Examination of Witnesses (Questions 660-679)|
TUESDAY 18 MARCH 2003
660. Dr Wake, your explanation was very clear,
but within a PCT, if you spend money on health protection units,
you do not spend the same money on other things. What are the
tensions here and how are the priorities set?
(Dr Wake) At the moment, I would not say there are
tensions in all honesty. Money which has been spent on health
protection is protected and will continue to be spent. Money which
is in a PCT's baseline I would not say generally at the moment
is under great threat. The difficulty is when one is faced with
new infections or enlarging problems of infection control. Hepatitis
C is a very good example. It becomes quite hard at PCT level to
see where the new investment will come from, so my concern is
not about maintaining those services, although they are about
to change with the formation of the Health Protection Agency,
but is rather about understanding how we do all that is necessary
for infection within our existing budgets which grow at a certain
661. When you say expenditure is "protected",
do you mean it is protected by you or is it ring-fenced before
it comes to you in your allocation?
(Dr Wake) My understandingmy colleagues might
want to correct meis that there is no money now which is
truly ring-fenced. The best example of that which I am aware of
was around HIV, which was ring-fenced. The ring-fence from that
has recently been removed. I might suggest that the issue we may
face there is that we continue to give money we have traditionally
given for HIV, for example, to a trust. It becomes difficult for
us to enforce ring-fencing on the trust, so I think in all honesty
one cannot be sure that HIV money is spent within each trust on
what it was originally meant for.
662. Mr Brogan, you said that there is under-reporting
of infectious diseases by general practitioners. Are general practitioners
given guidance as to which infectious diseases they should notify
and is the under-reporting related to that?
(Mr Brogan) They are given guidance and they are regularly
reminded by our director of public health and the CCDC, but they
tell me that in fact it is widely recognised that there is under-reporting
across the country. I cannot prove that to you and I am just repeating
what they have told me. What they also say is that the under-reporting
is consistent, so at least you know the trends are whatever the
trends are, they are not due to artefacts of the reporting system.
663. If I understand you clearly, this under-reporting
is in seriously notifiable diseases. What would the PCTs do about
(Mr Brogan) There is not an awful lot we can do about
it. The danger of fiddling with the thing too hard is that you
would then cause a blip in the disease allegedly, which would
actually cause a problem with the reporting system, rather than
the actual incidence of the disease.
664. You said at one point that PCTs will work
with the HPA. Do you want to enlarge on that?
(Mr Brogan) We will have a memorandum of understanding
with the HPA, which will set out our relationship with them. We
work together now because the CCDCs are part of the PCT in my
particular office building looking after the health protection
of the four PCTs, including my own, in the Vale of Aylesbury,
South Bucks and Chiltern and Wycombe and Milton Keynes PCTs. We
shall continue to have the same relationship, at least to begin
with, but over time we shall have to work hard to maintain that
relationship because there is always a danger when people are
in different organisations that they will gradually drift apart.
We shall have to be very careful to ensure that does not happen.
It is not the only area where we have to collaborate with other
people across a wider area. We are doing this all the time with
our neighbouring PCTs. It should not be too difficult and people
recognise the importance of this subject and our public health
team are very committed to continuing to work with the CCDC as
the CCDC is very committed to working with them. I do not see
a major problem here.
665. Is there a contractual relationship? Do
you have to fund them to do something for you or vice-versa, or
is it simply a collaboration?
(Mr Brogan) It will be a contractual relationship
but it will not be a contractual relationship where money changes
hands in the sense of having a contract. As I understand it, the
money for the CCDC or health protection team, will be taken from
us and put into the HPA. The money will go with the people and
the money for the desks and computers and all the rest of it.
666. My question relates to performance targets
and monitoring. Both PCTs and hospital trusts have to respond
to a variety of performance targets and national service frameworks.
Do communicable diseases feature within these targets? If they
do, how does the control of infection rank compared with other
targets such as cancer or care of the elderly or cardiovascular
disease or waiting-time targets? How do you make the decisions
on how resources are allocated and how much do you allocate?
(Dr Wake) It is fair to say that communicable diseases
do not form a part of a specific NSF or performance targets generally.
I had a quick read of the new GP contract, which we are all grappling
with at the moment, and there is only one very small reference
to infection control in it which relates to the hepatitis B status
of NHS staff working in practices. The hepatitis C strategy does
attempt to set out certain indicators of success, but they are
not performance targets by any means. They are laudable aims really.
