has been in the country. It is fairly
clear that a large percentage of people will develop the disease
in the first five years of being in the country which usually
suggests that they have been infected in their country of origin
but only developed the disease after being in this country for
a few years. We have only just started measuring treatment outcome
and I think the last figures are all between eighty and ninety
per cent, which is reasonable but not good enough.
388. Is this with directly observed therapy?
(Mrs Williams) Directly observed therapy is very intensive
treatment because it needs somebody to be observing treatment
either daily or three times a week. Probably about ten per cent
of our patients are on directly observed therapy and they are
usually assessed for risk. One of the pieces of information we
want to collect in our case load profile is how many people should
be recommended to have direct observed therapy and how many are
actually offered directly observed therapy according to the resources
389. Can we move on to other infections. Chlamydia
is of particular interest. Is there a target we should be setting
and is there a way of getting there? Can we use surveillance better
in this area?
(Mrs Howard) I have very little expertise but I am
aware of the work that is happening within the Public Health Laboratory
in the area where I work. We do not have targets at the moment
for reduction in the area. The problem is that to meet many of
these targets it requires a huge input of funding which is not
available at the moment. It is not just a question of meeting
the target, but also the funding of the other health promotion
services around overall reduction in sexually transmitted diseases
et cetera, and the funding of the action plan that came out of
the sexual health strategy. I am not an expert and I do not know
a great deal about it, but there are these big funding issues.
It is not only a question of the surveillance. It is how we target
the risk groups, where the funding comes from for the public health
promotion needs assessment type work. All these things interplay.
390. It is a neglected area at the moment.
(Mrs Howard) Very much so.
(Mrs Perry) I would like to echo Janet Howard's comments
about setting targets without the resourcing that goes with it
and also awareness of how setting one target impacts on other
targets that are set as well. The difficulty between balancing
the many targets that we are set and making those a priority for
funding with the very limited resources that are available, very
often it comes down to who is the champion of a specific target
that has been set as to where the finances are led towards.
391. Do we know how common asymptomatic chlamydia
infection is? Before you set the target you have to know what
the incidence of the disease is and chlamydia is one of these
infections that is quite asymptomatic.
(Mrs Howard) I cannot answer the question directly.
The question asks about whether we would provide information for
action or whether we have clear objectives and targets. There
are issues around looking very objectively at what is the public
health gain if we set an objective and a target. That is not an
answer essentially to the question, but it is on the periphery
of the answer. Certainly there are issues around setting clear
objectives for targets and about promotion of safe practices in
terms of preventing chlamydia infection or preventing food borne
disease or what have you. They place an enormous burden on the
public health and on the economy.
(Professor Little) I cannot claim to be a sexually
transmitted disease expert, but chlamydia does strike me as a
case where you could target providing you had the resources for
the implementation. As you are no doubt aware, GP's are a fairly
over-stretched demoralised bunch at the moment so telling them
to do yet more things will not go down well and they will not
do it properly. It does strike me that there is a potential. Smears
are an obvious time in which to take a chlamydia sample. I know
our practice does that routinely but I do not know how many other
practices do. There is an opportunity; it is happening anyway;
piggyback it on to what is happening anyway. The other thingand
this would be an example of targeted surveillanceis that
you can do chlamydia tests on urine. There is an argument for
anonymised testing so that there is the information in the public
domain about how common it is in particular areas. I think the
business of actually counselling somebody about the fact that
they might have a chlamydia test brings in a whole set of thorny
issues. People do need counselling. Just like counselling for
an HIV test you need counselling for a chlamydia test too. If
you are going to do it on a patient identified basis then patients
need counselling prior to doing the test. It is an extremely thorny
issue and brings in the issue of resources. I think if it could
be piggybacked on what is going on already, plus or minus using
some anonymised testing on the urine samples which are being collected
anyway, you will get useful and efficient information. You may
then want to do some particularly targeted patient identified
392. There is one other thing I would like to
ask. From some of your answers it makes me think that perhaps
you do think this but perhaps you could confirm or deny it. When
we were in New York we talked to the health commissioner and he
was very, very keen on programmatic work on specific infections.
