Examination of Witnesses (Questions 400-419)|
TUESDAY 4 FEBRUARY 2003
400. I am imagining a system which incorporated
NHS Direct and all of these sources to give you one unified feedback.
(Professor Little) Some form of feedback with that
information would be quite useful.
401. We are beginning to identify the question
of feedback and the lack of it. I think you have commented about
the willingness of people to report in the first place. There
is very little feedback. Is that a feeling amongst GPs?
(Professor Little) I think there is a real problem.
Over the years different governments have asked GPs to collect
all sorts of information which GPs do not see the point of and
have jumped through the hoops with very little relish and have
really undermined faith in the advice given by our political masters.
GPs need to know that there is a problem and this is why we need
you to do it. There needs to be a clear rationale rather than
the GPs being treated as data collection fodder.
Baroness Finlay of Llandaff
402. We have spoken about getting the data and
I wonder how you feel we could balance the tension between asking
clinicians not to overburden laboratories by sending in unnecessary
samples and to treat certain infections syndromically, with the
need to have up-to-date, representative surveillance data. Quite
apart from the asymptomatic issues there are the ones that present
one way and are bringing up resistance.
(Mrs Perry) I think you need clear protocols for specimen
collection so that you are obtaining the good quality sample in
the first place. There is a distinct lack of evidence to support
our specimen taking. A project that was commenced by one of our
regional infection control groups was to come up with guidelines
for specimen collection and the evidence just was not available.
I think there needs to be research done to focus on the appropriateness
of specimen collection. There is very little evidence to support
the actual collection methods that we use. I think that is the
first area to start on, to get the evidence to back it up. Then
to give the clear definitions where you can identify conditions
syndromically leading on to where you do take the diagnosis further
with the microbiological details.
403. Professor Little, you are at the sharp
end of collecting.
(Professor Little) As you have probably all guessed
from the way I have answered so far, I do not think there is any
great reason to change syndromic treatment of infection. I do
not think we should dramatically change that. On the other hand,
as you say, there clearly is a need for public health information.
Antibiotic resistance is hugely important and we need to have
some information at a national level as to how important this
is. You could do that by intermittent sampling from practices
once every couple of months. They could ask for not just the clinical
forms but also urine samples, throat swabs or whatever. You could
devise a system of intermittent sampling which is on a representative
basis so that it could be monitored at a public health level what
is going on. I think that kind of information at a very routine
level would not be particularly useful for most practices, so
I think the tension is, "What do you want this information
for?" This is a huge public health issue; we need to have
information about this so we will target our sampling at an intermittent
level so that we can get clearer idea of trends but by and large
we encourage syndromic management of infections backed by surveillance
which suggests whether there is an outbreak of something and targeted
sampling in those cases. That is how I see it, trying to manage
404. If something totally new, like West-Nile
virus, showed up, how prepared would you or the system be?
(Mrs Howard) From a public health perspective working
with a CCDC team the answer is that we are very aware of the necessity
to have plans in place to deal with unusual infections. We are
very aware that we can access the information from the Public
Health Service website, the CCDC website, et cetera and the microbiologists
in the Public Health Laboratories are very aware of the need to
be looking at trends and unusual specimens that are coming in
and to be asking questions. We are very aware that this type of
new infections could be an issue and a lot our planning and a
lot of the conversations we are having with the PCTs is about
how we would manage these types of incidents.
Chairman: I think the Public Health Laboratory Service
would pick up West-Nile virus, but so often these things start
in the consulting room or at the bedside. Is there a system that
you could see being put in place which would alert you to things
such as West-Nile virus coming in when the mosquito activity starts
again, just to alert you to the fact that the thing does exist
rather than just say that the Public Health Laboratory would pick
it up. The initial step, of course, is at the physicians.
405. How long would it take to get a response
from the PHLS from samples?
(Mrs Howard) I am talking about the local public health
laboratory. There are also the conversations that the clinicians
and the microbiologists have looking at the clinical picture that
a patient is presenting and what the laboratory is actually showing.
I am not suggesting that it is perfect and probably it is increasing
the index of suspicion that is perhaps what is needed. There are
those conversations that go on and then there is the close working
relationship between the microbiology laboratory and the public
health teams and the CCDC teams as well which, very locally, are
406. Do we have examples of infections like
West-Nile coming in that were picked up very quickly? That would
be the test of the system.
