Examination of Witnesses (Questions
TUESDAY 28 JANUARY 2003
DR GERRY BRYANT, SIR KENNETH CALMAN AND MR PALLAB
Baroness Finlay of Llandaff
340. May I pick up on the sexually transmitted diseases,
because it seems to me that there is a catastrophic problem when
you look at chlamydia. There isdespite a new editor`Page
3 News' and yet nobody is saying, But this woman has chlamydia."
If, week after week, day after day, there were these nudes with,
above them, Chlamydia positive", Gonococcal positive"
perhaps you might begin to get the message across. But the pressure
out there is to have unprotected sex and have Page 3.
(Dr Bryant) The other thing is the product
of the negative test, as well. Speaking to our local genito-urinary
colleagues, there are many people from sub-Saharan Africa who
enter this country, have an HIV test and it is negative, and,
subsequently, within the space of one or two years, present with
HIV positive as a consequence of infection in this country. We
are a low-incidence country and yet we are transmitting HIV within
a country of preventable disease.
Lord Lewis of Newnham
341. In the question communicating risk effectively"
comes in. I know this is a point that Sir Kenneth will be wanting
to discuss at some stage but it is this conception of how you
can express some of these problems to the public at large. I am
reminded that Sir Richard Southwood, when looking at the BSE problem,
made the remark that the probability of getting BSE was about
as great as being hit by lightning. Statistically that is not
a bad figure but it is just one that is not being appreciated
because it was taken to mean that there was no probability of
this particular thing happening. I do worry at times at the way
we express some of these things and the assumptions that we build
into that. Is there any sort of mechanism whereby, when you are
looking at the publication of these things, you do ask the question,
or, should I say scientific question, of a non-scientist? Because
scientists have a way of thinking in theirown dimension, in their
own particular way, and probability in particular, which is very
much associated with risk, is one of the features, of course,
that is very much a part of their way of thinking but is not necessarily
the way that the average public thinks about these things.
(Sir Kenneth Calman) The publicand
I include myself in thatoverestimate low risk and underestimate
major risk. The fact that 25 per cent of the population in this
country continue to smoke cigarettes when all the evidence and
all the publicity is so clear, suggests that it is important enough
for them to say, I'm prepared to take the risk that it won't happen
to me." Some of the publications I sent down try to look
at that language of risk and how you change that language. There
is not an easy way to do it. People stillalthough it is
perhaps changingput money on the Lottery. The chances of
winning that are extraordinarily small but they are prepared to
do it because it might just happen. Put it the other way round:
in terms of a nuclear power station blowing up, they are not prepared
to accept that risk because of the consequences. So it is a very
complicated issue. You can also change that by what in scientific
terms I think is called framing. You can frame the comment or
the question. It is quite an interesting exercise to get medical
students to do this, to present something to patients in three
different ways: The chances of getting an infection after an appendicectomy
for you, my dear, are not very high; the chances are actually
one in 20; you could be one of those who get that infection. You
can change the presentation very easily to change the way in which
that is perceived. Somehow we have to get better at doing that
342. To go back to the question Lord Turnberg spoke
about, the MMR/autism furore, in fact how could the Department
of Health have handled that better? The take-up is still diminished.
Where did things go wrong there?
(Mr Ghosh) I think that in the public's mind
were still memories of BSE, where there was a minority view that
was being snowballed and steamrollered by big Government, and
here you had Andrew Wakefield, this scientist who was concerned
about children, at odds with the medical establishment. Answering
the more general question about how to present risks, certainly
in the broadcast media it is about presentation and it is about
trust. I think BSE had a hugely damaging effect in losing the
public's trust from the scientific community and also from Government.
