Examination of Witnesses (Questions 680-696)|
TUESDAY 18 MARCH 2003
680. The question relates to whether the current
arrangements are satisfactory and the sense I am getting is that
we are not entirely unhappy with what we are doing and more money
here and there might ease things. It does make me wonder why we
are so anxious about communicable disease at the moment, if everything
is okay. Is it that you are describing particularly good examples
of what is going on? We recognise that perhaps you were chosen
because you are good people in the field. Is it just a local phenomenon
or is it general? In our position we are keen to see improvements
in the areas about which anxieties have been expressed to us.
We are really keen to see what the key problems are and what advice
we can give that would make a difference. If you are saying just
arrange a bit more money here or there, that does not sound terribly
entertaining to me.
(Mr Brogan) I am not saying everything is okay. The
newsletter Bandolier estimates that we could do away with
16 to 20 district general hospitals if we could get a grip of
hospital acquired infection. It is said that one in every ten
people in district general hospitals is there because of infection
caused by the hospital itself, so everything is not okay and there
is a lot to do. We need desperately to get a grip of this problem
in our area, because it is one way, if we could manage to control
it, of reducing our debts. We are on the case. We have a health
summit next month to try to look with clinicians at all sorts
of ways we can begin to save money and redesign services and improve
them. That does not get away from the general thrust of my opinion
which is that setting up the Health Protection Agency is right,
it needs to be got righter, it needs to be improved in how it
works, how it works with us and how we work with them. The general
thrust is right but there is plenty to do and there is no shortage
of problems to address.
(Dr Wake) I accept what Lord Turnberg says and it
is a difficult one. One would have to look at each infectious
disease individually. I certainly said that I was very worried
about the situation regarding blood-borne viruses. I do not think
we are on top of that. People do not appreciate the size of the
problem in relation to hepatitis C. When you consider that it
is affecting probably around 0.4 per cent of the population that
is an enormous issue and a disease which we can treat and we cannot
shrink away from that. I feel that all we are doing in relation
to hepatitis C is seeking to address the problem. I should like
to know what more we could do. Certainly we could work with prisons,
so that is one example. In sexually transmitted diseases we have
a different problem because some of this relates to culture, mores,
education, as well as what we can do in health. Therefore these
become areas where a very wide range of partners needs to be brought
in. As far as I understand it at the moment, the communicable
disease side in relation to sexually transmitted diseases, is
working reasonably well. I am not saying that it is successful.
681. What about chlamydia?
(Dr Wake) I perhaps do not know enough about chlamydia
personally, but it clearly is a major problem. I do not see agreement
from the experts on the way to deal with it. I have seen people
challenging the idea of screening people for chlamydia, which
is one thing, but my director of public health, who is an expert
on screening, assures me that the science behind that is probably
questionable in that you can have chlamydia more than once.
682. It needs to be looked at.
(Dr Wake) I come back therefore to the fact that chlamydia
is a multi-factorial problem and we have a role to play, but certainly
society has a role to play as well.
683. A group of individuals which seems to be
left out of infection control is the environmental health officers
and they obviously play a role in infection control at the very
basic level of hygiene. Do the primary care trusts liaise with
the environmental health officers at local level or is there a
recognition that they have a role to play?
(Dr Wake) I believe they do. I think there is a formal
relationship with the CCDCs, who act as their proper officer.
It is a good question, however, because other than that I am not
sure there are good links with environmental health officers.
PCTs do provide a good opportunity for us to develop those links
because they are so closely related now to local authorities and
indeed there is the opportunity even for budgets to be shared
between local authorities and PCTs in the future. I would feel
that at a personal level I do not have enough understanding of
the way environmental health officers work, though I know that
my director of public health would. Those links certainly need
to be improved and we do have the opportunity to do so.
(Mr Brogan) I echo those remarks. We have a very close
relationship with the district councils, which have carried that
responsibility in our area. We are envisaging putting this as
part of our strategic partnership. It has been a little difficult
in our case getting the local strategic partnership off the ground
in its written formal form because the district council did not
want it. We have now persuaded them that we should have one and
we are bringing various things together into that, including the
environmental health officers' area of responsibility. There is
a very close link between our CCDC and the environmental health
officers anyway, so the two things are reasonably well under control
in that area.
