To be published as HC 921-i

House of COMMONS





Wednesday 23 January 2013


Evidence heard in Public Questions 1 - 49



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Oral Evidence

Taken before the Science and Technology Committee

on Wednesday 23 January 2013

Members present:

Andrew Miller (Chair)

Jim Dowd

Stephen Metcalfe

David Morris

Pamela Nash

Sarah Newton


Examination of Witness

Witness: Professor Dame Sally Davies, Chief Medical Officer, Department of Health, gave evidence.

Q1 Chair: Good morning, Professor Davies. Thank you very much for coming to see us. We are a little thin on the ground today because the Welsh Grand Committee has taken the attention of three of our members, and Northern Ireland Questions another, but we have the cream of the bunch here. The whole Committee will be very interested in some of your responses.

Under your leadership, the roles of the CMO and the CSA have been combined. How does your role differ from those of the CSO and the chief scientist?

Professor Davies: I was appointed in 2004 as the director general for research and development in the Department, looking after science policy and the research spend in the NHS, and as chief scientific adviser. In that role, my chief scientific adviser post was much as others in that I advised on evidence, suggested where we could commission research to support policy making, and we commissioned evaluations of policy roll-out.

When I was appointed as CMO, I asked, with Sir John Beddington’s support, that, ad personam, the roles should come together for my tenure-it is not a joining for ever-for two reasons. First, every chief medical officer has espoused an issue and taken significant time on that, and, clearly, I am espousing science and evidence. We are going to discuss, no doubt, how and what I do in that role. Secondly, as the chief medical officer, I am a permanent secretary grade and it gives me far more opportunity to interpolate into the process science and evidence than I had even at the DG role. I am using the opportunity of being that senior to further the issues that I believe all the CSA community is trying to do.

Q2 Chair: In terms of undertaking your work-this is the question that my absent colleagues would have wanted to ask-how do you work with your colleagues in the devolved administrations? What are the mechanisms for co-ordinating things across the devolved administrations?

Professor Davies: I am the UK Government’s most senior medical adviser for things that are not derogated. As a result, I have just spent two days leading the UK delegation at the World Health Organisation in Geneva-incidentally, pushing science and evidence there, too-but, clearly, most health issues are local to our administrations, so we meet four times a year with a rotating chairmanship to chair things. Our officials are meeting all the time. We involve them as much as we can. Clearly, whenever I send out a letter to the doctors in the NHS or public health, I copy them in so that they are aware of what we do, we ask them to keep us aware and we build as good relationships as we can so that it is as seamless as possible. For instance, when you were kind enough to ask the Government to ask me to do a review of alcohol guidelines, I not only accepted but I then went to my colleague CMOs and said, "It would be much more powerful if we did this as a whole. Will you join me?" As it is us in England who are doing all the work and they will get the shared credit, they were very happy to join. It will be all the more powerful for that.

Q3 Chair: It was the UK Parliament that asked you to do that. What are your ambitions in your role? How would you like to sign off your legacy?

Professor Davies: I would like to sign it off that I have made a difference in science and evidence. I would like to talk to you in a minute about my annual reports and how I have changed how those are done. I would like to put, as I describe it, some pieces on the jigsaw of lifestyle diseases, to improve or reverse trends in obesity, alcohol, exercise and smoking, and I am very exercised about antimicrobial resistance. You might want to talk about that with me because this is a global issue that I am bringing some leadership to. I can tell you about that. I, clearly, hope, if there are events, be it a pandemic such as the coronavirus that we saw through the autumn, that I can play a role in bridging science between the clinical professions delivering services and the public so that we get to the best place for the nation. I also want to be remembered as having delivered some good stuff on R and D. So it is about science and evidence at the base of everything.

Q4 Sarah Newton: You are, obviously, a very ambitious woman.

Professor Davies: I am ambitious for the service. I will retire from this so it is not ambition for me.

Q5 Sarah Newton: But it is an extraordinary range of goals that you want to achieve; that is very impressive. I would like to start the discussions around particular aspects on the very impressive list of things that you want to achieve for your service.

This Committee undertook some research into guidelines on alcohol, and it is a much-debated subject, both with the public, probably down at the Dog & Fox on a Friday night, and certainly in the media. We very much welcome the Government’s response to say that there really should be a good evidence base over alcohol so that we can let people have clear guidance on how much alcohol they should consume. The response from the Government was published in September. By now, bearing in mind the scope of your review and the evidence underpinning your review, do you have a timetable for that?