I think that is something that is slowly being built up. I think
there are a lot of lessons to be learned from the way in which
the Food Standards Agency has operated, where it has been seen
to be neutral or on the side of the consumer rather than representing
MAFF (as it was then) or the DEFRA interests. Neutrality is important
but I also think presentational skills are important. The way
you come across is as important as the wording of your message
in the broadcast media, which I do thinkis more important in particularly
breaking news stories. I would suggest that you take a look at
some of the star performers. John Pattison during the BSE crisis;
Sir William Stewart over the case of mobile phones; and, increasingly,
Sir David King in instances. I think in the public's mind these
people come across as: We are not too sure about that, but they
are good blokes, they have not served us badly in the past, and
we are prepared to take on board what they are prepared to say."
I do think there is a case for better training in presentation.
There are a lot of training courses around but quite often it
is half a day on How to smile while talking" and Take out
the jargon," and really it is a far more complex and difficult
process than that, not just for the performance but for the people
within organisations who are trying to deal with crises. There
might be a case for identifying star performers within organisations
and giving them more extensive training. I think those are the
points I would make.
343. The question of communicating uncertainty is
one in which I am interested. In most instances it is very difficult
to get black and white views. How do you get that across? It is
not very appealing to the press, it seems to me, to have uncertainty
(Mr Ghosh) Sir William Stewart did it quite
well in his mobile phone report. I still remember that in the
first paragraph the first line was The balance of evidence suggests
that there is no risk to human health from mobile phone radiation."
He said, However there are some anomalous results and further
research is required, so we should adopt a precautionary approach
and the public are advised to make sure their children do not
excessively use mobile phones." That was something that conveyed
uncertainty. It also gave the public a choice, which I think was
one of the issues with MMR, and it let the public make their own
minds up. People smoke because they enjoy it and it is their choice.
I think it is about being straight and coming across as being
straight with people and letting people make their own minds up
rather than building up some view that the Government is hiding
something. Gradually that is changing.
344. Jeremy Paxman always says things like, Come
off the fence." Is it so or is it not so?"that
is to politicians, of course, so they can stomach thatbut
by and large scientists are not very good at being pushed in that
sort of way. The press do have something here, as well as those
who are presenting to the press, do they not?
(Mr Ghosh) Jeremy's job, which he does extremely
well, is to put people in positions of influence under pressure.
So it is not the kind of work-a-day scientist, it is people who
deserve to be put under that kind of pressure. But there is an
answer to that question: Jeremy, I honestly wish I could answer
that question." It is also about showing that you are a human
being, rather than being evasive.
Lord Lewis or Newnham
345. Whenever one considers the whole concept of
risk from variations of this particular type, there really are
two categories: those over which you have control and choice yourself,
and those which are imposed upon you and over which you have no
choice. I would argue that MMR would probably fall in the latter
class, whereas many other things, such as mobile phones, fall
into the former class. I think, realistically speaking, those
are very important aspects in any presentation of risk as a whole.
You have to recognise which of these two categories you are talking
about and how you are then going to present them.
(Mr Ghosh) I think what you are talking about
is empowerment. At the end of the day, all you can do is provide
information with whatever form of media you are dealing with as
honestly and as clearly as you can because the alternative is
(Sir Kenneth Calman) One of the things which
it is interesting to compare is the communication of risk between
the patient and the doctor and the communication of risk between
the public and some other figure. I think we have come a long
way in the first category in terms of openness, and it has not
in any sense destroyed the medial professionin fact, I
think it has strengthened it greatly. But, under these circumstances,
you build up a relationship in which you can say, I'm not sure,"
and it is easy to say that, And if you are not happy with that
go and see Dr X down the corridor." In the public sense,
it is more difficult to do that. I think, in spite of Pallab's
nice reflections on some of his colleagues, they do want you to
give an answer. Particularly if you are a particular type of person,
they want an answer. You know,"You must know because you
are in that position. What is the answer?" and uncertainty
is more difficult. I think part of that is the public beginning
to understand the concepts of uncertainty. If I look back over
the last 10 years, there has been a very significant shift that
waywhich, of course, I think is a good thingin that
we do not have all the answers and we might not have all the answers
and you have to be prepared to wait a little bit until we get
the answers. That I think is easier to say now than it was 10
years ago. I think our journalist colleagues have helped greatly
Baroness Finlay of Llandaff
346. May I pick up on Pallab Ghosh's comment that
Jeremy Paxman is doing a good job, because the problem is that
the people who may represent, as Sir Kenneth has said, a balanced
view are not going to go on that programme. Nobody in their right
mind would go on that programme. It is for those who want to be
lamb slaughtered. If you have suicidal inclinations, then it is
fine. But you are not goingto get the balanced view. So it becomes
self-perpetuating, because the sort of person who tries honestly
to present the uncertainty is just going to be made to look a
fool, because they are outwitted by Jeremy Paxman who is doing
that all the time. That is his job. Their job is scientifically
to assess whatever processes they are going to be presenting to
the media. So I am not sure that you can say that it is good.
