Examination of Witnesses(Questions 264-279)|
TUESDAY 17 DECEMBER 2002
Professor Brian Duerden and Professor Angus Nicoll
264. Gentlemen, thank you very much for coming along.
I see you are not accompanied by any public, I am not sure why
that is. Would you like, for the record, to introduce yourselves,
please, and if you have any opening comments to make now is the
time to make them, before we get on to the questions?
(Professor Duerden) Thank you. I am Professor
Brian Duerden. I am the Director of the Public Health Laboratory
(Professor Nicoll) I am Professor Angus Nicoll.
I am Director of the Communicable Disease Surveillance Centre,
at the PHLS.
265. Any opening comments?
(Professor Duerden) I think, two opening comments.
We welcome the opportunity to meet with your Committee to discuss
areas of infection, and we are pleased at the high priority that
this gives to infection and communicable diseases. Obviously,
one of the main areas that we are concerned with at the moment
is the implementation of the Health Protection Agency, with the
Department of Health, and that features obviously in your considerations
and featured in our submission. We want to stress from the outset
that the PHLS is committed to implementing the Health Protection
Agency, and we are putting all our efforts into doing it and doing
it properly. And any concerns we may have raised, and we did raise,
in our submission to you is purely about getting it done properly
and effectively, not in any way to be taken as being opposed to
or trying to prevent any of this happening, quite the opposite.
(Professor Nicoll) I have nothing to add to
266. In a way, Professor Duerden, you have answered
the first question, but if I could pursue it just a little. In
written evidence you expressed concern about the pace of change,
and is this a concern about (a) yourself and (b) the staff of
the Public Health Laboratory Service, the apparent speed at which
this is being done?
(Professor Duerden) The speed with which it
is being done we are still concerned about, because from the publication
of the strategy, in the middle of January last year, to implementation,
on 31 March/1 April in 2003, it was a very short time to take
the outline that was in the strategy into a proper plan and implement
it, so that things have been going on in parallel with the implementation,
even before some of the details of the strategy have really been
worked out, and that has created some difficulties. In particular
also, the fact that it is being linked with the transfer of the
majority, 31, of the Public Health Laboratories in England into
the NHS. This is quite a major exercise to do, and it was only
last Friday that we had the definitive guidance document agreed
with the Department of Health and published in order to guide
that process. And although we had been able to start some things
in advance, that leaves only three and a half months in which
to implement that part of the activity. And that has meant that
the staff have been concerned about where they are going to be,
who their employer is going to be next year, and also then the
negotiations with our partners in the NHS to make the transfers.
So the whole of that has been a somewhat tight schedule. As far
as the Health Protection Agency itself is concerned, again, the
timing, we learned only at the end of November the decision that
it would be a special health authority, in the first instance,
and not an NDPB, and that it would be a two-stage process to move
to an NDPB. This again has meant that appointments have been delayed
into the new organisation; currently there is a shadow Chairman
in place, Sir William Stewart, but he is the only person actually
appointed to the Health Protection Agency yet. The appointment
of the Chief Executive Officer is going on at the moment, and
it is anticipated that they hope to make that appointment at the
end of January. But it means that we have nobody to discuss and
negotiate with on the organisational front, other than the implementation
team at the Department of Health. So that is a short timescale.
As far as that is concerned, we were very pleased, last week,
that the Chief Medical Officer and the Deputy CMO did say to us
that they would be making interim acting appointments into the
Health Protection Agency, so that people would have the authority
and the responsibility to carry forward from 1 April 2003 the
activities, because it is quite clear that there will not be the
executive officers in place, other than the Chief Executive, at
that time. We do now have the reassurance that people will be
appointed very shortly on this acting, temporary basis.
267. These interim acting appointments, is that another
way of saying You are going to be in a position that you are interimly
acting, appointed to," or could it be that different people
will occupy that position?
(Professor Duerden) We understand that it
will be generally people who are in post in the existing organisations
that will go into the Health Protection Agency that will be given
roles in the new organisation, without prejudice and without commitment
as to what their future will be, to ensure continuity.