(Mrs Howard) I am sorry, I cannot answer that.
Baroness Finlay of Llandaff
407. I want to go a little further with the
accurate diagnosing of infections. One of the dangers of treating
syndromically is that there is a presumption that this is a bacterial
infection that will respond to routine antibiotics and not picking
up viral components or other types of micro-organisms. A group
of infections which I worry are tremendously ignored are fungal
infections in people who are ill with other things; they are so
difficult to diagnose. I wonder what you feel is the level of
knowledge amongst primary care out there in terms of the trigger
at which you stop treating syndromicallyby ringing the
changes on yet another type of antibioticand you say that
there is something odd here and you need to send the right type
of samples, and the level of knowledge of the right type of samples
to send off.
(Professor Little) There is not very much information
for most GPs. I think the whole issue is the index of suspicion.
There would hopefully be some information either from syndromic
reporting or from other sources that West-Nile was going to hit
or whatever. I think the issue of odd infections that are not
responding is a matter of index of suspicion and guidelines to
GP's about when it is appropriate to do samples and what samples
to do. The level of knowledge about that is very low. We would
need adviceGPs and perhaps nursesabout what samples
to take and when.
(Mrs Williams) This is particularly acute in TB and
the outbreaks we have seen over the last couple of years have
been due to cases being missed at an earlier stage and being identified
as something else like asthma or a chest infection. We constantly
see patients in clinics who have had a chest infection for weeksif
not monthsand had their antibiotics changed and changed
again. The problem with TB is that you do have antibiotics such
as clarithromycin and ciprofloxacin which will actually treat
the symptoms for a short time so people will see a slight improvement
and then they will get sick again. You go through this kind of
cycle. In some parts of London there has been some effort to work
with the GPs providing small laminate cards that they can put
on the desk with the main TB symptoms and who to contact locally.
Usually we want GPs to directly refer into a service which can
respond very quickly and take on those initial diagnostic tests
anyway. If you have GPs starting to wonder whether they need to
x-ray, do they need to send off sputum, do I need to do this,
it just delays the diagnostic process further. Ideally you want
a very close relationship with the TB team and the GP and then
a constant updating via the PCT Professional Development Committee.
There are mechanisms that we can use to improve this, but it is
about index of suspicion, certainly with something like TB.
408. In GP training schemes how sophisticated
is training on infections?
(Professor Little) Very unsophisticated; there is
very little training at all. I am often asked to speak at our
local course but they want to hear about the very common things
which are equally difficult to manage. I doubt whether there is
very much training at all about the management of rare infections.
(Mrs Howard) I would like to mention the Public Health
Link System whereby if a case of West-Nile fever was diagnosed
in England then the information would come down via the Public
Health Link System to the Public Health Department and when we
are on call we carry bleeps. When they go off we ask if it is
an urgent cascade or can it wait 24 hours or what. If it is an
urgent cascade then within a 24 hour period we actually dispatch
the information out to general practice. We did that recently
with the ricin scare; that is how the information went out. We
use the same technique if there are issues around serious infection
in particular areas. We are guided by what comes down as to how
quickly we need to respond.
409. What is the role of nurses in surveillance
and control of infection and how might that change as a consequence
of the extended role of nurses? You might like, in your answer,
to be quite specific about different nurses and different settings
as the answer may be different.
(Mrs Perry) As you pointed out, there are different
roles within this. I very much see the role of the infection control
and the communicable disease nurses in surveillance in facilitating
this, supporting the clinical teams in providing the data. The
role would be analysis and interpretation supporting action and
response to the surveillance information that we have available.
With the extending role of the nurse there may be a role for nurse
epidemiologists as there are in the United States who concentrate
very much on surveillance data, getting the correct data, interpreting
the analysis, et cetera. I am a very firm believeras are
the majority of my colleagues in infection control and communicable
disease nursesthat prevention of infection should be owned
by the people at clinical level with the advice and support from
specialists such as ourselves in protocols and determining actions
that should be taken. The role of the nurses who are carrying
out clinical practice is to be aware of predominant infections
and have good infection control practice throughout all levels
of their practice. I do think there is a role looking at the extended
practice in other areas, for example in emergency departments
of nurse practitioners, in the diagnosis of infections. Janet
Howard has mentioned previously about the changes needed for notification
where, at the moment, the formal method is by medical staff. I
firmly believe that we have to move that forward so that nursing
staff are able to formally notify infections.