Professor Davies: We have, and it is much slower than I and you would like. It took time to get agreement from the other CMOs, and then, sadly, it took more time than it should have done to agree who would support the evidence-gathering process. Professor Mark Bellis and the North West Public Health Observatory are supporting that, and that will go on into the reformed organisations from 1 April from Public Health England. So Mark Bellis is supporting it in that way. I have appointed two chairs and set up the terms of reference. The membership has been written to and agreed.

We have two groups starting on about 12 months each of evidence gathering. Mark Petticrew, a professor at the London School, is doing the physiology-the pathology-of what does alcohol does to the body with a group. He and Dame Sally Macintyre, from Glasgow, who is leading the behavioural group, are sitting on each other’s groups, so we will have information at the end of that about the evidence base on behaviour and guidelines and what you can do, on the good and bad effects of alcohol on the body and, therefore, at what sort of level. I will then bring that together and it will be published-I believe, totally, in transparency-with a group of experts to think what that means for the guidelines.

There are two ways of doing guidelines. You can do a guideline that has a series of segments, and we did that for exercise by age group. That works. Clearly, at the moment, the guideline is two to three units a day for women and three to four for men. That is simple. If people know what a unit is, they can abide by it. As a moderate drinker, my guideline would be different from a heavy drinker, possibly. Are we going to need a very simple message from the behavioural perspective-the five a day or two units a day and two days off-in order to have an impact? There is something about what the science says and something about the behaviour on the social sciences, and trying to bring that together into a guideline for the public that works but making sure that the evidence is available to everyone.

Q6 Sarah Newton: Great; that sounds like a very sensible process. From what you are saying, that takes us pretty much to 2015, it seems.

Professor Davies: It means that in about 12 months, which is 2014, we will have the first stage, the evidence reviews, and then, I hope, in six to 12 months later, yes, the actual guidelines.

Q7 Sarah Newton: Will there be some thought at some stage during that process, or maybe at the end of the process, as to how you go about communicating that to the public? As the intention is to improve public health and prevent harmful use of alcohol-there is so much confusion in people’s minds about the current guidelines-will there be proper consideration of how you go about communicating this information to the public so that it actually achieves the public health benefit that we all want to see?

Professor Davies: Thank you; you have put it better than I was trying to explain it. That is exactly why we will bring the evidence together with a third group. There will be crossover with those to think about how we put together guidelines that will make a difference to the public that they can take note of, which are not too complex, stratified or segmented. Absolutely, I am with you. We need the evidence and then we need to think, "How do we help people change?"

Q8 Chair: In the meantime, because there is a here and now in this, as we do have a part of the population that is drinking too much at the present time, is it your view, in the absence of any stronger evidence, that the current guidelines using units, and, indeed, guidance coming from this Committee that one should take at least two days off a week from consuming alcohol, is sensible interim advice?

Professor Davies: It is, based on the evidence as I understand it.

Q9 Sarah Newton: Thank you, Chairman. On a related issue, which is substance abuse, every few months we hear more people popping up suggesting that certain drugs should be decriminalised and that certain drugs are not as harmful as we thought. I am wondering how you are going to be involved in looking at the latest calls for particular drugs to be decriminalised. So much of the debate is around drugs and criminality, and not drugs and health. Personally, I am very concerned about emerging evidence about cannabis use and the impact on the mental health of, particularly, boys and young men. What have you got in your current work programme to look at the evidence base for the health side of guidelines for drug usage rather than the public debate, which is very much around criminality and drug use?

Professor Davies: We have a health problem, and we would do well as a nation to look at it as a health problem. There is quite a lot of evidence and science from other countries about how we could go about that. The lead for drugs and alcohol is the Home Office, and this Government are choosing to continue to treat it in that way. I am watching the accumulation of evidence and advice-last week, the BMA talked about the health harms and everything-but it is not high on my list of "to try and do", because I have got so much else on it. The coalition have not chosen to decriminalise it. If they choose to, we will be ready with quite a lot of advice.

Q10 Sarah Newton: So you are collecting an evidence base, and there is an evidence base available. It is considered from a health point of view, but it is not as high up your list as, say, obesity, too much salt in the diet and alcohol, but the evidence base is there and being looked at. For example, if we or the Health Select Committee really wanted to look at the health implications for illegal drug usage, that is something that could be done.

Professor Davies: We would have to assemble it. I just keep an eye out as I read. I am not doing a formal collection. I would have to ask an expert to assemble it, but there is an evidence base about how we should treat it as a health issue, even if you want to criminalise it as well. It would be worth waiting before you move on that to see how Public Health England and the National Treatment Agency for Substance Misuse amalgamation into it works, because that is looking at it from a health perspective in trying to help people to stop taking drugs.