Perhaps it is very irresponsible not to have a haven of reasonableness
within a programme like that.
(Mr Ghosh) I think, if you see the way in
which Newsnight is currently covering the Iraq crisis,
Jeremy is quite capable of actually bringing out some of the major
points. It is only a weapon that he uses occasionally where he
feels it is appropriate. I would encourage as many people as possible
to go on Newsnight because it is a very influential and
Lord Lewis of Newnham
347. There is an important point, which simply is
that science can only be disprove something, it cannot prove anything.
(Dr Bryant) Particularly a negative.
348. I think that is an important concept which is
not appreciated by many people, including many scientists.
(Sir Kenneth Calman) Yes. I have just a brief
comment. I have always said that when I grow up I would quite
like to be a TV producer. I would have a weekly programme, I would
pick a disease, any disease; I would find patients who are dissatisfied;
I would find a professor somewhere who had a cure; I would find
a dark room and put a senior doctor in it who was confused. You
could do that on a weekly basis. We have talked really about the
press and the serious media but there is a lot of that kind of
journalism around too, which I really do not think helps those
who happen to have particular illnesses.
Chairman: We must move on. Lady Emerton.
349. We talked about the communication skills of
health professionals earlier this morning. Could we just move
on to think about the health professionals' knowledge base. Do
you think that health professionals are sufficiently aware of
the issues around the risk of contracting infectious disease and
the risk of being vaccinated, in order to provide effective advice
to the public?
(Dr Bryant) It depends on what we mean by
350. Do you feel health professionals have adequate
(Dr Bryant) We can look at this on two scores.
One is the professional dealing with the individual and the second
is the professional dealing with the public. If we look at it
from the personal physician or personal nurse perspective, then
I think there is fairly recent evidenceand I hate to go
back to MMRrelating to MMR that the people trying to encourage
and advise patients as to what is likely to be the best course
of action are not fully versed with all the information relating
to the subject that there is. On the other hand, can we expect
that? There is a huge amount of information; we are an information
overloaded society. I think the important thing is for those individuals
to acknowledge that they may not have all the answers at their
fingertipsand this, again, is the honesty: Okay, I don't
have that information now but I will find out and we will have
a discussion about it again in the future." I think there
is a tendency for people to feel they have to have all of the
answers at their fingertips and if they do not then they are failing.
I think acknowledging that we need to find out more is important.
I think whenever we are about to speak on a particular subject,
it is important that we do our homework, because we cannot remember
all the latest and I think we cannot retain and hold all of that
information. I think, again, we have to acknowledge that and do
our immediate homework before talking in public about an issue.
(Sir Kenneth Calman) I agree very much with
that. I think the key point that Dr Bryant has made is that when
you do not know the answer you should be able to get it. This
is the issue of briefing notes. The technology is now available
to get that quite quickly. If something new turns upand
this was Pallab's point right at the beginningthe ability
to get into the Internet or whatever way you wish to get some
information quite quickly should be available. All of us will
see things that we do not know enough about. If that is the case,
we should be able to find that out and find it out very quickly.