It is fair to say that infection control does not have quite the
same significance for PCTs as those targets which we are really
performance managed on, for instance within the NHS plan, or within
national service frameworks. That said, it should be remembered
that within our contractual framework, the framework we have with
primary care contractors, key immunisation targets are set, particularly
in relation to children's diseases and also for influenza in adults.
Infection control is certainly seen as a core function of the
PCT and I think that element of funding is protected and would
not seem to me to be at any risk in the way we prioritise care
at the moment. You may be aware that resources are allocated from
this year via a three-year plan called a local delivery plan,
which is an attempt for the first time to plan clinical services
in an area on a three-year basis. PCTs do have the freedom to
allocate resources to the control of infection and it remains
to be seen how well we do that. I can give you an example from
our own local development plan or LDP that in London it has been
agreed that the control of tuberculosis is a priority for investment
and that is certainly reflected as a commitment in our sectorwide
LDP. I know that one of our local trusts has also put in a bid
for additional consultant time in their chest unit, which will
again relate to work with tuberculosis. That is new money, so
it is certainly possible for new money to go into infection control.
The problem for PCTs is that we are performance managed on other
things and they are around access to primary care. We are performance
managed on the way that our hospital trusts perform, particularly
on waiting times in accident and emergency. We would have to see
these as our top priorities, but I would still argue quite strongly
that PCTs would see communicable disease control as of high importance.
Lord Lewis of Newnham
667. When you say "we", do you mean
your particular organisation, or could another PCT actually look
at it in a totally different way, put a different ordering of
(Dr Wake) It would be impossible for me to speak on
behalf of other PCTs. I should be surprised if they took a dramatically
different view from that since these are resources which we have
invested for many years. It would be hard to take away from them.
The difficulty is that in certain areas of the country, PCTs and
their health authorities find themselves in a less easy financial
environment. I would not pretend that ours is easy, but it is
not the worst in the country and in areas further south, they
may have more difficult decisions to make in relation to that
and that is a perfectly fair thing to say.
(Mr Naylor) I can speak in relation to hospital trusts.
First of all, performance targets are numerous for hospital trusts.
Communicable diseases, particularly hospital acquired infection,
do feature in those performance targets, but I would say only
in the last year or so. In particular, the way we are measured
through the new star rating system, there are two levels of performance
measures which we have to take particular note of. The first level
of performance measures has what we call nine key indicators.
One of those nine key indicators relates to cleanliness in hospitals.
Around cleanliness of course is the major issue of hospital acquired
infection. Beneath those nine key targets there is a series of
36 sub-targets which of course are less important than the nine
key targets but still important targets to hit. Two of those 36
targets specifically relate to these issues. The first is to ensure
that hospital trusts such as mine have quality infection control
procedures in operation. The second target is to measure the rates
of MRSA bacteraemia which occur within the hospital trust. Both
of these latter measures are new measures for this year. Up until
this year, it would be fair to say that we have only measured
our performance very, very loosely in relation to these targets.
The government quite reasonably and rightly, have taken notice
of a number of reports, not least of which is the National Audit
Office report of February 2000 and more recently the Chief Medical
Officer's report Getting Ahead of the Curve, in increasing
the number and the weight of these targets which relate to hospital
acquired infection. It is now a key issue for us to be measured
on and indeed our star rating and therefore the reputation of
our hospital trusts and our individual hospitals will be measured
by the relative position that we sit within the star rating of
hospital trusts in the future.
668. Could I ask whether the PCTs would welcome
a performance target on control of infection or not, in relation
to what you have just told us?
(Mr Brogan) My instinct would be to say no more targets
669. I thought that would be the answer.
(Mr Brogan) We have about 360 of them already; although
I am very committed to this particular target actually. We have
11 key targets in our strategic health authority area and our
PCT alone has £2.5 million projected deficit next year. Our
local acute trust, Stoke Mandeville, which is joining with another
acute trust, has deficits in the order of £3 or £4 million.
It is extremely difficult to maintain priorities. I am not saying
we will change the financial flows we have going into communicable
disease control. We will keep them as they are. Were it to require
new money, that would be extremely difficult because we are cutting
everything at the moment in order to try to get into balance next
670. Are you consulted about the targets that
you are set? Is this an iterative process or do these just come
at you out of the blue?
(Mr Brogan) They come at us from the NHS plan, not
out of the blue. We all know.
671. But you feel you do not have input. If
a target were inappropriate, going to be clearly inappropriate
and distort what you were doing because of local circumstances,
would you be able to negotiate that one away and say it is not
sensible for you?