Q11 Sarah Newton: Do you think that those particular agencies, quite rightly in my view, have a rigorous focus on science and evidence for policy making?

Professor Davies: We are developing it. Public Health England, I am determined, will be a scientific agency. They will be civil servants, but I am quite clear that one of my roles is to protect their right to speak out about what the evidence is. That is quite different from political advocacy. I have made that clear. I will make sure that the truth, or scientific evidence peer-reviewed, is published, if they have problems, even if it is uncomfortable for me.

Sarah Newton: Thank you very much.

Q12 Stephen Metcalfe: Good morning. One issue that is not yet criminal is the amount of sugar, salt and fats in food. That is the point. Is voluntary regulation working, or do we need statutory regulation?

Professor Davies: There is some evidence that it is beginning to work. You are talking about the Responsibility Deal. I should give you the evidence, shouldn’t I? If you want my personal view, you will ask for it. I can tell you that 70% of off-licences now list the calories and reformulations are going on for smaller portions. We now have to work going forward, because the chocolate companies have got the point, and it is much more about the catering industry and everything. It is not just about calories; it is about salt. We have had some dramatic improvements in salt as a result of the Responsibility Deal. It is working and there is quite a lot of improvement.

Would it work if there was no risk or threat of regulation behind it? Perhaps not. After all, as a society, we set up business to make a profit, and we all know that foods give you a kick if they contain sugar, and they taste better, if you are used to salt, if they are high in salt. I would argue that businesses might want to continue producing unhealthy foods if there was not a good reason to come down, and one is social responsibility. That is what we are appealing to and pushing, because everyone knows which companies are involved and which are not. The other reason is the threat of regulation. I think we are making decent progress. I was sceptical. It is making more progress than I had expected, and this is a good start, but the threat of regulation needs always to be there.

Q13 Stephen Metcalfe: And the threat of regulation is what is motivating people to do it on a voluntary basis. You said that people know the companies involved. Do you mean that other companies know which companies are involved, so it is peer pressure, or do you think that it is a public issue?

Professor Davies: It is a public issue. It is on the website. We have 450 companies signed up now, but the first 180 companies have put up on the website their data on what they have done. It is there for peer pressure and public pressure. I know that the public health specialist community keeps an eye on that and makes comments. Whether we can move to getting shareholders to take a more active role would be interesting, wouldn’t it?

Q14 Stephen Metcalfe: You talked about evidence earlier on and how everything should be evidence-based. How systematic is your collection of evidence that the voluntary system is working, and how often is that evidence collected and reviewed to see if there is a trend?

Professor Davies: They self-declare data on what they are doing, which is up on the website so that anyone can review it, manipulate it and use it. I have agreed £1 million towards an independent evaluation of this process. It is not about what an individual company is doing, but it is more about whether the Responsibility Deal is a good way to go forward. We have an independent group chairing the steering group for that £1 million. They have agreed an initial scoping study, which we have now seen-it is out for peer review prior to publication-looking at the relevant literature from health and other sectors on this sort of thing and looking at the evaluability of the current pledges. Interestingly, I understand that quite a lot of them are very difficult to evaluate. Then it is a matter of developing the logic model through stakeholder interviews as to what the process is.

You have to remember that this was not a policy driven from a research and evidence base. It was a political policy that is having an impact. We are now putting in that evidence base under it and going to look at some of it and evaluate it. It is not about rapid feedback. It is about robust outputs that will be peer-reviewed to help us go forward with the Responsibility Deal on diet, smoking and everything, but also so that other Government Departments think about voluntary things. So it is a broad evaluation.

Q15 Stephen Metcalfe: Thank you. I have one final question. I would be interested in your opinion because it might be difficult to provide evidence on this point. Do you think that the successes you have demonstrated are because people are making positive choices about what they eat, or because the industry has changed what they offer?

Professor Davies: It is both. I know that the industry is reducing salt. The scientific evidence is that, if you reduce it within two weeks, you don’t notice that it is lower, but by four weeks you really notice the previous level. You can taste it and think it is very salty. So four weeks is the time you need with lower salt or no salt to get it out of your taste buds. I did not explain that very well but the science is there.

Stephen Metcalfe: I’ve got the idea.

Professor Davies: It is about the offer that is changing, but also the more noise people make about this, the more people think about what they are eating and whether it is healthy. Some of it is working with supermarkets about where they put foods and how they display them. We all know that social marketing and nudge plays a role in what people buy, and that is having an impact.