351. Do you feel that is built into the official
training of medical students and health professionals generally
(Sir Kenneth Calman) I think it increasingly
isI mean, increasingly in terms of the evidence base and
where you go for it and how you get it. I think that should be
there. But in terms of the continuing professional development
of professionals, that has to be seen as something you will do.
If I may return to the cancer issue: testicular cancer, I used
to see lots of them. It is an extraordinarily rare thing. If you
were a general practitioner, you would see one every 30 years.
How do you expect to know about it? You cannot. But when you see
it, you should be able to go directly to where you get the evidence,
what happens, and to get a specialist who can help. That is a
key for any professional, to be able to use that information.
(Dr Bryant) It is as much about information
management as holding all of the knowledge.
Baroness Emerton: Yes, and I think the experience
of being able to say, I don't know but I will go and look."
That calls for considerable experience and maturity.
Chairman: Lady Finlay.
Baroness Finlay of Llandaff
352. Why do you feel we have such appalling antibiotic
prescribing for things which are probably viral infections? The
classic is the number of antibiotics given out in general practice
for upper respiratory tract infections still without any evidence
that they are going to be antibiotic sensitive. There the health
care professionals have been taught, have been told, but their
behaviours have not changed at all.
(Dr Bryant) I think there are several answersor
possible reasons for that, one of which is uncertaintyfear
of uncertainty and fear of getting it wrong: If this is not a
viral infection, I have got it wrong and there is going to be
a problem for the patient and me." I think that is a very
real fear. Lack of time: it is unfortunately for many people still
quicker to reach for the prescription pad, coupled with that doubt.
The final point is that if we actually look, particularly, around
a sore throat or ear infection in children, the evidence is that,
yes, antibiotics may overall reduce symptoms by one day. For that
individual, in that situation, that one day may be important and
may be worthwhile. I do not think we should definitely dismiss
all antibiotic prescribing in those situations as being a problem,
so the `convenience prescription'. The other problem is patient
expectation. There are many strategies that can actually be used
to overcome that. I think it is, again, this feeling by the patient:
You are refusing me. You are just preventing me having this."
Negotiation is what comes in there. It is negotiation around,
Okay, I do not think antibiotics are needed in this case. I do
not want you in my surgery tomorrow morning and the next day and
the next day, though, so let us temporise on this. If you are
no better within 48 hours, then perhaps a prescription may be
of some help to you. You can, by phoning, obtain a prescription
at that point, unless you need to see me if you are worse."
It is a matter of time and negotiation and I think time, particularly
in general practice, is one of the key factors as well.
353. In all fairness to the antibiotic resistance
issue, since I chaired that Committee, the Department of Health
and Sir Kenneth when he was there did an enormous amount in the
medical profession. Whether one can say that in the press and
in the media is a different matter. It was a very determined effort
which I think was very effective in the medical profession. I
think there has been a tendency to go back a little or to flatten
out the effect, but the communication of the medical media on
this issue I think was quite good.
(Dr Bryant) We should not knock ourselves
too much because we fare far better than many of our European
and other counterparts.
Chairman: May we move on? Questions 6 and 7
are rather connected. Lady Warwick.
Baroness Warwick of Undercliffe
354. We have touched on training and decided to come
back to it, and I think these two questions very much concentrate
on that. I remember, when this Committee looked at the public
understanding of science, that one of the conclusions we drew
was that scientists really needed to understand the public a bit
better as well. I wonder whether you think that scientists should
be trained in communicatingas I have said, we have touched
on it with the public and mediaand how best that can be
done. You were positing the possibility of drawing out from the
medical profession individuals who have particular communication
skills. Do you think it is a question of general training or whether
or not we really ought to be identifying individuals better?
(Mr Ghosh) I think it is down to individual
organisations, because there are some organisations, like PHLS,
that will be required to respond tobig emergency situations, or
there are smaller universities where nothing may happen for years.