(Mr Brogan) No, is the short answer. To be fair, it
is extremely unlikely that ridiculous targets would be imposed
because they do go through an enormous sifting process and national
expert groups and so on. That is not something I fear, it is just
the weight of the number of targets.
(Dr Wake) Mr Naylor referred to star ratings which
made my ears prick up a bit. Primary care trusts have not been
star rated yet and I have not seen what we will be star rated
on. In fairness to those who set them, they do consult us about
them in general, there is an important process of consultation,
it is likely that star ratings would relate to some things which
could be related to communicable disease control and that would
be particularly around our success in immunising people against
the flu and probably children's immunisations as well. That would
be about the level of it.
(Mr Naylor) On the question of setting targets, I
think it would be fair to say that a number of people in the Health
Service are involved in the development of these targets and for
my sins personally, I was a member of the performance management
group which advised the NHS modernisation board on the setting
of targets which originally led eventually to the star rating
system. People such as myself are involved and although individual
PCTs and hospital trusts might not be involved, representatives
of trusts and PCTs will have been involved in the process. There
is a mechanism, either through colleagues or through professional
groups, to influence the development of the star rating system,
but it is quite correct for my colleague Shaun Brogan to say that
the targets do reflect government priorities and they were originally
derived from the NHS plan. These targetsas I have already
explained in relation to hospital acquired infectionare
emerging and developing to take account of reports as they are
developed through organisations such as the National Audit Office.
672. We have heard evidence that CCDCs and hospital
control infection personnel have felt undervalued and under-resourced.
Can we take it from your comments that this is changing and that
it will change in a much more positive way?
(Mr Naylor) I have no doubt that it has changed. I
also have little doubt that it needs to change further. The extent
of hospital acquired infection is still much too high. A lot of
that infection is preventable within hospitals and a lot of additional
investment needs to go in, both in terms of the experts we need
on the medical side within hospitals and their relationships with
primary care trusts, the Health Protection Agency and so on, but
also in the investment in infection control nurses who are the
key to controlling infection in hospitals and also the relationship
between hospital infection control nurses and their counterparts
in the community. You asked a question earlier on about the flow
of patients through the system and at the moment the flow of patients
occurs in quite discrete ways. Patients are seen in primary care
and are referred then into a completely new system which is the
hospital system. Once the patient has been through the hospital
system, they go back to the primary care system again. The connections
between these systems is not as good as it might be. Certainly
one of the things we are doing in my part of London in relation
to our PCT is talking through the development of joint infection
control nurses between the community and the hospital, so that
there is a rotation of such nurses, so that they see the problems
which occur in the hospital, but also follow the patients back
into the community. Bridging the gaps between the systems will
become an increasingly important factor in terms of control of
infection between the community and hospitals in the future.
673. How does NHS Direct fit into this surveillance?
(Dr Wake) I understand that they provide a good source
of high quality advice, both directly to individual patients and
to professionals as well. Their website acts as a good source
of advice to the public.
674. I was asking more about the overall picture
of surveillance of infections. How do the PCTs relate to it?
(Dr Wake) I am not aware that they have a role at
the moment, although over the next year things will change in
that NHS Direct will work much more closely with our out of hours
services. I understand that is likely to be one of the routes
through which patients receive out of hours care.
675. There has been an answer about CCDCs being
one of the key contacts for you in PCTs and the HPA. I gained
the impression you were talking about how it can and should work,
but I was not quite sure whether it is and will work in this sort
of way. Are we talking specifically about your own experience,
which is what you are relating to, or what PCTs in general will
feel? The reason I put it like that is because I hear from CCDCs
around that they are very uncertain to which PCT they should be
responsible and how they must work together. Can I probe you a
bit on that?
(Mr Brogan) I imagine that there is considerable uncertainty
amongst CCDCs because they are going through a period of change.
They are not the only people in the NHS feeling that way. All
of us feel it most of the time now, there is so much constant
change. The relationship is being clarified. The Health Protection
Agency is being set up. Discussions are going on and there was
a discussion yesterday in the Thames Valley Strategic Health Authority,
of which I am part, about the memorandum of understanding, about
public health doctors, public health consultants and directors
of public health and the CCDCsnot all of them but mostgetting
together to carry on working on the memorandum of understanding
which is now in its fifth version. Progress is being made. There
will be a new Health Protection Agency; that ought to give those
staff comfort in the sense of belonging to a national organisation
in the way they have not belonged to one in that sense before.
Whilst I can see difficulties ahead, not enormous difficulties
but difficulties which need to be recognised and overcome, in
overall terms I am optimistic about the future.