268. But the fear of redundancy does not arise, does
(Professor Duerden) The fear of redundancy
does not arise, because all staff in the bodies going into the
Health Protection Agency have been assured of employment through
until 31 March 2004; the first year is guaranteed.
(Professor Nicoll) But there are some key
posts, they are new posts, which have to be filled, where it is
not simply a question of people continuing doing their jobs, and
so it is going to be important to attract people in, which is
quite difficult if you are saying to somebody, Well, you're acting
and you're interim," and also you have got to persuade their
employer that that is the case. But I would add, My Lord Chairman,
I would not want you to get the idea that the PHLS is necessarily
slow, we are used to moving very fast in things, but part of our
worry is that it is not as though there is a static world outside,
with all the change that is going on in the Health Service, and
you have somehow to get the attention, let us say, of a Trust
chief executive, to say to him, Look, this laboratory needs to
transfer into you by April 1, everything's got to be sorted out;
these are the things that we feel it is important to continue
to do, and here's the money." Now that is not necessarily
something that a chief executive is happy to sign off very quickly,
especially at the moment. So there is a lot of detailed negotiation
which people are working on very hard, but actually to get that
done by March 31 is a tall order.
Lord Lewis of Newnham
269. Can I just ask you, Sir, I am sorry, I am slightly
confused, you used the word `interim' post; it seems to me that
the interim post carries with it, for me, the connotation that
you may not continue with that person in that particular post.
Is not this going to provide you with difficulties actually in
getting people to accept these type of appointments?
(Professor Duerden) The proposal that there
would be interim acting posts was made only last week, and I share
the concern that in some areas people may not be happy to take
these on, particularly if they have other options, in other areas,
other jobs they could take on. It is vitally important that we
have people in place to run the organisation from 1 April onwards
and that they do need perhaps quite quickly some longer-term security.
270. May I pursue that just a little bit further.
Does that mean then that the interim post-holders are going to
be the ones that are actually formulating policy and formulating
a new structure?
(Professor Duerden) I cannot say that at the
moment, because that will be for the Department of Health to determine,
but the Chairman, Sir William Stewart, has created an interim
Advisory Board that is helping him, and that is separate from
this; these interim posts are operational posts.
271. I see. It is really to carry on the business?
(Professor Duerden) Yes. May I mention one
thing I missed about the change. The fact that it becomes a special
health authority means also that there is a residual PHLS proposed
for the first year, which would retain the PHLS Board, but purely
with the role of overseeing the production of bacteriological
media for the laboratories, which is a function that the PHLS
does currently for all its laboratories. This is fraught with
complications and the PHLS Board is unhappy that this is something
that is feasible, certainly as far as retaining any people employed
by the PHLS. It may be that the remnant of the PHLS Board has
to commission such activities, but it will be very difficult to
retain any employees within the PHLS, because if it was for only
one year that would be seen very much as an end stage with no
Lord Lewis of Newnham
272. We have had some concern given to us about the
fact that some surveillance activities will be carried on on a
regional basis and that this may affect the coherence and overall
co-ordination on a national basis. Do you have any problems with
this, and how should the organisational changes proposed in Getting
Ahead of the Curve be implemented so as to avoid any form
of fragmentation of these type of services?
(Professor Duerden) It is certainly essential
to avoid that fragmentation, to ensure a coherent national picture.
Professor Nicoll is Head of the Surveillance Centre.
(Professor Nicoll) I will try to deal with
that, Lord Lewis, combining surveillance and response, because
I think that it is best always to look at the two together. I
am worried but I am not desperately worried. I am concerned, when
you look at countries like Spain and Italy, which have moved towards
regionalisation, and you get bizarre circumstances in Spain where
Madrid is the last place that Barcelona will tell about the local
problems and they would feel that they ought to be telling Brussels
first, rather than Madrid. And, there, I think, you have an example,
that we must not repeat, of a country that is less than the sum
of its parts, in terms of its surveillance and response, because
infections are not very forgiving of that kind of fragmentation.