Chairman: That is good news; thank you.
684. This concerns the interface between primary
and secondary care. Infection moves freely between the hospital
and the community and a community includes residential care homes
and nursing homes whose clinical care is often provided by GPs.
Could infection control services in these two arenas be better
integrated? Mr Naylor touched on this already when he talked about
the infection control nurses who had responsibility for both hospital
and the community. Perhaps you could amplify on this.
(Mr Brogan) I certainly agree that it can be better
co-ordinated. This is why we are putting this as the main item
on this health summit meeting we have next month to discuss ways
in which we can re-design services for the 21st century and look
particularly at items like hospital acquired infection, things
like lengths of stay and day case rates and so on and any other
areas we can come up with which will enable us to redesign services,
thereby making them more efficient and costing us less money and
improving them for the patient most of all. We will be doing that
sort of work against a backdrop of trying to improve the levels
of hospital acquired infection and to make sure those sorts of
infections are not crossing over into the community. We do not
have a very serious problem at the moment in our community hospitals;
we have two in our PCT and we do not have much of an infection
problem in those two hospitals. I am not trying to sound complacent.
We need to keep on top of it and make sure that does not happen
in the future.
685. Sometimes hospital acquired infections
must come from somewhere, possibly outside the hospitals.
(Mr Brogan) You are straying out of the area of my
competence now. I do not know where it starts.
(Mr Naylor) Perhaps I could address that, going back
to the experience we are having at the Heart Hospital to which
I referred earlier. We have detected an increasing incidence of
infection being brought into the hospital now that we are measuring
it more accurately and in a more controlled environment. Although
there has been a very substantial increase in the number of patients
coming in with these infections, we have managed to maintain the
level of hospital acquired infection, even though more patients
are coming in. Our understanding of the situation is that there
is a growing degree of infection within the community. That may
be because it is growing absolutely in value terms, or it may
be because we are reporting it better than we were previously.
We need to commission more research to try to understand that
further. Coming back to the key question, there is great merit
in joint appointments and in agreements between primary care trusts
and acute hospitals, particularly in major urban areas where the
level of hospital acquired infection seems to be greater in cities
than it is in rural environments. The highest levels of hospital
acquired infection in all of our hospitals tend to be in London
and tend to be in our major teaching hospitals and that is largely
because patients are coming into these hospitals from all parts
of the community. My trust, for example, only has 20 per cent
of patients from our local community. Eighty per cent of our patients,
because of the specialist nature of our hospitals, come from all
over the UK and they bring infections with them. Managing that
degree of infection which is brought into the hospitals and controlling
it within hospitals, I think is the really big challenge. The
really big improvement we can make and I really believe we do
have to make, is to control the extent of hospital acquired infection.
At the moment, that level of infection, as has already been referred
to, is about one in nine or one in ten patients acquiring an infection
whilst in hospital. Although it is not possible to manage some
of those acquisitions it is possible with a proportion of them.
There is an awful lot to do in the health service in terms of
further investment, in cleaning procedures, in new protocols,
in hospital design and building. There are some short-term gains
such as hand washing, but there need to be longer-term policies
as well in terms of whole hospital re-design. This is a long-term
battle in which there are short-term strategies and long-term
strategies and a great deal can be done. The cost of this is very
considerable indeed, but the benefit is also very considerable
because of the amount of resource we currently waste in treating
patients who acquire hospital infection. We need to develop a
new strategy for this across the health service and therefore
I personally am pleased to see it being given such a high profile
both in the media and by government.
686. With respect to what you have just been
saying, but looking at the thing as a whole, do you have concerns
over the transfer of public health laboratories to the National
Health Service? Given the clinical pressures on laboratories,
will they be able to dedicate the time and resources necessary
to fulfil the public health requirements to which you have just
(Mr Naylor) My experience before I came to London
was of a major teaching hospital in the Midlands where we had
a major public health laboratory on site. The relationship there
between the Public Health Laboratory Service and the hospital
was very satisfactory. I have come to a hospital in London which
does not have such strong relationships, though the relationships
are still very good. Across the health service there have not
always been good relationships between public health laboratories
and NHS microbiology services. I should certainly support the
move of the Public Health Laboratory Service into the Health Protection
Agency, but I should also very strongly support the requirement
which must be placed upon NHS microbiology departments to improve
surveillance and report infection through to the new Health Protection
Agency. This reporting process has been patchy in the past. It
has tended to be good where there are strong public health laboratory
services on the hospital site, but where there are not, it has
tended to be deficient in many areas. Alongside transferring the
PHLS into the HPA, it is important to impose new standards upon
NHS microbiology departments to improve surveillance into the
central HPA of the future.