Q16 Jim Dowd: Just on a related issue about the supermarkets regarding packaging information, do you have a view on that, because all the evidence indicates that the public find the traffic light system most informative in terms of salts, saturated fats and the rest of it, whereas most of the food-processing industry is doggedly sticking to the GDA system, which may have fact but has no information. Do you have a view on that?

Professor Davies: That is the John Krebs’ solution or the industry. I, personally, quite like traffic lights when I am in the supermarket. It is easy. I think, but we can send you a note, that what the Government have decided is a hybrid of the two is where we are going, but we will send you a note on that.

Jim Dowd: Thank you.

Q17 Chair: I do not know if you have read the papers this morning, but there is an interesting article in The Daily Telegraph quoting, extensively, the Public Health Minister, who, basically, said that you can tell who the poor people are in a community because they are all overweight. I paraphrase. What are your thoughts on that? Was it evidence-based?

Professor Davies: The evidence is that overweight and obesity is running at about 24% of children, who, from our child measurement programme, come from deprived homes, as compared with about 11% from other households. We know that, if you have social inequalities, you suffer health inequalities; it is more difficult for those parents to feed those children with not calorie-dense food, and they resort, for reasons of cost, to fast food and unhealthy food more often, and it may well be that there are more sugary drinks. There is a higher risk. It goes with the social inequalities that you get with health inequalities, and there is a higher risk.

Q18 Chair: That is, in a sense, an argument to back up Jim Dowd’s point about the strength of simple messages.

Professor Davies: Yes.

Q19 Chair: And that is how to shift behaviour, is it not?

Professor Davies: You shift behaviour with simple messages. You shift behaviour with education. Schools have a big role to play in this, because not only what they provide at lunchtime needs to be healthy, but they need to explain to children. It is a very good way of teaching families if you can teach the children.

Q20 Chair: Taking this on to another legal product, and that is cigarettes, you said you have some ambitions about shifting behaviour on cigarettes. What advice could you give to Ministers on the issue of plain packaging?

Professor Davies: There is a consultation on plain packaging that has closed. Clearly, I have a view, but, were I to express it at this point, it might prejudice the final outcome of where we end up.

Q21 Chair: Let me put it slightly differently. What evidence did you unearth that shock advertising works, for example?

Professor Davies: The evidence base was put in the consultation. I would have to go back and check what it was.

Q22 Chair: You believe that there is an evidence base that supports shock advertising both on television and on packaging.

Professor Davies: Yes. Indeed, let me move to our campaigns on television. You know that for the first time in eight years we launched on 28 December a health harms advert with a man smoking a cigarette and a tumour growing out of it, which does look like a tumour. That has had a massive impact. It has actually gone viral. Over 3.5 million people have viewed it. The take-up of our quit kits has been high and people are thinking and talking about it. We know that.

What we are watching on plain packaging is how it works in Australia, which has introduced it. The early signs are that it is successful in reducing smoking.

Q23 Chair: Do you work in parallel with your colleagues in the Home Office, for example, and other agencies, such as the police, in terms of the impact of any change of policy on the importation of illegal cigarettes?

Professor Davies: Yes, of course. Each Government Department has its own role, but HMRC has been very vigorous about the illegal imports of tobacco, and it is steadily going down. There is a lot of cross-government work; yes.

Q24 Jim Dowd: After this meeting, there is a reception on the Terrace to launch a report on the illicit tobacco trade from a noted academic-aren’t they all?-which I do not think supports the view that you have just given. I was more interested in what you said about the Australian experience. I quite understand your caution, and it was a bit cheeky to ask you what advice you give to Ministers, because we all know that you could not possibly do that. I was on the Health Select Committee when one of your predecessors, Liam Donaldson, got into a bit of a spat over the consultations on smoking in closed public spaces. I respect your caution. I am surprised that you say there are early indications from Australia, because the legislation only came in 10 or 11 weeks ago.

Professor Davies: I had dinner with the permanent secretary of the Department of Health for Australia on Monday evening.

Q25 Jim Dowd: Does that count as scientific evidence?

Professor Davies: No. I did not claim it as evidence. I am very careful to wait until something has been properly evaluated, peer-reviewed and published. I said, "What is the early evidence?" She said that the purchasing looked as if it was responding.

Q26 Jim Dowd: What-in 11 weeks?

Professor Davies: Yes. You can get data on purchasing. I am only reporting to you what I have understood as early evidence.