But to give you an example of why it would be crucial in this
country, at the moment we are in the midst of the largest resurgence
of egg-related infection that we have seen since the time of Edwina
Currie, and part of the way that that has worked, to get the information,
has been that they have been referring up specimens and information
in real time to, the Central Public Health Laboratory, and to
the Gastrointestinal Disease Division of CDSC. And I think as
long as it is understood that there must be that transparency
and the flow of information, and as long as there is somebody
who is overseeingand this is what CDSC doesthe response
mechanisms and the surveillance mechanisms, to make sure that
they work together, then we will be okay. That is why I think
we are having very frequent meetings informing the Agency, and
it is why I am very keen to keep the excellent team of people
that I have because I am lucky in that I have got both staff in
Colindale but as many medical staff now out in the nine regions,
and also in Wales and Northern Ireland, who work together. I think
we need to be using some of the electronic mechanisms better,
so that when there is a substantial incident in the North West
or the North East I can get to know about it very quickly; equally
that when there is something occurring nationally that I can communicate
this to field staff. Now we have those mechanisms at the moment
for some of the people who will be in the Agency but not necessarily
all of the people. So I have got some concerns, and if we discovered
that a particular region was doing something which was totally
incompatible with national strategy or a national investigation
I would have no hesitation in saying to Sir Liam Donaldson, Look,
I think this is potentially dangerous, can we sort it out?"
And he has been very supportive to us all the time in saying,
Yes, we will sort it out." But I think you raise a bigger
issue, which is how one keeps UK plc together, where there is
more of an issue there, which is not something which the technical
people, like myself or the Chief Medical Officers, want to see
happen. There is pressure, I would say, from the politicians in
the devolved administrations, saying, What is the added value
in Wales, what should we be doing that is different in Wales?"
Or Scotland, or Northern Ireland. And that is potentially dangerous.
We had an interesting example of this two years ago when the Scottish
politicians very nearly did something different on MMR and saying,
We should make single vaccines available," and it took quite
a lot of work by their officials to say, No, you must do the same
and consult with England." But I think that is a tension.
I am more concerned about that fragmentation than I am about fragmentation
(Professor Duerden) And this is particularly
the case with the fact that the PHLS has served both England and
Wales as an integrated whole for the 50 years, and now there will
be two distinct Services, in Wales and in England, and we have
to ensure the proper links between them.
(Professor Nicoll) We have set up a structure
to overcome that informally, which is called the Five Nations
Group. In case you are wondering who the fifth one is.
(Professor Duerden) It is Ireland.
(Professor Nicoll) This is because our colleagues
in Dublin felt that they had something to contribute, and Northern
Ireland is now working so closely with the Republic. This is a
meeting of the technical heads of the surveillance and response
centres, like myself, and we meet on a four-monthly basis and
have teleconferences when issues arise in-between that time. It
is rather like the way, actually, the Chief Medical Officers meet
on occasion. Indeed it is a technical version of that meeting.
273. Can I just follow up on this fragmentation.
You have talked predominantly about the epidemiological function,
but the question refers also to the laboratory fragmentation.
I wondered if you would like to comment on that?
(Professor Duerden) There are two aspects
of the laboratory fragmentation. One is the split between England
and Wales in relation to reference laboratories, in that there
are three of the National Reference Laboratories and one of the
regional Mycobacteriology Centres based in Wales, that will have
to continue to provide services to England as well as Wales, and
similarly Wales will need access to the reference services in
England. So we need to have strong agreements there so that nothing
gets held up, for example, with the question as to who pays for
any particular aspect at the time, because these services need
to be provided without question when they are needed. So the reference
laboratories are one aspect. The other risk of fragmentation is
the PHLS laboratory network around England and Wales. Currently,
47 laboratories cover England and Wales; in England, this will
come down to one nominated Health Protection Agency regional laboratory
in each region, with two in London, for north and south. In order
to maintain the very necessary network of public health microbiology
activities, the Health Protection Agency will continue to fund
activities in the laboratories that have transferred from PHLS
into the NHS, and will pay for consultant medical staff and scientific
input and support. But what we have to ensure is that it works.
