Examination of Witnesses (Questions 653-659)|
TUESDAY 18 MARCH 2003
653. Good morning, gentlemen. Thank you very
much for coming along. We have a very interesting morning ahead
of us. For the record could you first of all please identify yourselves
and secondly, if you have any introductory comments to make, either
collectively or individually, now is the time to make them.
(Mr Brogan) My name is Shaun Brogan. I am the Chief
Executive of the Vale of Aylesbury Primary Care Trust (PCT). We
have 195,000 population, budget of around £130 million and
we come from Aylesbury in Buckinghamshire.
(Dr Wake) My name is Martyn Wake. I am
co-chair of a professional executive. I am a GP in south-west
London. The PCT is in Sutton and Merton, which is an unusual two-borough
PCT covering a large population of 360,000 or 370,000 patients.
Our budget is around £370 million.
(Mr Naylor) I am Robert Naylor. I am the Chief Executive
of University College London Hospitals, which is a group of eight
internationally known hospitals in central London including hospitals
such as the Middlesex Hospital, University College Hospital, the
National Hospital in Queen's Square amongst others. We are a very
complex and very large trust; one of the largest in the health
service. We are a three-star trust and have just applied to become
a foundation trust. We have the single largest PFI project in
the health service. Personally I have been a chief executive at
major teaching hospitals for nearly 20 years and my experience,
which is perhaps relevant to this group, is that I was the deputy
chairman of the national review of pathology services in the mid
1990s and I have recently been a member of the chief medical officers'
group which ended up in the publication of the document Getting
Ahead of the Curve.
654. Dr Wake, is there a parallel lay executive
in your PCT? You mentioned that you are the professional executive,
so is there a lay executive? Could you explain what that means?
(Dr Wake) Probably not very well. It is called the
professional executive because of the unusual structure we have
within the PCT, where essentially you have a more traditional
boardand I have a place on the board as wellwhich
does contain lay non-executive members. The professional executive
is another structure which arose out of the original structures
which we had in primary care groups, which were less formal bodies.
They contain professionals in the majority, but also contain officers
from the trust, including the chief executive, the finance director
and other significant directors within the organisation.
655. How do the two interact?
(Dr Wake) There is a formal relationship in that we
report to the board and our executive minutes go to the board.
Some members of the executive sit on the board, we share meetings
together. Non-executives would chair a lot of our sub-committees,
particularly in areas where we would have a conflict of interest,
for example. There is quite a close relationship. Within the organisation
as a whole, there is also a management team. Unusual NHS complexity.
656. Do you have any opening comments?
(Dr Wake) I am sorry; I am new to this kind of process.
The Committee might be interested in knowing that I was a GP representative
recently on the group which has given rise to the national strategy
on hepatitis C published last year, which has links with the Getting
Ahead of the Curve document you are familiar with.
(Mr Brogan) It may interest the Committee to know
that my first health management job between 1985 and 1990 was
running four primary health care and public health programmes
in Oman in the Middle East: immunisation, mother and child health,
control of tuberculosis and prevention of blindness. This has
given me a reasonably good background in a managerial sense, not
a clinical sense, in the subject we are here discussing today.
657. Mr Naylor, any comments to make?
(Mr Naylor) No, thank you.
658. We shall move right on to the questions.
Since contagious diseases are very much in the news and I have
an interest to declare in that I am a member of the Scientific
Advisory Committee on Antibiotic Resistance, could you briefly
outline the role of the PCT and in particular how it contributes
to communicable disease control?
(Mr Brogan) May I start by saying that the role of
the PCT overall has three main functions. The first one is the
promotion of health and the tackling of inequalities. The second
one is the development of primary community care and the third
one is the commissioning of secondary and tertiary services. Those
are the main overarching roles of the PCT. As far as communicable
disease control is concerned, we have a number of roles. First
of all, with the HPA, we shall be involved in surveillance, prevention,
diagnosis, support and out of hours commitments. All those are
roles where we shall have responsibilities with the HPA representative,
who actually sits on my PCT for mid and south Buckinghamshire.
(Dr Wake) The PCTs' role in communicable disease is
necessarily and historically quite complex. It is very multi-faceted
because of the nature of all the organisations we relate to. We
would have a director of public health who is a member of our
board and our executive and the director of public health would
have a role in planning, monitoring and informing colleagues locally
about infectious diseases. That would be a role which affects
community services, ordinary GP services and hospital services.
In the generality, primary care trusts commission their health
protection servicesthis is general nationallyon
a sectorwide basis, so covering quite a large population. In our
area we would have a health protection unit which has within it
a number of consultants in communicable disease as well as community
infection nurses who work together in the area. Health protection
units would have quite clear links with occupational health services,
for example within local hospital trusts and also within primary
care to deal with the very basic, everyday health problems, such
as needle-stick injuries, screening of health workers and that
kind of thing. Health protection units would also deal, for example,
with communicable disease outbreaks in their sector. They would
be responsible for co-ordinating childhood immunisation and some
adult immunisations as well, for instance influenza. I mention
these areas particularly because they are the subject of particularly
intense interest and target setting by the government. Community
infection nurses in the area where I work have a more hands-on
role and they are involved in contact tracing and would give quite
detailed advice right down to practice level about handling individual
outbreaks, such as outbreaks of meningitis, measles and TB. It
is worth understanding how new the role of PCTs is in infection
control, because we are able much more now to influence directly
the services both that we provide, which are services which come
from district nurses, health visitors and others, our own employees,
as well as those services which we contract for through primary
care services, GPs. That is a new role and we are able to give
advice. For example my own PCT publishes infection control guidelines
which are now sitting and acted on one hopes in every practice.
That is quite a new development and that would include basic advice
about needle-stick injuries, hand washing, handling vaccines and
storing vaccines, sterilisation, which is of critical importance,
monitoring detailed information like the use of autoclaves for
sterilisation, ensuring they are the right standard and also such
things as waste management. They would also want to have an influence
over infection control by helping to prevent development of antibiotic
resistance and that can be done in quite detailed ways, either
by having a formulary, although we do not operate a formulary
in our PCT, or by devising incentive schemes for prescribing for
practices, which ensure that practices focus on a small number
of sensible antibiotics rather than prescribing unnecessary, sometimes
expensive and certainly antibiotics which cause problems with
(Mr Naylor) I do not have any comment in relation
to the PCT, because it is outside my sphere of responsibility,
but maybe a little later I could tell you about the roles of infection
control within NHS hospitals.
659. How does one see the patient in this flow
of control? A patient comes in to see his or her doctor. What
is the process where the infection control primary care trust
cuts in on the care of that patient? Is it quite clear where that
happens to the individual GP and to the individual member of the
(Mr Brogan) If the GP detects a notifiable disease
they are supposed to report them on a paper form to the CCDC.
It is generally understood that there is considerable under-reporting
throughout the country. It would obviously be much more efficient
if in time this were made into an electronic reporting system,
where the disease was registered by a read code on the system
and immediately a letter pops up behind it or an e-mail; he fills
in the rest of the details, takes the address out of the main
computer system without having to take all the other extraneous
stuff and sends it straight off by e-mail to the CCDC. We are
a little way away from that at the moment. It is a paper-based
system and is pretty inefficient; not very inefficient, but not
very efficient either.