(Mrs Williams) I would like to give an example of
the TB situation. I strongly echo the need for nurses to be able
to formally notify. Essentially in TB most of the notification
is done by nurses already. Because of the nature of the TB case
load there is a lot of flexibility needed to make services accessible
and as acceptable as possible to patients. This needs a lot of
flexibility so that patients have a lot of different ports of
entry into the service and also have a lot of choice about how
their care can be managed and also what access they have to other
services. There needs to be a lot of individual tailoring of care
to each individual patient. Mostly TB patients are not very sick.
Some of them are very sick initially; if you find them early enough
they are not necessarily very sick. They have a lot of other problems
that need to be dealt with which are a much higher priority to
them than their tuberculosis. We think it would be terrible to
have TB. If we were diagnosed with TB we would take our six months
of treatment; that would be the most important thing, to get rid
of our TB and move on. Whereas for a lot of people who do not
have adequate housing, have a lot of issues that go along with
seeking asylum in this country, have stress at work, marital problems,
whatever, there are a lot of chaotic things that are going on
in people's lives with TB and in a six month period that can change
as well. Priorities change. It is very important to be very patient
focussed with patients with TB and, I think, with other infectious
diseases, particularly sexually transmitted diseases. There is
a lot of scope for nurse led services and there are some very
good models of nurse led TB services particularly in London. Firstly
they can enable rapid diagnosis if the nursing services take direct
referral from patients themselves, GPs and other specialities.
They also have the flexibility of being able to work across the
hospital and the community. This works very well in places where
it does work (if that makes sense), but in places where there
are barriers between organisations this can really cause great
difficulties for nurses trying to offer these types of holistic
services. Thirdly they can reduce consultant waiting time. If
a patient is asked to come back every month for a consultant appointment,
that means they are taking a whole morning out of their lives
to come and sit in a waiting room to see a consultant for ten
minutes, when really they only need expert clinical care probably
on diagnosis, on the change of treatment at two months and at
the end of treatment to assess their clinical cure. In between
that time they could be perfectly well supported by specialist
nurses and they may be seen at least monthly or more frequentlyup
to daily in some casesentirely dependent upon that patient's
circumstances. I think there is a lot of scope for nurse led services.
I think nurses are pivotal for patients in order to be able to
tailor the different types of care the patient needs. They have
access to other community agencies such as housing and social
services, welfare advice. We need to draw on those and create
a network of services to be able to support patients in the community
and to keep them on treatment.
(Mrs Howard) I want to make the comment that often
the data collection is seen as being the end product but it needs
to be seen as a means to an end. I think the development of the
role of the nurseparticularly a nurse epidemiologistwho
is then going to action as a result of the findings is key to
this because the background to the professional development of
the nurse gives them a very clear insight to how the community
works, and it is a different type of training and brings a different
perspective than a medical training would bring. There are two
issues here, though. The pre-registration training for nursing
does not concentrate on these issues very well. Post-registration
training and the specialist nursing courses also tend not to give
good in-depth understanding of how you can use data and surveillance,
et cetera. Critical analysis skills are not good within post-registration
training for nurses; it is a gap. Then there is the other issue
that nurses, even those working at quite a senior levels, do not
quite understand what their public health role is within their
overall role. There is still a view that perhaps public health
is something that is done in a public health department rather
than overall. I think these are issues that need clarifying so
that we can make better use of these expert nursing roles and
senior nursing roles as well within this context.
410. Professor Little, do you have any comment
about nurses working in general practice?
(Professor Little) There is no doubt about it, nurses
have hugely extended roles now in the management of acute infections
particularly. Our practice has a triage nurse; she takes the phone
calls; she sees patients. Their training is perhaps just as limited
as a GP's in terms of the index of suspicion of something unusual
going on. Nurses have to be integrated into the system of training
and feedback of surveillance and targeting of sampling just like
the GP's do. I think they are absolutely key.