687. Could we get back to control of infection
in the community? I should very much like to hear what Dr Wake
as a GP has to say about monitoring and control of infection in
(Dr Wake) A couple of small points. I should be slightly
concerned if the Committee went away with the idea that community
acquired infection was our biggest problem. This is multi-factorial
and Mr Naylor mentioned the fact that London hospitals may have
a greater degree of problem with infection. I cannot give you
the evidence on this, but I think we would need to understand
clearly the evidence around this. My understanding would be that
in London hospitals particularly, where we tend to be working
under the greatest amount of pressure, the largest throughput
of patients, there is, for example, a large number of different
professionals seeing patients, particularly in teaching hospitals.
My understanding is that all of these things contribute to hospital
acquired infection. I am not sure I have seen any strong evidence
that we have major problems as yet with community acquired infection,
certainly of that infection going into hospitals. In primary care
and in community hospitals where procedures are done, I always
understood that infection rates were generally lower and there
were fewer resistant organisms. That is the sum of my knowledge
on it, but I would feel it would be worth understanding all the
evidence we have in relation to these problems.
688. May I ask to what extent there is adequate
IT in hospital trust and PCT settings to allow health professionals
to receive up-to-date information about best practice in communicable
diseases and to allow rapid sharing of surveillance information,
bearing in mind the range of staff that is employed within PCTs
and within hospitals?
(Mr Naylor) May I start in relation to hospitals?
The simple answer to the question is that they are inadequate.
There has been gross under-investment in IT services in the NHS
for decades. The current government has recognised that and has
allocated a very, very substantial increase in resources, some
£2.3 billion, to improve information technology in the health
service. This is a truly massive challenge for the health service.
Again I can talk with some confidence from my own trust's perspective.
We are building a new hospital, the hospital is going to be virtually
paperless, was planned to be virtually paperless in 2005. We have
just gone through the process of trying to identify IT systems
which will allow that to be achieved and, to put it bluntly, there
is none in the world, because we have surveyed every country's
IT capability. We are going to have to develop new IT systems
to manage healthcare in the 21st century, not just within our
hospitals where the IT systems will be extraordinarily complicated
because of the complexity of hospitals, but also across a spectrum
of patient care from primary care through secondary, tertiary
care and back into the community again. This is a massive challenge
for government, not only to find the resources, which they have
done to a significant degree, but then working with industry to
provide the capability to put these IT systems across the NHS.
689. What about the training and skills of staff
(Mr Naylor) It is an enormous challenge. Because we
do not have well-developed IT in our hospitals or across the health
service as a whole, there is a massive agenda of training and
development. That will have to go alongside the investment in
the new technology and new software.
690. Is there any strategy about new IT coming
into the NHS both in terms of investment and in terms of training?
(Mr Naylor) Yes, there is. There has been a recent
appointment of a gentleman called Richard Granger, who effectively
is the IT czar. It is his responsibility to the Department of
Health, to the Permanent Secretary and Chief Executive of the
National Health Service, to develop a strategy for the development
and improvement in information technology across the health service.
He has been given the responsibility of allocating this additional
£2.3 billion resource to add to the existing investment in
IT healthcare which, brought together, will hopefully make a very
significant change both in the architecture of IT systems and
communication systems between computerised systems and also in
training and development of staff.
691. Could we hear about the primary healthcare
side in terms of the IT there and the links with the hospital
services as well?
(Dr Wake) I can be a little bit more upbeat about
the development of IT systems in primary care in that we have
been investing in IT to a reasonable level for at least ten years.