I think training needs to be thought about. Quite often organisations
think, Yes, we should have some media training and we will bring
someone in for a day or half a day," and that is that box
ticked. I think training needs to be thought about strategically.
Also key performers, star performers, should be identified as
people who can be put out, put in front of camera, and they should
perhaps be given more intensive courses in, I suppose, the dark
arts, really, about what the message is, what is required from
different forms of media, who the individuals are within various
organisations. One of the things I have noticed as a customer
of media resources from various organisations is how undervalued
the press offices are. There are so many organisations where the
press office is usually the last place to hear about thingsI
am often the one who tells themand they are often treated
like clerks by an organisation, where everything is done and dusted
and then a matter is sent to them to try to get some publicity
for it. Better organisationsand I cannot think of many
in this scientific field, but certainly in private industrydo
have a proper director of communications at the heart of the decision-making
process. Dare I mention Alistair Campbellsomeone who is
involved at the very basic level of policy making, can advise
at that level and then can see it through in a more strategic
way. I think there is an issue there which needs to be thought
right from the board outwards.
355. There is a leadership issue as well, is there?
(Mr Ghosh) It is about the status of communications
within organisations fundamentally.Also, getting someone with
enough seniority and clout and knowledge at the highest possible
level and of course paying them accordingly.
(Sir Kenneth Calman) The answer is yes, but
I think there are some caveats. First of all, the point that Pallab
has made and I have made already about the need for preparation
and the role of the press officers. They are actually terribly
important and sometimes, I think, undervalued. Secondly, in educational
terms, the one-day course on media communications is likely not
to be necessarily helpful in the long term but it might just sensitise
people to think again. Finally, I have been involved in two courses,
interestingly. One is in Scotland, where all the new PHD students
come together and they discuss things like Ethics" and what
the media think and what social policy is and what the Government
is thinking. I thought that was really very helpful. The second
was in the Netherlands, a British Council arranged meeting in
which young scientists, newly post-docs had a couple of days with
some very distinguished media people, trying to work through and
having to present information back to their colleagues. Again,
it sensitises. I do not think it answers all of the questions,
but I think we could do more and the opportunities are there.
It should be part of a PHD programme's training.
Lord Lewis of Newnham
356. We have touched on what happens in Scotland
and Holland. Are there any countries which do this job very well
indeed? If so, do they actually have courses or arrangements of
some form or another? Is there anything we can learn from this
sort of presentation in other countries?
(Sir Kenneth Calman) I am not sure if there
are. I think there are generic issues. This is not about scientists,
I think, or about medical people or whatever; it is about generic
skills which we build up, I think, by experience and by watching
star performers and listening to them. There needs to be perhaps
a greater apprenticeship within that to do it, rather than a particular
Baroness Warwick of Undercliffe
357. If I may follow up on the next point, which
is the question of whether there is sufficient knowledge and clear
information available and whether scientists should themselves
be trying to develop courses which would assist the media. You
talked about the headline-writers, for example, being quite separate.
We have all suffered from that, when you have had a decent discussion
with a journalist, only to discover that the message has been
completely distorted by the headline, and you wonder just how
much is read below. Is there, in a set of complex issues which
often characterise science, technology and medicine, the development
of courses by the scientists themselves for the journalists?
(Mr Ghosh) I would love to go on a half-day
course on gene therapy and so forth, but I would not have the
time really and I think that is the same for all my colleagues.
First of all, I would say that, with issues of complex science,
quite often it is a specialist that is put on to it, so we do
have a bit of a background in what we are reporting. It is more
important for me to get the right briefing, the right conversations,
at the right time. I think emphasis should be put on thinking
through those structures. I also think that for our part we need
to be raising our bar a bit, to make sure that our standards of
reporting are high, and we try to do that internally and also
amongthe science community, the science journalism community,
(Sir Kenneth Calman) There is quite a good
model for this in things like Medicine for Managers, put on by
a number of groups, of which the Royal Society of Medicine just
happens to be one. I think there are ways in which we could help
with that, but there are two issues. One is: Do I know enough
about the subject? The second is: When it happens, who do I contact
to know about that subject now? And I think they are both relevant.