Q27 Jim Dowd: I recall that there is this stuff about shock advertising as well. I shall look this up separately. I remember, many years ago, and others of more mature status on this Committee may do as well, a tobacco product-a cigarette-introduced called "Death", and its logo was a skull and crossbones. It made plain that this is what happens ultimately when you smoke. Huge pressure was placed by the Department and officialdom generally to get this product banned, and I think it was in the end. I thought that this was a fairly reasonable approach, even radical maybe, to say "This is what happens and this is what you are dealing with", but officialdom seemed to take against it, rather. Do you recall that?

Professor Davies: No. I think I was just doing haematology at the time.

Jim Dowd: Then we will not go into that.

Chair: Okay. We will move on from cigarettes to homeopathy.

Q28 David Morris: A predecessor Science and Technology Committee published a report that said that homeopathy was just a placebo and it had no place in the NHS. What advice is available or given to the Health Secretary and his team of Ministers on homeopathy at this moment in time?

Professor Davies: I am on record in Hansard, when talking to the Lords Science and Technology Committee, as saying that, outwith the placebo effect, homeopathy has no impact. I am very concerned when homeopathic practitioners try and peddle this way of life to prevent malaria or other infectious diseases. I am quite clear about where I believe the evidence is.

Q29 David Morris: At this moment in time, the NHS provides homeopathy as a choice factor. Do you think it is wise to do so? Do you think there is a place for it in the NHS?

Professor Davies: I believe there is a place for an holistic approach with patients. I am perpetually surprised that homeopathy is available on the NHS.

David Morris: That is very clear. Thank you, Chair. I do not think that I can ask any more than that.

Q30 Stephen Metcalfe: I want to change tack slightly. Can we talk a little about clinical trials and the recent investigation by the National Institute for Health Research, which discovered that the availability of trials was not made known to patients in a systematic and consistent way?

Professor Davies: The mystery shoppers study.

Stephen Metcalfe: Yes. There are two points on that. First, why is it important for patients that they take part in doing the trials? Secondly, what are you doing to improve the situation following the mystery shopper experience?

Professor Davies: It is very important for patients to know about clinical trials and then decide whether they want to join in once they know about it, because, first of all, it should not be being done, or it won’t be being done, unless an ethics committee has agreed it. Normally, one arm is best present treatment, and on the other there is equipoise that it is at least as good, or a belief that it will be better. In this way, patients are getting best treatment or something that may be better. That offer should be there for all patients.

I can also tell you about the literature, though it is soft. There is no RCT evidence that shows that services that are active in research in this way are usually better as a whole service and get better outcomes. It does appear, and I could debate with you why, that doctors and nurses in research-driven services give better care to patients. We are perpetually updating it. If you are always doing trials, you know what the latest evidence is and what to do.

The third thing is that patients like being in trials. We have a lot of social science evidence that patients like the input and they are sad when they finish because they were being interrogated about a broader set of things rather than just facing a doctor and having one interaction. I believe it is very important.

What can we do about it? We set up NIHR, which is my brainchild. I established it and I am really proud of it. Part of it is the research networks, which are now active in 99% of hospitals, not 100%. What we are trying to do through that, and I thought the mystery shopper effort was rather an interesting way of doing it, is to get more hospitals, doctors, nurses and physiotherapists really involved in seeing the benefits. The way we fund the networks-a small proportion is based on population for management and stuff-is that money follows patients. The people who are really active get a good income stream for putting patients into studies. We have tried to incentivise joining in because we want patients to have that opportunity.

It is an apolitical issue. Labour supported this; the coalition government supports it. Patients should have the right to choose and not be excluded because no one thought to tell them. In the NHS constitution consultation, which has recently started, there is an issue about using patient data, suitably anonymised, for research. We had previously put into it that it is a patient’s right to know about research. I feel very strongly that patients should have that opportunity.

Q31 Stephen Metcalfe: You said that since the mystery shopper exercise things have improved.

Professor Davies: No, I did not. It is so recent that we will not have seen an improvement, but it is one way to try and get an improvement. We try all sorts of things.

Q32 Stephen Metcalfe: My actual question is: when are you going to do it again to see if there has been an improvement?

Professor Davies: I would imagine that the co-ordinating centre for the networks will think about doing it every year, but they have not told me their plans yet. As with all these questionnaires, you do not want to do it too quickly. We also collect the data; so I can tell you that 568,000 patients were put into studies through our networks last year and 22% of cancer patients were put into studies. America can’t get above 2½% of cancer patients going into studies. It just shows that, if you make the offer and it is properly supported, patients do want to take it up.

Q33 Stephen Metcalfe: Absolutely; that sounds very good. I understand that there have been problems in recruiting patients for clinical trials. Do you think that that has had an impact on health research?