At the moment, it is a direct line of accountability; the Director
of the Service can instruct, if necessary, and certainly require,
any of the laboratories to do what is necessary immediately, and
we have to maintain that immediate response capability in a situation
where it will not be a managerial accountability line.
274. I am rather concerned about your suggestion
that there might be difficulties in getting paid because of the
regionalisation. There are paper chases in other areas of the
Health Service, like drugs rehabilitation, for example, people
have to chase invoices all round the country. So is anything being
put into place to avoid the concern that you expressed a few moments
(Professor Duerden) I understand that there
are discussions between the Welsh Assembly Government and the
Department of Health to ensure that the cross-border flows between
England and Wales for reference services are maintained and are
not subject to individual pricing blocks or cost blocks. As far
as the laboratories in England are concerned, the ones that are
currently Public Health Laboratories and will become NHS laboratories,
the funding stream that goes in from the Health Protection Agency
will need to have with it a very carefully drafted service level
agreement to show what the laboratories will provide in return
for that funding. And I would be very keen to see that that was
not prescribed in such tight detail, in terms of saying numbers
of samples that had to be examined, and so on, that there could
ever be a time when somebody turned round and said, Oh, sorry,
we've used up all our allocation." When there are big outbreaks,
we know that funds have to be provided for extra testing, and
so on, but that should be done after the event and should not
get in the way of the immediate response.
Lord Lewis of Newnham
275. I realise this may not be your area, but could
I just ask, what about Scotland and Northern Ireland, are they
stand-alone, or do they have any form of interaction with the
system in England and Wales?
(Professor Duerden) At present, we have good
relations with Scotland. They have their own system, they have
the Scottish Centre for Infection and Environmental Health, SCIEH,
which relates very closely and works closely with CDSC. They have
some of their own reference laboratories, and again we work in
co-operation with them, and we provide services to Scotland from
the PHLS in areas where they do not have their own services. In
Northern Ireland, we provide the communicable disease surveillance
function under an agreement with them, so there is an outpost
of CDSC in Northern Ireland, and they have their own Public Health
Laboratory in Belfast.
(Professor Nicoll) And to cover those two,
to give you tangible examples, because a month ago there was the
rabid bat problem in Scotland, and, although that was rather sprung
on both Scotland and England, in that nobody realised what was
going on until four days after the initial diagnosis had been
queried, we were then very rapidly able to give to our Scottish
colleagues the experience we had gathered with two previous cases
of rabid bats in Lancashire and in Sussex. And then I was visiting
Northern Ireland, as I do regular visits to all of the CDSC regional
offices, two weeks ago, and they are identifying one of the crucial
things for them is that the laboratory in Liverpool still continues
to deliver brucella serology testing, because they have a particular
problem there of rising rates of brucellosis in people in contact
with cattle, in Northern Ireland. So things have to hang together,
and it is those details which I think are worrying me, that as
labs move over into the NHS the things that we now take for granted,
that individuals do, or that laboratories do, which do not seem
to be that vital on an overall scheme, actually become very important
suddenly. So what we are doing is getting all the bits of CDSC,
national and regional, to list These are the things that individual
laboratories do now and we would like to see preserved as they
move over into the NHS." I would not want to give you the
impression though that there are NHS labs who do nothing, we get
a lot of work done by NHS laboratories as well, in terms of reporting
and helping in some parts of the country where there are not a
lot of Public Health Laboratories. The difference will be as Professor
Duerden says, that when a laboratory finds something odd and they
have to do something because of that odd finding, some further
work, some tracing of notes, etc. there is not the managerial
relationship. In the middle of the egg-related outbreak, we were
getting the hints from one or two laboratories and hospitals that
they were saying Why should we look out the notes, that's not
our job?" While CDSC was saying, Well, the fact is that you're
the only people who can do that." When we spoke to the local
public health people and they spoke to the people in the hospital,
it was not a problem. But we talked about fragmentation on a regional
level, I am concerned also about fragmentation of different bits
of the Health Service. And I was wondering what was the implication
of foundation hospitals. I have nothing against foundation hospitals
per se, but when somebody said they would be removed from
some of the shackles of the NHS administration, I was wondering
whether CDSC was one of those shackles. Because we do ask people
to go the extra mile when they have got an outbreak that is related
to them; equally, we provide a lot of support and expert advice
when they have got an outbreak. And I would point out one of the
reasons CDSC was set up was following two disastrous outbreaks
that were poorly co-ordinated in hospitals, and I do not want
to get back to the time where the first time you discover that
there is an outbreak in a hospital is when there are deaths and
it appears in the local paper. That is not the case at the moment,
but I could see that, if you had these hospitals which were rather
stand-alone, that might become the case.