Again, I do not want to sound complacent, because IT development
is advancing all the time. I am sure my own trust is one of the
leading trusts for the development of IT nationally, so I probably
speak from a slightly different perspective. I am sure levels
of investment vary throughout the country. Nevertheless, it is
true to say that all GPs at the moment would have access to the
NHS net: I am afraid there might be one or two GPs who do not
turn their systems on. Broadly, they do have access to the NHS
net and in my own PCT the great majority would use that kind of
access regularly for information. One of the key areas of importance
for me, is that I practice in a paperless practice. You have to
develop paperless systems yourselves, but it is much easier to
develop paperless systems in a small business environment, which
is what general practice is like, than in a large hospital trust.
We are in control and it is a small enterprise. In a paperless
system like mine, I can now do a blood test in the morning and
have the result on my screen in the evening. That is not true
so much for infection because there is a lead time in getting
results for infectious diseases. I can now get a simple urine
test back within a maximum of three days from having done it and
it is on my screen and it is in the patient's record. That is
a very different world from the world we knew a few years ago.
It is possible to speed a lot of these things up and I do hope
that we will be able to do that through working with our laboratories.
That is important. The other aspect of the use of IT is around
information and the cascade system that we have for reporting
on disease outbreaks, national concerns. We receive a lot of these.
At the moment, even in my own PCT, these cascades are received
mainly by fax rather than via e-mail, although that e-mail facility
is there. It will all be e-mail very soon. The only problem we
have in our systems locally is that they are still a little bit
slow, so there is another step of investment. We have a clear
investment strategy for IT and, for example, you would see PCTs
moving in a few years to servers, which are centrally held at
PCT offices, improving issues around maintenance, confidentiality,
security, etcetera, with just online access from each individual
site, which could be a GP service, a dentist service or could
be a district nurse's centre. There is a great opportunity for
integration and development there at the moment and I would say
fairly good access to information at the moment.
(Mr Brogan) We are not quite as advanced as that,
but we have made progress. We have electronic referrals to hospital
and we are starting electronic referrals to physiotherapy and
so on. We do have two distinct, different GP systems; some of
our GPs use one system, some use another, other PCTs have lots
of systems. It is a bit of a muddle. There have been attempts
over a number of years to bring them together using a special
standardised way of migrating the systems towards similar functionality
if not the same sort of system. We have a pretty poor computer
system in our community trust covering our community hospitals
and all our physiotherapists and therapists generally, district
nurses, health visitors, speech therapists and so on. That system
is very poor, it does not work properly and does not give us good
information. We have pretty poor systems in the local hospitals
at the moment which are due to change and develop new electronic
patient records systems, but investment is massive and the objectives
are very ambitious. There is much to be done. In relation to control
of infectious diseases, we have pretty bog-standard systems; we
are not using any special system at the moment. We are not e-mailing,
we are still faxing the cascade information down. That is not
too bad, but it could be better and will be, I am sure, when the
Health Protection Agency gets a grip of it. This is all going
to take a bit of time. As far as investing in primary care systems
is concerned, given that the requirement is to put in acute hospital
systems first with the new electronic patient records in acute
hospitals first, it is going to take some time before we get community
and GP systems sorted out.
692. Dr Wake talked about the receipt of information
in order to help the practice. What about transmission of information?
Some of these data you collect on infection which make up such
a large proportion of the practice, might well be useful for surveillance
purposes. Do you transmit as well as receive?
(Dr Wake) We do not, but I believe those systems are
better developed in Scotland and there is a great deal of use
of primary care information in an integrated way. The new GP contract
will start to collect certain information which will then be able
to be aggregated and help us in health needs assessment and health
planning, but very little of that directed towards infection control.
693. Do you think it would be useful to do that?
(Dr Wake) I think it will be useful and particularly
once we have information on a single server for an area. Programmes
are already in existence which allow you to extract relevant information,
although again it is going to depend on accuracy of diagnosis,
good diagnostics and being sure we are all coding things correctly,
as ever, the quality of information we put in.
694. My question is about feedback. Do PCTs
and hospital trusts receive enough information from the surveillance
system and about best treatment practice in order to improve their
decision making and implement strategies to prevent and treat
infection and also perhaps to encourage them to input information?
Could you say something about how that information would be most
usefully received by the PCTs and hospital trusts?