TB in particular is what we were talking about. This had specific
objectives and ring-fenced money and particular resources, professionals,
training, public information and the whole thing. What potential
do you think there is to that kind of approach? Probably to TB
your answer will be yes, but are there any other diseases such
as chlamydia and other things which you think are not addressed
in that way in this country currently, but do you think there
is potential for it and are there advantages?
(Mrs Howard) I think there is the potential there
but there is also the danger in that if you ring-fence money for
a particular programme it does not give the flexibility that you
need in a low incidence area. I think a better way forward would
be to be encouraging the primary care trusts when they are developing
the local development plans to have a place for health protection
within thatalongside their cancer care and all the other
issues they have to addressand to have a system whereby
we are able to bid on an equal footing for development monies.
At the moment we have to weave our arguments into other issues
because there is not a specific line that you can bid for within
health protection, if you see what I mean. I can see a case for
tuberculosis in London, for example, but it is a very different
thing when you have low incidence in particular areas.
(Mrs Williams) I would share some of Janet's concerns
because in TB as well, if you did ring-fence money and give it
a programmatic approach, the danger is that you take it out of
mainstream services and other people would disengage from it.
Having PCTs with particular priorities for health protection and
tasking them with coming up with action plans which they are then
able to resource for different types of infectious diseases would
be helpful. In areas of high incidence obviously you need expert
teams and there need to be specialist units. There also needs
to be flexibility across organisations and geographical boundaries
which I would hope we would be able to achieve without having
to do down the programmatic approach entirely. I think it is a
kind of hybrid in a way because we still need people in primary
care to be very aware of the disease. Patients do not just turn
up on the specialist unit doorstep; they have to be identified.
I think there have to be specialist units with expertise who can
support the general health services and make sure they are kept
updated. Specialist units should be ultimately responsible and
accountable for managing and finding TB in the community. But
it is a kind of balance.
(Professor Little) I basically support the principle
of a targeted approach and I think that if you are targeting something
for action you need to identify the resources to go with it. That
is the bottom line for me. If you are asking people in general
practice to do something that they would not normally do for particular
targeting then it would definitely be helpful to provide the resources.
How you would specifically target chlamydia, for example, other
than in the sort of approaches I have identified, I do not know.
How you then provide the resources to general practice needs some
working through. But I would agree with the principle.
393. I think much of the question I was going
to ask has been answered, so you might just address the specifics
if you wish to. The question relates to two issues, surveillance
systems as they are and the need for the professionals to have
information to do their job properly. Do they need information
and how does that information get to them? Are they able to influence
the surveillance system to make the information they get better?
(Mrs Perry) Can I give you an example of how surveillance
is performed both between primary and secondary care? In the Old
Avon area we are currently participating in a research project
led by the Central Public Health Laboratory on enhanced surveillance
of viral gastro-enteritis. That is based on both syndromic reporting
as well as virological data. The value of that has been in preventing
the risk of spread to other patients. We now have a link up between
what is happening in the community, particularly in residential
and nursing homes in an early warning system for patients who
have been admitted to hospital with these conditions and hopefully
preventing widespread outbreaks which can occur in hospitals at
this time of year. It has also been very useful in informing us
in making risk management decisions. As many other trusts, we
are under considerable pressure to continue admitting patients
and maintaining a normal service. Whereas normally we would comply
with management guidelines that we have not admitting patients
into wards or notif you have two wards closed you would
normally keep those two wards closed and not mix patientsbut
with the additional surveillance information that we had we knew
we had one predominant strain circulating so we were able to adapt
our management strategies based on that kind of data. That is
a kind of practical approach as to how we use surveillance data
to inform our management across both primary and acute care.