276. Before we move on to the next question, could
I just ask, as well as co-ordination of existing structures, is
this an opportunity to bring in other structures to the body of
the HPA that could with benefit be brought in?
(Professor Nicoll) Absolutely. It is partially
that you have got the new partners, in CAMR, NRPB and the chemical
service providers though it is worthwhile recalling that this
is something that, in part, was happening already; not with the
radiological, but after the American anthrax releases and September
11 we were already getting to know the other people. But there
is a larger family, and one of my hobby-horses is to say that
health protection is too important to be left to the Agency alone.
At the local, regional and national levels there are other partners
who one gets to know through experience; in foot and mouth we
got to know the Environment Agency very well and reinforced our
relationships with the Food Standards Agency. With the bioterrorism
we got to meet all sorts of people that we had heard of but we
had never met before properly. So there are opportunities there.
I suppose my worry is to ask will the Agency be given the authority
to pull these people together, how will that work?. When we are
dealing with the foot and mouth report, (we do a report on what
were the implications for human health of the foot and mouth disposal
campaign process, which is done with a number of agencies,) when
CDSC says can people come from these different agencies, they
are busy people, they do not necessarily come. When Dr Troop or
Sir Liam Donaldson says I'm convening a meeting," they are
more likely to come. So I am hoping that the Agency will have
that same sort of authority that the Department has.
(Professor Duerden) Can I just put into that,
that is one of the reasons why we believe strongly it should become
a non-departmental public body, as the PHLS is now, in due course
and that the special health authority is not the appropriate long-term
type of body for the Health Protection Agency.
277. In your evidence, you describe the need to use
information technology intelligently to modernise surveillance,
and can you describe what the major deficiencies of current IT
management might be, and what the potential benefits would be
of doing things better, and what is stopping you doing it anyway?
(Professor Duerden) I think one of the overall
major difficulties here, and this is not something new because
of the Health Protection Agency, this is a general one, is the
differences in the IT systems across the Health Service, and,
whether they are laboratory systems or patient administration
systems, there are so many different types. The need is to be
able to extract data, to integrate the information that is held
in these systems, to bring it in centrally, to make the analyses,
and I am looking forward to the development of the National Electronic
Patient Record, which is the next big development coming on stream.
Again, we need to be able to harness that sort of information
into national surveillance. And, of course, there, without getting
across the problems of patient confidentiality, there is a very
fine line between getting information about patients for public
health purposes, and very necessary public health purposes, without
contravening the very necessary and appropriate rules on patient
confidentiality. So those are the headline bits of it. Professor
Nicoll is more concerned than I with the detail of it, because
it is the feed-in to CDSC.
(Professor Nicoll) I always feel, in answering
that question, it is sort of like the man being asked, How do
I get to Dublin?" who is answered I wouldn't start from here."
What we seem to find still to be at the moment is that every system
we go to has not really been set up to give the information that
is needed for health protection. We need to get into a culture,
working with the NHS Information Authority, who we have had difficulties
engaging with, is that there should be specifications for each
system and there ought to be an output which will do the business.