Professor Davies: It does, because you have to close the trial because you have not done it, or it takes a long time, which is not very ethical or good. The other side of that is growth. If we are doing trials with the pharmaceutical or the biotech industry, much of the recruitment to those is competitive across the world. So it is the first people to put in the 100 or 5,000 patients that they need for the study. If we are slow recruiters, we will not get that opportunity for our patients, that learning for our staff and that income stream for the NHS.

Stephen Metcalfe: Let us hope that the situation improves rather quickly.

Professor Davies: We will not stop working at it, but it is difficult. So anything that you can do to draw attention to this is welcomed.

Stephen Metcalfe: Thank you.

Q34 Jim Dowd: I want to look at flu vaccinations for a moment. It was reported this winter that there were problems with the supply of vaccine. I am never sure; perhaps one has just been around for too long, but that is a story we get every year, anyway, regardless, from the newspapers and television. Is there in your estimation any causative relationship between problems with the supply of vaccines and rising numbers of cases of flu?

Professor Davies: Clearly, people who are vaccinated have protection against flu and are less likely to have a serious infection and die, but it does not give you 100% protection, so we would like the people whom we are aiming at to be vaccinated. I am talking about the over-65s, the under-65s in risk groups and pregnant women. Those groups are worked out by the Joint Committee on Vaccination and Immunisation as being cost- effective.

If you look at this year’s data, which I have to hand, we were aiming for 80% in the over-65s, and we got to about 75%, so we are on course to be much as in previous years, whereas for the at risks, where we were aiming similarly at about 75% to 80%, we have only got to 50%; but for pregnant women, this year, we have got to 40%. We have not seen higher uptakes in this year, in part, due to the weather, it having been a warm winter until the last few days, and, in part, presumably, because of the strains that are circulating. We have a flu B, whereas New York, where they have a state of emergency, has a quite virulent flu A going. We have not had much flu around. It has been quite a low year. I have my graph here. It is one of the lowest years. It looks a bit like 2009-10, which was low as well. It is only when people see it on the news and see friends getting it that some go and get their vaccination, so our uptake has not been that great.

Have we had vaccine problems? There was early in the season a problem with one supplier, who withdrew it, but that was a small supplier. We purchased this year, and will continue to do so, a central stockpile, and we released from that so it was available. There was a short hiccup, but with our central stockpile we ameliorated that. I don’t think that lack of vaccines has been an issue in why we have not got as high vaccination rates as we want.

Q35 Jim Dowd: As to the strategic reserve that you have referred to, I am led to believe that there are about 400,000 doses available. How did that cope with the circumstances this year and how much of it was used?

Professor Davies: It coped absolutely fine. I know I have a briefing on the actual numbers but I have not yet found it. We still have some left.

Q36 Jim Dowd: If you have the figures there, perhaps someone can send us a note on it after the Committee. The other point is this. Given all this stuff that means a great deal to you and very little to lay people like myself of As, Bs and things in different parts of the world, given that there are so many variables in flu rates of infection, how can you be sure of the effect that vaccination has?

Professor Davies: As you know, flu sweeps around the globe following the cold weather-the autumn and winter. It mutates as it goes. The WHO gets together scientific experts every year to look at what is going on and what we expect to come round. Then the vaccines are made, generally trivalent, to cover the three most likely and most prevalent flu strains, and that is what we give to patients. We are investigating a quadrivalent so we would add a fourth. It is pretty successful, unless along comes a strain that the scientific experts did not predict. Then it can be quite dramatic. We have had some flu this year-I can’t remember what strain it was-which is not in the vaccine, but not a high level, so that happens.

Q37 Jim Dowd: Is there no predictability in this at all? It is just try your best and see what happens.

Professor Davies: There is predictability, and it is generally pretty good but it is not a 100% hit. As it takes such a long time to make the vaccines because they are grown in eggs, you have to predict it about a year before you use the vaccine. It is to do with how early you have to predict and the length of time it takes to produce the vaccines. I think that the WHO does us pretty proud, but occasionally something escapes or changes.

Q38 Jim Dowd: I come on to norovirus, particularly as last weekend was personally considerably disrupted by my own experience of this-

Professor Davies: I am sorry to hear that.

Jim Dowd: -although, as my briefing note here says, (a) there is no cure and (b) it goes away after a few days.

Professor Davies: And (c) you will not get that particular strain again.

Chair: That’s good news.

Jim Dowd: Both of those appear to be true in my case, at least. It has been reported that there has been an increase in those catching the norovirus. I cannot remember how recently it has become known, popularly, as the norovirus. It just used to be known as the winter vomiting disease, as far as I am aware.