394. How do the GPs get that information?
(Mrs Perry) The GPs' information did go out via the
CCDC office. It was a completely joined up working process. When
we realised that we were having considerable admissions with viral
gastro-enteritis into our trusts we had the normal outbreak meeting
and the information went out to the GPs to make them aware of
395. Is there feedback as to whether this is
an effective surveillance system or not?
(Mrs Perry) There will be. The surveillance is continuing
until April and then there will be a review of whether we do another
(Mrs Howard) I just want to give another practical
example that I have recently read about where they have used surveillance
within an acute hospital. They have actually looked at the surveillance
in conjunction with the admission rates and turnover of patients
and patient days, et cetera. They have collated all that data
and interrogated it and used it to put a business case forward
for a 24-hour domestic service in terms of cleaning on the wards
and cleaning the isolation rooms because they found that what
was happening was that the majority of patients were actually
being moved after eight o'clock at night when, in fact, the cleaning
service ended. I read that just recently in a professional journal.
That was a very practical way of using it.
(Professor Little) I think I have outlined how I think
surveillance could work with the available information from NHS
Direct. It is not beyond the wit of man either to download data
from computerised practices for surveillance. Not all practices
are computerised and there is the issue of the different systems,
but in principle I do not see why some of that data should not
be downloaded, anonymised and fed into the system. You might not
need it because you have NHS Direct and you could argue that whatever
is happening after six o'clock is probably representative of what
is happening during the day. I know there is some surveillance
of that information at the moment. How that is fed back I honestly
do not know, but I think that information could be quite useful.
If it could be fed back rapidly with some advice about what to
do I think that could be potentially very useful. At the moment
we get intermittent communication from our local CCDC which is
a two-sided piece of A4 about the samples that are being sent
and whether they are resistant samples, unusual organisms which
I personally find very helpful. The question is, how should you
be acting on that? Some of the information is quite difficult
to act on, so the fact that the lab says that twenty per cent
of the samples are resistant to trimethoprim does that mean you
should not prescribe trimethoprim? Or are they an unusual group
of patients who are being sampled. Or are they the difficult and
recurrent cases with higher rates than the rates for most people
presenting. So twenty per cent to the lab is probably ten per
cent in reality. Then there is the issue of whether the fact that
the lab says it is resistant will that translate to clinical resistance
in practice. You are concentrating an antibiotic in the urine
and the lab reporting a resistance is quite sensitive, so do the
two match up? The answer is we do not know. I think it is quite
useful information for the public domain and it tells you there
might be something funny going on, but whether GPs can or should
use that information clinically is another matter.
(Mrs Williams) In terms of influencing surveillance
systems what has been quite frustrating over the last couple of
years - particularly in the London sceneis that most of
the money that was coming into TB has gone on surveillance when
we have known that there have been very serious operational issues
that need to be addressed. In terms of having control over which
part is given to surveillance or operational issues can be a conflict.
396. Professor Little, could you just imagine
an ideal world. You are a pressed GP. You go into your office
in the morning. What sort of information would you like to come
up automatically on your screen about surveillance or incidence
in your broad area? What would you like?
(Professor Little) What sort of ideal world are we
talking about? Where there are no resource implications?
397. Let us not talk about resources, but what
would you like? I do not think this question has been asked.
(Professor Little) I would like to know whether there
are any particular problems in the locality. Ias a GP managing
patients with a sore throat or a chest infection or urinary infectiondo
not know whether there is a particular problem.
398. Your locality is a radius of twenty miles,
(Professor Little) Yes, I suppose that would be nice.
You would like to know if there is a particular problem in the
Romsey area, for example, or is there an outbreak of something
in Southampton. That would be useful. It would also be useful
to have some advice on whether we should send samples of people
presenting with acute urinary syndromeseven though you
would not normallyfor the next week. That sort of information
and some advice about sampling strategy would be useful.
399. You would like that to be there on your
screen first thing in the morning.
(Professor Little) It would not have to be there on
my screen. NHS Direct would get the information, feed it back
to the local CCDC the next day maybe. They would cascade that
out by fax or e-mail. It could happen quite rapidly; it might
not be the next day.