At the moment we feel as though we are going rather like hunter-gatherers,
and trying to work out, Well, how are we going to extract the
information out of this system?" when clearly it was not
set up for that purpose. It would be just so much easier if the
systems were set up so that its not the only thing that they have
to do, but one of the things they had to do was to produce that
information. It is vastly wasteful of time to have to go into
every laboratory to work out the intricacies of tweaking the system
to give you what it is that CDSC needs. So that is one thought.
Professor Duerden has mentioned the confidentiality, and I am
sure we will come back to that. There are a lot of systems out
there that we are finding considerable untapped potential for
supporting health protection. Dr Douglas Fleming's work with the
general practitioners has been a beacon for us, and then, building
on that, we have found the NHS Direct systems has been particularly
useful, for a surprising number of purposes, including responding
to deliberate release. So I would not want you to get the impression
that it is all doom and gloom out there on the IT side, we are
finding that there are some hidden nooks and crannies that are
proving to be very useful. I think another development in the
future we have to look for is much more secure web-based work.
Being part of the Agency and having in the family some of the
people who have been making good local developments means that
people are beginning to show to us their work: Dr Mike Painter
in Manchester, and Dr Ruth Gelletlie, in Yorkshire, which we are
now looking at, along with systems from WHO, to see whether those
systems have value at a wider level. However a difficulty we always
face is that having something that works well in one locality,
or even in a region or a smaller country, does not mean necessarily
that you can roll it out successfully everywhere. We have had
our fingers burned with things that look very good at a local
level and then imagining that therefore it will be easy to use
them across the country without investment. I think the final
point on this topic is that `investment' word, because the idea
that you can get IT on the cheap is a non-starter. It has been
interesting, when we have been comparing the groups that have
been brought together to form the Agency at a national level,
in terms of what it does and number of people, the PHLS has by
far the least IT investment on a per capita basis.
278. As I understand it then, picking up the various
threads of your response, first of all, it is the diversity of
systems with which you have to cope, and probably a lack of common
interface protocols between your systems and the local system,
and clearly that is something that one hopes the NHS IT strategy
will tackle. The question of confidentiality keeps coming up in
a variety of contexts, not just that of this inquiry, and presumably
your requirements and those of patient confidentiality would be
satisfied if the information came to you simply in an encoded
form that identified a practice from which it emerged?
(Professor Nicoll) Not necessarily. In some
instances, the data coming in can be anonymised and we just need
to know where things are happening for what I might call the routine
purposes. However for quite a bit of our activities indeed some
of the most important work, you do actually need patient identifiable
data. Infection starts off with individual patients who are ill,
spreads to other people, and the public health action that you
have to take is to achieve the protection of other individuals.
But you have to sometimes come back to individuals to achieve
279. Right; but provided that this was an interface
through which you could go back, in other words, if you like,
the practice was the trusted whole, the key to the individual,
that would be satisfied, that would be alright from your point
of view? If you could go back to the practice and simply say,
Sample so-and-so that has come in is serious and has these implications
for the patient," that is the point at which presumably the
practice could, say, contact the individual and say, Look, there
are major public health implications here"?
(Professor Nicoll) I think it is difficult.
We have to do investigations immediately over weekends, that means
that all practice would have to be willing and able to deliver
a 24/7 service that can de-encrypt. Another difficulty is that
you do not know that something is going to be important until
the lab result comes. So I cannot say `yes' to that, even though
it sounds very reasonable, because my experience has been that
there have been a number of complex solutions like encryption
which mean that CDSC cannot deliver what we have to to protect
health and practice based encryption is one of these. In the circumstances
that we face, we do not now get patient names with a lot of our
information. What we have been doing in the past two, three years,
through our Caldicott Guardians, has been going to each of our
systems, saying, Do you really need patient names?" And that
has taken out about 70 per cent where we do not need it. But we
are left with about 20 to 30 per cent where there is genuine need
at the moment that in order to protect people we have to have
the names so we can go back to the GP.