Professor Davies: True.

Q39 Jim Dowd: People in A and E units were very aware of this because they used to see the bug particularly among older people, with increases in attendances and presentations there, whereas the rest of the population got on with their lives without undue concern about it. Has it become more prevalent in recent times, and, if it has, is that because of a variation in strain, poor hand hygiene or any other attributable reason?

Professor Davies: You have got a good briefing. I would just point out, before I start answering that question, that hand hygiene in the NHS has increased amazingly because of MRSA and clostridium difficile. People were taught to do it and it is pretty effective. This year we have got 58% higher than the same period last year in laboratory reports, so it is higher. The reason it is-

Q40 Jim Dowd: Can I just stop you there before you go on? You said "in laboratory reports", but it is not a notifiable disease, is it, so where do the indicators come from?

Professor Davies: If you had gone to a casualty department, if they had seen rather a lot, they might not have done much about it, but, if you were admitted and they then ended up closing a ward, a lab would have checked that it was norovirus. We collect all that data through the Health Protection Agency, and, in the future, through Public Health England. Despite being not notifiable, you would not close a ward or a bay without at least sending off the samples so that you knew later that you had got the diagnosis right. It is 58% higher than the same period last year. We have got a hospital-outbreak reporting system, as I said. The reason seems to be that we have a slightly different strain, which is called Sydney. We were on New Orleans, apparently. At some time, down south, it mutated or a new one emerged, and it is now much more prevalent. We do not have protection against it because we have not encountered it before. Over 50% of recent diagnoses have been of the Sydney type rather than the one we have had in previous years, which is the New Orleans type.

Jim Dowd: I think I now have my antibodies.

Professor Davies: You do to Sydney.

Q41 Jim Dowd: I just hope that Melbourne does not turn up next year. Can I go on to another subject, while I have the chance? In relation to MMR, have rates now recovered from the Andrew Wakefield debacle?

Professor Davies: They have recovered.

Q42 Jim Dowd: Have they recovered to where they were previously?

Professor Davies: I am trying to remember. I will ask those behind me, if they can, to see if we have got it in my annual report. They have recovered. To give you the exact data, I don’t know.

I did want to talk to you about my annual report. As it is not printed, I have brought you it on a stick. I thought you might find it interesting because it is different from previous CMOs.

Chair: We will be looking at that very carefully. Thank you very much.

Q43 Jim Dowd: My final point is this. I noticed-perhaps I am not very sensitive in these matters-a certain antipathy towards homeopathy on your part. It is not a view, I am led to believe, shared by the Secretary of State. Nevertheless, there was a time, before the PCT that we have in Lewisham, when it funded a project at Lewisham hospital for a time for what they called complementary medicine, which I have to tell you was extremely popular with GPs, largely because I think they sent all their hypochondriacs there whom they could not deal with normally. That experiment was a failure and they withdrew funding after a couple of years, but it did have a very high presentation rate. So there is clearly a market out there for it.

Professor Davies: Whether it is for homeopathy or other alternative medicines, there is no doubt that there is a role for osteopathy, massage and all sorts of things. I just do not think that homeopathy has the impact that it-well, I know it does not. Why am I being wishy-washy? It’s rubbish.

Chair: That is very clear.

Jim Dowd: So other than that, you have no particular opinion.

Q44 Chair: In your introductory remarks, you touched on antimicrobial resistance. In The Times Higher, you are quoted as saying that you see it as serious a threat to mankind as global warming. That is quite a bold statement. If it is that serious, what are you doing about it?

Professor Davies: I didn’t know that it had hit The Times Higher. Right; so it does take me to my annual report. Since the beginning of CMOs, they have produced annual reports. My role, as you know, is statutory and it is as an independent adviser to the Government. The first volume each year will be that grand compendium of facts-it can’t be found by those sitting behind me-and evidence all displayed as cartograms where the size of the bit of the map relates to the population. So it is a very easy way to find a vast amount of data. It has taken a year to put together. The young doctors who did it have done a fabulous job, and in true scientific manner they are recognised in the report. All that data is available on data.gov by local authorities, so every local authority can now have access to that.

I am also doing a second volume each year, which is an in-depth review of something. I chose infection this year, thinking that it should not be too controversial. I started with a workshop with a whole series of experts from across the country. We debated things; they went away and wrote chapters, and then came back and we debated what that meant. Out of that came antibiotic resistance, which was something I knew a bit about but I was not an expert. It is clear that we might never see global warming. The apocalyptic scenario is that, when I need a new hip in 20 years, I will die of a routine infection because we have run out of antibiotics.