Baroness Warwick of Undercliffe
411. Given the extended role that Mrs Williams
was talking aboutwhich was really quite a comprehensive
rolethat would mean liaison and co-ordination with a very
large number of professionals, assuming that that was introducedor
in certain areas is being introducedinto training, are
there any barriers subsequently to fulfilling that role? What
are the expectations of other professionals in the field as to
what those nurses might be able to do?
(Mrs Williams) It varies. You can see it across London.
One of the big problems in TB is that there are very different
models of service in different parts of the city. Also it often
depends on the personalities of the people involved in the local
area. In some cases what happens is that the nurse-led service
gets developed in parallel to what is offered by the medical team.
In other areas there is very good partnership and team work and
very good acceptance of those different roles. I think it was
mentioned earlier that the important thing is that people bring
different expertise and different types of approaches and they
all have something valid to offer. It is really the flexibility
that is added by having nurse leadership, but it does create quite
a lot of difficulties in some areas because of the ownership of
(Mrs Howard) I think this acceptance of the extended
role for nursing is a very important point. Ultimately the crux
of the matter is accountability. There have to be very clear lines
of accountability within these very multi-disciplinary teams that
a nurse may be leading or may be liaising with. These accountabilities
as such have not quite been bottomed out so there are difficulties
and, exactly as my colleague said, it is mixed. But I think it
is coming and it has been thought about very carefully in the
context of the Health Protection Agency about the role that we
will have there. One of the key things, as I say, is accountability.
412. What is the role of the GP and the nurse
in communicating with the public about infectious disease issues
and what training do they receive, both about the nature of infectious
diseases and vaccination and about communicating risk?
(Mrs Williams) In terms of tuberculosis the nurse
often works across acute and community settings. They have a very
important role in updating their colleagues, updating people in
general practice about TB and the risks involved. I think it is
very important for the nurses to be linked in with the local health
promotion departments and work with them so that they do not try
to do it all themselves but they are linked in with the expertise
that is available locally and make sure that TB does become part
of the local health promotion activity. There is a whole different
range of aspects that they can be involved in but it is also about
mobilising resources available locally such as health promotion
(Mrs Howard) I think they have a very important role
but I also think there are a lot of barriers. Pre- and post- registration
nursing trainingwhich I have already mentionedis
very poor in terms of information on basic microbiology, basic
immunology and therefore the underpinning knowledge tends not
to be there. That is a barrier to communicating risk if you do
not actually understand the principles. Time is another issue.
Time is at a premium. For practice nurses with huge immunisation
clinics time is needed if they have a mother who requires information
about immunisation. From experience at work, the information flow
systems within general practice and within the primary care trust
are poor therefore the people who need the information that we
are trying to get out to them does not always get there. There
is very little understandingcertainly amongst nurses that
I work withabout the psychological emphasis that is placed
on the anti sites that you find on the Internet and the way they
actually work the public, if you see what I mean. They do not
understand that so how can they counteract the arguments. Generally
speaking, training in vaccination and immunisation for nurses
is very poor. Even health visitors who obtain consent do not have
specific modules on this within their training.
(Mrs Perry) I echo what Janet Howard has said which
links across to the acute sector as well. The lack of trainingboth
pre- and post-registrationfor nurses does impact on them
being able to carry out their public health function on patients
that are in acute care. For example, along the lines of tuberculosis
there is still a general fear amongst nurses about the acquisition
of these infectious diseases and if they do not have the correct
knowledge to protect themselves they will present an image to
patients, visitors, relatives that the risk is actually greater
than it is. They will enter an isolation room wearing head to
toe protective clothing when the need is not there. That presents
an image to the public that the risk is actually greater than
the existing risk is. There is also a problem of a reliance on
experts such as Mrs Williams, myself and Janet, to be able to
provide that information. What is actually needed is a level of
information to be able to inform patients and relatives at that
point in time and not make it seem like this is a greater issue
than it is by involving the experts when they are not needed.