(Dr Wake) I would not dissent from that view. In my
own area, where we had a system which we feel works reasonably
well and where we understand our relationships, there is some
comfort. We are entering into a period of some uncertainty. A
lot of reassurance has been given that the PCTs will not feel
a loss of the CCDCs to themselves, though it must inevitably result
in some loss of control to them if they are no longer locally
but are nationally employed. Therefore I think we shall need to
work fairly strenuously together to ensure that we get the best
of what we want here. I have no argument with the direction of
travel. Clearly we need national co-ordinated services. Nobody
disagrees with that. Equally we do need to preserve and improve
on local services which are directed to infection control. These
memoranda must really work quite positively to ensure that local
services are protected.
676. May I follow that up a bit? You mentioned
CCDCs as being a very valuable local part of the HPA. Do you see
a relationship with the HPA beyond that in other ways?
(Dr Wake) I can imagine one and there are areas where
we have been much under-involved. I am afraid this goes outside
the realm of just infection. Our relationship to chemical incidents,
safety in factories and matters like that has been very inadequate,
I understand, and our director of public health has traditionally
not been involved with global, in the sense of general, environmental
health issues. I would see that as a positive influence, if that
is what you were meaning in the question.
677. I am sorry, I did not mention my interest.
A year or so ago I was Chairman of the Public Health Laboratory
Service. I have to say that for the record.
(Mr Naylor) In a wider sense everyone supports the
development of the national Health Protection Agency. It is clearly
very much in tune with the times in which we live at the moment.
There are concerns about the relationships between the various
bodies. PCTs still have responsibility for the health protection
in their population and therefore need to develop relationships
and memoranda of understanding between the PCTs and the HPA. Equally,
within NHS trusts, where we have a lot of expertise, both in terms
of pathology and in particular microbiology services and the strong
relationships with the old Public Health Laboratory Services,
we need to have relationships with both organisations as well,
particularly with the PCTs in the area of managing infection between
the community and the hospitals, but also with the HPA through
the reporting of microbiological results in major pathology departments
such as mine through to what was the PHLS and is now the HPA to
ensure that surveillance is kept up to standards so that we can
identify diseases as they develop.
678. I ought to express a former interest as
a member of the Hammersmith Hospital Trust board and I am occasional
adviser to FLE Ltd. May I ask to what extent you regard the arrangements
for communicable disease control to be satisfactory, just standing
back and taking a broad view? In particular, are there any policy,
organisational and/or resource changes which would enable a better
service to be delivered? As a rider to that, who do you think
should be responsible for R&D in communicable disease control?
I am not thinking of fundamental R&D but I am thinking, for
example, of establishing best practice in hospitals to control
the spread of communicable disease.
(Mr Brogan) I have a number of concerns. First of
all, where the teams are going to be based. There is an idea abroad
that they may be consolidated at strategic health authority level
rather than at PCT level as we have them at the moment in the
Thames Valley Strategic Health Authority area which covers Buckinghamshire,
Berkshire and Oxfordshire. That would be a mistake, because it
would be putting them too far away. They are already 20 miles
from the two PCTs at the southern end of Buckinghamshire, Wycombe
and Chiltern and South Bucks, operating from my PCT building.
To move them any further away would be to distance them from their
clients and I think that would be a bad move. I am concerned about
whether or not you can set up this national Health Protection
Agency at no extra cost and improve the service. It is extremely
unlikely. With the sorts of computer systems I was talking about
earlier, modifying GPs' computer systems or whatever is required
to deliver that much faster summary of surveillance back down
to the troops in the field and so on, you are going to need to
spend more money on it, perhaps not a fortune but some more money
on it in order to improve things, otherwise you will in effect
not be realising the promise of setting up a national Health Protection
Agency. There are difficulties with the shortage of staff in the
sense that for Buckinghamshire, where I work, we used to have
a director of public health and four public health consultants.
The director of public health has moved to the strategic health
authority as the director of public health in the strategic health
authority. One consultant has left and we have three consultants
remaining each of whom is the director of public health or the
acting director of public health on a PCT. They have corporate
responsibilities which, quite rightly, take them away from their
public health job and from liaising with the CCDC. There are difficulties
here. I am not saying they are insuperable difficulties, difficulties
which cannot be overcome, but they are matters which deserve attention
and need working on to get right in my opinion.
(Dr Wake) As we see it at the moment, I feel that
arrangements for communicable disease control are certainly satisfactory.