Chairman: Dr Bryant?
(Dr Bryant) There are several strands to this.
The first is that our children today are being trained and educated
in presentation skills. Even at primary school, they present their
work to their classmates, to their school, so I think for our
future generations the situation may be looking rather more rosy
than for the older ones among us. I think personal presentation
is something which is going throughout our education system. If
we look at the specifics relating to these lines of questioning,
we have already had discussions about whether the media has a
responsibility to report science and health honestly. I think
we, in science and health, equally have a duty to present scientific
and medical findings in a manner which is understandable by the
public, and I think that is the flip side to the coin. As I have
said before, that is something that takes time. As to whether
there is any possibility of putting on courses specifically for
the media related to science, I think there are two elements.
One is the general, but most of these issues are around complex
specifics, and again it is the investment in time in briefing
the various portions of the media around that specific subject.
That is down to the team or the units doing the work, to spend
and invest that time in educating around that specific subject.
Looking at media training, I had a small amount of formal media
training but the vast bulk of my media training was by experience
and I think the apprenticeship is important. I think we fail,
in general, to use opportunities. If we look at public health
medicine, it is a core competency to have some media training
and media experience. For the vast majority, that is a very brief
course and not a lot more. Those people who have gone through
that brief training should then be being allowed, encouraged,
facilitated actually to work with local media at a small level
to gain experience, to put them on the next footing and the next
step up, and we need to up-date and use those skills continually,
otherwise they will become rusty and less useful to us. I think
training is one thing but using the training is more important.
(Mr Ghosh) In reality, it is just a handful
of people having a handful of conversations with a number of journalists
that makes the difference. I think, as well as training, what
is also necessary are relationships with some of those key people,
whether at national or at regional level.
Lord Lewis of Newnham
358. How far do you find that you are able to approach
the professional bodies? I am reminded of the fact that in Denmark
they have an arrangement with their chemistry society that if
there is any major catastrophe involving chemistry they are contacted,
and they will guarantee to give you an answer of some sort or
another within a limited period and the answer, if that is possible,
within a larger time. Does this apply to other areas and disciplines?
(Mr Ghosh) I find it varies. I think the Royal
Society has really cleaned its act up. During the GM crops debacle
I tried to get a comment for the 1 o'clock news and I was told
they were having a meeting and they would issue a press release
the next day. Now they are much, much better, they will respond
straightaway and they understand the requirements of broadcasting
and media print much, much better. The research councils have
undervalued and under-resourced press officers, they are regarded
as clerks. At the Department of Health there are very, very good
people who do not feel empowered to say anything before it is
cleared and if you ask for a briefing you might get a briefing
in about two or three weeks' time, which for a breaking news story
359. As an addendum to this question some of us were
in the United States last week and we visited Atlanta where the
CDC, the Centre for Disease Control, existed, which is a pretty
big federal organisation. In order to handle some of the press
situations they are developing the concept of media fellowships
so that journalists in the USA can see how CDC works and report
on developments. Firstly, would such attempt in the United Kingdom
be worthwhile? Secondly, would such fellowships be of interest
in the media?
(Mr Ghosh) Fellowships are always interesting.
A number of my colleagues have been on such things, it provides
an opportunity for us to get off the treadmill and stand back.
It is not so much to learn about a specific area, like health,
or whatever, but to reflect on how we do our jobs. As I say, in
the main there are certainly pressures on our time and to take
3 months out, or sometimes 6 months, is something that some of
us do maybe once during our career. If such a thing were offered
it would be useful to think about what we are trying to achieve
here. There is no point in somebody being an expert on malaria,
you want to be able to understand the scientific process more.