Baroness Finlay of Llandaff
413. Going back to the lack of training in immunisation,
is there a place for having an accredited training route that
could be provided be something like NHSUwhenever it gets
off the groundso that you would know there was a minimum
standard that had been ascertained before people were undertaking
some of the schemes. That is one question. Linked into that question,
going back to your issue about answerability, accountability or
clinical answerability, and whether in secondary care the clinical
answerability should be across the disciplines into the speciality
teamssuch as the tuberculosis teamto the consultant
in chest diseases perhaps, the clinician who takes ultimate responsibility
rather than up through the nursing management hierarchy to somebody
who is not actually involved clinically in that area of work?
(Mrs Perry) I agree with the need to have accredited
programmes so that you have very clearly defined objectives and
a base line level of knowledge. We do need to consider different
levels of knowledge. For example, the generalist nurse would need
to have a very basic background level knowledge about immunology
and the role of vaccines in infection prevention, whereas the
person who is actually going to give the immunisation would need
more detailed knowledge to be able to answer patients' questions
about what the general risk is and to be able to identify where
they should not be giving vaccines, where people are having reactions
to vaccines. I believe there is the need to have standard objectives
within those modules so we are very clear that each university
is giving the same information to people.
414. What is the role of the GP in this? Talking
individually to the patients or setting the atmosphere in the
primary care unit so that there is a general level of understanding
about these issues among the whole team?
(Professor Little) One of the commonest things we
see are acute infections so we are always talking to patients
about it. It is usually reassurance that there is nothing horrible
going on and hopefully some sensible advice about when patients
might need to come back and see us again. I think it is a key
part of our role. Management of situations where patients do not
want vaccinationsit can be important for the GP and nurse
to be able to talk to patients about and explain what the evidence
is. Our practice went as far as sending out a leaflet to all patients
putting the arguments to and from. Communicating within the team
is vital. I think it is important that GPs and nurses sing to
the same hymn sheet so that you are not getting dramatically different
advice from one GP compared to another. In the best of worlds
that would not happen, but it does happen and is clearly an important
issue for communicating within the team.
(Mrs Williams) Just a point about tuberculosis in
in-patient settings. There should really be a protocol within
the hospital about where TB patients should be placed. If we take
the people with pulmonary tuberculosisbeing the most infectious
and therefore needing isolationthere should be a protocol
as to where these patients should be placed. They should be in
isolation until active TB has been ruled out. It is a broader
issue than having everybody in hospital updated about TB. If you
have a clear protocol about where patients go you can then work
with that particular staff team making sure they are regularly
updated about TB so that you have a very knowledgeable team. That
is what I have done in the past in hospitals I have worked with.
You have minimal specialist input, but equally every TB nurse
would like to see a TB patient as soon as they arrive at the hospital
so there is that contact with the ward as well. There are ways
to make it more rational and actually deal with those issues with
patients in an in-patient setting. In terms of vaccination, I
think it is very important that the people who are offering BCG
vaccinations do have some knowledge of the disease to be able
to answer people's questions about the level of risk. It is quite
a tricky subject.
(Mrs Howard) I would like to see the issue around
communicating risk and perceptions of risk extended beyond the
medical profession and nursing to other health care professionals
and to social service carers and all those that are involved within
the care family essentially.
415. How do you see the new Health Protection
Agency helping you with all your work? Does it support you or
is it irrelevant in the things you have been talking about? How
would it work?
(Mrs Howard) It is very difficult to know. Everybody
is still trying to sort out what they are going to look like and
what format they are going to take. One of my main concerns is
about the emphasis on data and surveillance and the potential
loss of any kind of strategic vision in management of diseases.
That is just a concern. The public health departments have tended
to be diluted into PCTs. The people at the PHLS have been very
focussed on surveillance which has been very useful but not necessarily
Baroness Warwick of Undercliffe
416. We talked about self-help right at the
start of our discussions. As general practitioners or indeed nurse
practitioners what are the benefits and problems associated with
a possible increase in the availability of near-patient testing
and over the counter treatments?
(Professor Little) I think this is the real nub of
the issue as a front line GP. In the context of antibiotic resistance
which I do believe is a hugely important threat to our nation
and to the world, the key issue is: "How can I tell that
the patient in front of me is somebody who will benefit from antibiotics
or not, or, indeed, benefit from antivirals or not?" That
requires a whole series of steps, the information for which we
do not have. We need to know whether a near-patient test is valid.