I do not experience problems at a local level. That is not meant
to sound complacent and that assumes the current level of risk
we have locally and nationally and that could change. I am sorry
if this is a plug for hepatitis C but it also probably applies
to hepatitis B and HIV. I would feel that we are not yet concentrating
resources in areas of maximum effectiveness for those diseases
and you can take that for an example in many areas. It is well
known that one of the biggest risk areas for these blood-borne
viruses is within prison and the prison population is a very difficult
population to deliver health care to. Nevertheless it is also
apparent that we have not got to grips with the level of investment
which is required there and it would seem to me obvious that we
need to devote resources to those places where the greatest amount
of infection exists and arises. PCTs will have a responsibility
once again in this area in that although I do not think arrangements
are quite clear on this, they will have an increasing role in
the development of healthcare services for prisons in their area.
I welcome that but it does need a big investment in resource as
well. At a local level, PCTs will really need to work with all
their employees and contractor services to improve infection control
and they are starting to do that. I meant to mention earlier and
this is quite important, that the remit of PCTs in the last six
months has also come to include dentists, community pharmacists
and optometrists and, particularly among dentists, infection control
will be quite important. Once again, I see that as quite an integrating
move and a sensible direction of travel. It will need quite an
improvement in our understanding of the need for screening of
health workers and some work has been done nationally which has
been published recently about that. We will have to develop a
modern approach to the provision of sterile equipment and that
will in fact lead on to further expenditure requirements either
for disposable instruments or for sterilisation using CSSDs. I
am not sure that we have got to grips with the financial implications
or the organisational arrangements which we will need to have.
I would not regard myself as an expert on the R&D question.
There is though, I would feel, an opportunity for the development
of teaching PCTs to improve our investment in R&D in this
particular area. I think PCTs should form part of it, but clearly
that will not be the only area where R&D can take place. R&D
is starting to take place at a PCT level and in our own area we
have recently appointed a professor of R&D in primary care.
(Mr Naylor) May I pick up the very last point about
R&D, which is something I have been musing on since you asked
the question but which is not something I had really thought about
until today. It does seem to me that there is potentially a strong
connection between the centralisation of expert resources in university
hospitals such as mine, particularly in the aggregation of pathology
services. If I might just digress for one moment, we are currently
in the process of putting together a proposal to bring together
pathology services across a whole range of hospitals in north
London. This is part of a series of recommendations which has
come through the NHS Executive and from government for a number
of years. We are really only now getting to grips with the centralisation
of pathology services. If these pathology services were centralised
in collaboration with universities, universities have enormous
power houses of intellectual capability around infection in general,
I could see the potential opportunity in the future for the HPA
to commission research jointly with PCTs and perhaps through joint
academic appointments between PCTs and institutions such as my
own. It is a very interesting question and one we need to reflect
679. I was also thinking of research at a much
more applied and practical level. In our travels and visits we
have seen very different models for managing isolation wards or
intensive care units, where the spread of infection is important.
Clearly there are some very good ideas there which are confined
locally. On the other hand, there has not really been any very
systematic study of how effective these are. People say they have
the feeling it would be better like this or like that and it does
seem to me that if control of infection is as important as we
are now all agreed it is, that is not quite good enough. I do
not know whether you have any comment on that from the University
College Hospital point of view?
(Mr Naylor) I agree with you that a great deal more
can be done and there are some excellent examples. If I may just
tell you about one that we have been working on in my trust over
the last year or so, you may recollect that my trust acquired
the Heart Hospital, which was a private hospital, from the private
sector and brought it into the NHS just over a year ago. One of
the things we have been able to do in that new environment, because
the environment is so superior, more akin to a five-star hotel
than a classical NHS hospital, and there is a very high proportion
of single rooms and a lot more space and capacity to be able to
develop those services, to put in improved policies to control
infection around the organisation because of the greater degree
of isolation. Not only that, we are about to publish some research
where there is a clear indication that by screening patients who
come into hospital prior to surgery, particularly for complex
invasive surgery such as cardiac surgery and dealing with their
infections before they come into hospital, there is a very substantially
reduced subsequent rate of wound infection which can be fatal.
There is a great deal of research which can be done in these kinds
of areas around screening patients prior to admission, particularly
for complex surgery, but also in hospital design. I am personally
a great believer in designing hospitals with a much higher proportion
of single rooms, moving away from the old Nightingale ward where
you might have 30 patients in one area to a situation in our new
hospital for example, in Euston Road, where, when it is complete
in 2005, we shall have a very substantial proportion of single
rooms, therefore our ability to control infection within the hospital
environment will be greatly improved. I would welcome further
research into that kind of detail within the hospital environment.