(Mr Brogan) The information would be best received
electronically, I am sure of that. Most GPs would prefer to get
e-mails rather than paper documents. We are a little way away
from that, as we have discussed in answer to earlier questions.
Public health and GPs do get quite a lot of information already
on communicable diseases so there is quite a lot of that sort
of information passing already. I would expect the Health Protection
Agency would improve that over the next year or two years as they
begin to get a grip with their new responsibilities. I am moderately
optimistic about how that would proceed. There is plenty to be
done. I am not being complacent. We are on track.
(Dr Wake) In terms of best practice we would already
have on our desktops access at a keystroke to information about
a particular disease we are faced with in front of us. That is
already there, depending on which company you get your IT from.
Certainly there are plans to have access to NHS agreed systems
of work. Initially there was a system called Prodigy, although
I think that has gone a bit quiet at the moment. I am not quite
sure where that is going. I am quite confident we would have that.
As far as information goesand I speak from my local experiencewe
would always be notified of a particular outbreak in order to
be alerted to particular diseases. I know that we have had an
alert this week about this international virus problem, we have
had an alert locally about an outbreak of syphilis and wherever
we get a notification like that, we would be informed what to
watch for, because you do not see it terribly often in primary
care, how to treat it, where to refer them to, etcetera. Again
I sound complacent, but those structures are there and I am assuming
they work as well in every area.
695. Do you think the information about smallpox
that you are getting at the moment is adequate?
(Dr Wake) We understand where we are about smallpox.
If I were honest, for a GP on the ground, while I feel they are
clear that they are not able to provide the immunisation, I do
not feel they will be entirely clear about the degree of the threat.
It is a good point to make that while the health protection units
are completely aware of what government is thinking and planning
around the control of an outbreak like that, I am not convinced
that emergency plans are uppermost in the minds of people practising
on the ground. That is certainly true in primary care. I am not
sure whether that is true in hospital. It may be slightly different
in hospital settings.
(Mr Naylor) In relation to hospitals, I would say
that the receipt of electronic information about surveillance
systems is excellent, certainly greatly improved over what it
has been in the past. I agree with my colleagues here, that electronic
information around best treatment practice is very easily available,
what we call integrated care protocols. That is greatly improved
in recent years, but I guess the area where I would have concern
would be in the transmission of information about infections which
are being identified within hospital pathology laboratories, to
which I referred earlier. Where it is good it has been good, but
there are many areas where there are big holes in the transmission
of information. I would hope that is something the new Health
Protection Agency would pick up and improve the flow of information
about infections in hospital environments and in primary care
so that we collect a greater proportion of the total available
information which can then be sent back to those people out in
the field who need to know.
Chairman: Finally, still connected with this area,
designing surveillance systems.
Lord Lewis of Newnham
696. To what extent do PCTs and hospital trusts
have input into designing the surveillance system in order to
ensure that it delivers the sort of appropriate information for
your needs? I know you have been telling us a lot about receiving
it, but what actual input do you have in designing the systems
(Mr Brogan) At the moment our CCDC is working with
our director of public health and has beennot the same
individualsworking together for years. There is good communication,
mutual trust, mutual respect and a very good working relationship.
The creation of the HPA will change things, not necessarily for
the worse, in fact I do not think it will be for the worse at
all, but it will change things and will take a while to settle
down and consolidate itself. As long as that process is well led
and well managed, in the next year or two we shall see an improvement
in this area.
(Mr Naylor) I would simply endorse what Mr Brogan
has just said. There is not direct involvement in the majority
of NHS trusts in development of these systems and the systems
have historically been developed through the public health network
and, through the arrangements which we have described and hope
to see developed, through the HPA in the future.
Chairman: Any further points? If not, gentlemen,
thank you very much for coming along. If there is any issue which
you feel we have not touched upon and should have touched upon,
or any issue we have dealt with rather peremptorily and should
have followed it further, if you would like to submit any information
to us, we shall gladly receive it. You will get a copy of the
transcript which you will have an opportunity to correct factually
in due course. Thank you very much indeed.
Lord Turnberg: If the witnesses come up with any
ideas that they would like to see in our recommendations for change
which would make a difference to their work, can they perhaps
Chairman: Thank you very much.