Does it predict microbiological or virological diagnosis? Then
we need to know, if you use it, what are the implications in terms
of predicting benefit. Just because you can predict whether a
bug is there does not mean to say that you will necessarily have
a huge symptomatic benefit from the patient by targeting antibiotics
accordingly. Then there are the downstream implications, that
if you have widespread use of near-patient tests does this actually
encourage the iceberg effect that I was talking about earlier
in that you encourage the idea that you need to see the doctor
or nurse in order to do a test. I can talk about the area which
I know, which are dipsticks and rapid tests for throats and near-patient
testing for flu. Those are the commonest available near-patient
testing at the moment. There are major validity issues there.
Then there is the issue of whether a near-patient test perform
any better than clinical targeting. Those are issues on the research
agenda that urgently need to be sorted out that nobody is really
sorting out at the moment. We are doing a study at the moment
on the use of dipsticks and it looks like, for example, the severity
of symptoms might be combined with looking at whether the urine
is clear or not which may do just as well as a dipstick, or almost
as well. If these provisional findings are confirmed then it would
be much better to use a clinical scoring system rather than use
a dipstickwith all the potential problems. My feeling would
be that we really need to sort this problem out in order for the
key question about targeting of treatment to be sorted out in
general practice. There is a whole series of issues. It is not
just about the management of self-limiting illness. You want to
identify people who will benefit symptomatically; you do not want
people to be denied if they have very severe symptoms. It is also
about who is at risk of complications and who is not. We do not
have that information. There is a really clear research agenda
that needs to be worked on.
417. Has it not been tackled by anybody at the
(Professor Little) We are doing a study on dipsticks.
I have put in a proposal to the MRC to look at the implications
of a rapid throat test as part of other things developing a clinical
score to see whether either a clinical score or a rapid throat
test actually does predict benefit from antibiotics. There is
clearly a research agenda round these things. Whether I can persuade
the MRC that that is more important than other things remains
to be seen. It is very difficult to get funding out of anybody
at the moment. The MRC is particularly stuck for cash. The NHSR
and regional system which used to be a very promising source of
funding for pilot studies and small trials has gone now. It is
very difficult to get funds. There is not an identified funding
stream for infectious diseases research. It is very difficult
to get funds for this really basic research. It is not that much
money compared to the size of the problem and the number of people
who are managed every day. It really is a priority that needs
(Mrs Howard) I want to say one thing about over the
counter treatments. Unless we include pharmacies within the syndromic
selection data or even surveillance then we are going to miss
huge pockets of information.
(Mrs Perry) In relation to near-patient testing and
the quality of testing, bearing in mind that in the laboratory
settings we have very good quality control systems to ensure that
we are maintaining high standards and reporting appropriately,
with near-patient testing it is important that those kind of quality
control systems are in place as well to make sure that we do have
some kind of accuracy and control over the results.
418. I think we turn to IT now. It is clear,
I think, that at least part of the strategy for dealing with infectious
disease depends on the collection and management, presentation
and transmission of information fairly rapidly. IT is clearly
key to this. How do you feel in your separate experiences that
the IT systems are coping at the moment? To what extent do they
fall short of what you think are legitimate expectations?
(Professor Little) We are at the start of being ablemuch
more effectivelyto use IT and I think NHS Direct is a really
important step. If that is integrated and cascaded down through
appropriate IT systems it would be great. We clearly need somebody
at the other end making a judgment about what information is important
and what represents a significant outbreak. I think I have indicated
earlier that I think there could be greater use of existing routine
consultation data collected in general practices every day; that
could be anonymised, downloaded and fed into the system. We are
now in a generation where most practices have computers. Some
have links; those links could be better utilised. The rapid feeding
back of clinical results is an example. Our practice has a link
system but a lot of practices do not. If you are stuck managing
a patient you want a rapid feedback of what organism is there,
preferably you want some advice about whether you need to do any
other sampling (for example in the case of severe fungal infection
or potential fungal infection), some little comment from the lab.
The use of rapid feedback of results, the use of rapid feedback
of information about local problems.
419. What does rapid mean in that context?
(Professor Little) I do not see why you should not
actually have information within 24 hours about a local problem.