For gonorrhoea, there is only one useful antibiotic now. 80% is resistant to tetracycline, and 35% to ciprofloxacin, yet gonorrhoea in young people and middle-aged women, so probably middle-aged men too, is going up. It is very serious because we are not using our antibiotics effectively in countries. There is a broken-market model for making new antibiotics, so it is an empty pipeline. As they become resistant to these bugs, which they would naturally, but we are breeding them in because of the way antibiotics are used, there will not be new antibiotics to come. Think about multiple drug resistance to TB as well as one of the big threats. It then feeds into global issues around counterfeit medicines as well.

Clearly, we need to get our act together in this country. My annual report will come out at the beginning of March, alongside a cross-government antibiotic strategy that takes in DEFRA, and will promote antibiotic stewardship from the clinical professions and doctors, generally. As a result of this work, we have already put antimicrobial resistance on the Department of Health’s risk register and DEFRA’s risk register. I will call for it and they will agree for the Government to put it on the Government’s risk register as well.

We need to take international action. So I met with the assistant director general. Our ambassador set up a dinner for me at the World Health Organisation on Monday to discuss this with the assistant director general, who is in charge of this area, and a number of key people-leaders from other countries. We are going to work together to try and see what we can do at the global level under the leadership of the WHO on this.

You asked what I am doing. I am doing quite a lot to push our own nation and push globally that we take this seriously. I would like us to live to see whether climate change is as serious as we fear or whether we have mitigated it.

Q45 Chair: I want to turn back to the observations of the Public Health Minister this morning. My old friend and colleague, who I am sure you have come across, Professor John Ashton, did a fabulous piece of work in the north-west of England that was entitled "Where Wealth means Health", where he plotted a massive amount of data, down to super-output areas, showing the prevalence of different cancers in areas of deprivation. There were one or two fluky bits of work, but those of us with political knowledge of the areas could see the relevance of it. It was an incredibly painstaking piece of work, and the collection of data is mission critical to that kind of exercise, which has enormous importance both in public health but also in terms of research into stratified medicines-areas like identifying where occupational diseases are prevalent, which is an area where I want the HSE to spend more time.

With the restructuring of the health service, are you satisfied that the mechanisms are in place for legitimate researchers to collect the kind of data that they need at a very localised level to help inform research?

Professor Davies: Of course a number of people have done studies such as the one that you have just talked about, and it is at the basis of my annual report, as you can see. I was shocked, having been a graduate of Manchester, how badly the north-west and some other bits of the country do. It is deprivation, and we have got the deprivation indicators in here.

Significant work is going on in Public Health England under a board level director from Knowledge Management. Professor John Newton from Oxford is leading that. I think we are going to have better data going forward once we have got Public Health England, because, instead of having public health observatories, which are loosely linked to the federation, doing what they fancy, it will all be part of Public Health England, all with a duty to collect data across the country, to make sure that it is available and to build into my annual reports so that it is transparently available to researchers.

The future looks better than the past on all of this. One example is that, at the moment, congenital malformation registers are patchy across the country. I asked, as soon as we knew we were going to have Public Health England and that they would take on the observatories, that one of the first tasks would be to have complete coverage of the country, and it is well on the way to making that happen. That is very important for all sorts of reasons, as you can imagine, because you can start to look at whether there are environmental threats and issues in that area. I am hopeful that it will be better.

Q46 Chair: So the mechanisms will be in place for legitimate researchers to access that information.

Professor Davies: Yes, of course they will be. First of all, I believe in transparency.

Q47 Chair: That is my point; yes. It will be transparent.

Professor Davies: I believe in transparency. It should all be up there on the website.

Q48 Chair: Professor Davies, thank you very much for a very informative session. We look forward to reading your memory stick. It is a modern way of doing it. It is great as it saves chopping down several trees. We would like to keep an open link with you for a number of our pieces of work. We are intending, in the near future, to start doing some work on clinical trials, and there will be other issues that will spill over into your bailiwick. Thank you very much for coming this morning.

Professor Davies: Thank you. The data you wanted on MMR for 2011-12 is that 91% of children were vaccinated before the age of two, and that is comparable with pre-Wakefield, but for true herd immunity we want 95%. We are back where we were but not good enough yet. Thank you very much.

Q49 Jim Dowd: The figures in inner London are the worst in the country. We have got below that. Thank you very much.

Professor Davies: I will send you my next annual report at the beginning of March on infection, which raises antimicrobial resistance. Any help you can give me on this would be very welcome.

Chair: Thank you very much.

Prepared 1st February 2013