Examination of Witnesses (Questions 43-59)|
TUESDAY 29 OCTOBER 2002
43. Good morning, gentlemen. I apologise for
keeping you waiting just for a short while. Sir Peter, presumably
you would like to introduce your colleagues and if there is anything
you wish to say or make any statement, perhaps you would like
to do so.
(Professor Sir Peter Lachmann) Thank you, My Lord
Chairman. Yes, I would like to introduce my colleagues. On my
right is Professor Jonathan Cohen who is Dean of the new Medical
School at Brighton and Sussex. Before that he was Professor of
Infectious Disease at the Royal Post Graduate Medical School,
(subsequently Imperial College School of Medicine). He is an infectious
disease physician with his principal interests in the pathogenesis
of bacterial infections and bacterial sepsis and shock. On my
left is Professor Hugh Pennington who is Professor of Bacteriology
in Aberdeen. His principal interest is food-borne pathogens. He
is probably the world authority on infections with E coli
0157. In addition, he is the public face of bacteriology in the
United Kingdom. Just behind us is Mrs Mary Manning our Executive
Director of the Academy whom, in all our deliberations, represents
the view of the intelligent but lay public. We also have written
comment, which we will incorporate, from Professor Andrew Haines
who is the Dean of the London School of Hygiene and Tropical Medicine.
He cannot be with us this morning; he is here in spirit and on
paper, but not in the flesh. My Lord Chairman, may I say that
the Academy of Medical Sciences greatly welcomes that you are
holding this inquiry into Fighting Infection which did arise from
some of the problems which we set out for you when we were before
you before. We would also like to give a general welcome to the
CMO's paper "Getting Ahead of the Curve" and
I am pleased to see that the government is beginning to take an
interest in the problems that infection continues to give to public
health and to patients. We have quite major concerns about the
persisting problems in infectious diseasewith all classes
of infectious agents (bacterial, viral, protozoal and, if you
wish to include them as such, also prions). This has been getting
worse over recent times because there is much greater movement
of both people and animals round the globe, because of the growth
of antibiotic resistance, and because of social dislocation in
parts of the world and famine. All of these have made our attempts
to control infectious disease much less effective. We are very
concerned in this country about the state of academic microbiology
and we have written a report on this which I am sure you have
(and which we can make available). There are concerns about education
in and development of microbiology and all its associated disciplines.
In Getting Ahead of the Curve we have concerns about the
changes that have been proposed for the Public Health Laboratory
Service and about the creation of the Health Protection Agency.
I might just quote for you a statement written by the late Sir
Douglas Black (one of the greatest British physicians) in the
very last paper he ever wrote called Lessons from Nostalgia.
When writing about the National Health Service Registration Act
of 1973 he wrote that it "was the first major step in a long
series of vain attempts to improve function by tampering with
structure". Improving function is probably better done by
concentrating on improving function rather than by creating an
entire set of new structures.
44. Thank you very much Sir Peter. May I say
that the two documents pertaining to our meeting this morning
are quite forceful documents and they cover a wide area. I will
start off with the first question which is pertinent to what you
have just dealt with, namely education and training. The two documents
do identify a lacuna there in the supply of personnel, but what
are the reasons which underline the paucity of infection specialists
in England and Wales, and what suggestions do you have for reversing
(Professor Cohen) I think that part of the reason
is historical. It is certainly true that during the 1960's when
it was widely thought that infection was a problem that was going
to go away as a real issue, many of the infection specialist posts
that then existed were allowed to come to an end; the posts were
not renewed so there was a general attrition. I think it is fair
to say that, under this general heading of infection specialists,
there were several sub-groups, as it were. There are infectious
disease physicians, there are medical microbiologists and then
there are experts in infectious disease and public health epidemiology.
While it is true to say that there is a general shortage of those
groups in the UK, I think here we were referring in particular
to infectious disease physicians. It is striking, I think, that
the total number of infectious disease physicians in England and
Wales is about 70 or 80, which is substantially less than it is
for New York City, let alone in other parts of the developed world.
I think the lack of numbers is unarguable. Why has it come about
and what could one do about it? I think that this is probably
substantially due to the fact that the trustsbe they hospital
trusts or PCT'sinvesting in these kind of specialists,
do not see them as high priority. Inevitably where there are resources
which are going to be limited anyway, where they have to make
choices about where to invest those resources, they tend to focus
on those areas which the government has identified as being high
prioritycancer, heart disease and so onand in particular
where those high priority areas are linked to very specific targets.
If, for example, a consultant physician post becomes vacant the
great pressure would be to appoint another cardiologist or another
orthopaedic surgeonor whatever it may bein order
to cut the waiting list or to hit some particular target which
has been identified. So, inevitably there is great pressure on
fields such as infection which is seen, I suppose, as fire fighting
rather than as a core kind of speciality. As a result, posts are
either left vacant or unappointed or opportunities are not taken
to appoint individuals to them. I suppose one of the ways to specifically
answer your question would be to try and encourage a circumstance
where, if you like, the appointment of these posts are linked
to specific targets. There is clear evidenceand, indeed,
the data exists in the literatureto show that appointing
individuals with this kind of expertise can produce specific quantifiable
measurable beneficial outcomes and perhaps if this were more explicit
and if there were some guidance given to trusts to show that this
was something that the government and the NHS regarded as valuable
and important, there would be more incentive to appoint people
to these kind of positions.
Chairman: Any other points? Baroness Walmsley?
45. You have described a situation where targets
are actually affecting this area of medicine. Are there any targets
already in terms of infectious disease and, if not, how do you
think they ought to be established?
(Professor Cohen) If I may respond to that, there
are, in one particular area. Lately, the government, through the
National Audit Office and others, have identified infection controla
very specific area of infectious diseasesas an area which
does require additional resource and investment. And so about
nine months agoby memorythere was some specific
guidance given to trusts about the need to invest in that particular
aspect of the subject. Other than that, no.
(Professor Sir Peter Lachmann) The problem of the
paucity of posts feeds back into the training. We have an actuarially
determined medical training system where the number of specialist
registrar posts depends on how many consultant vacancies are envisaged.
This makes for a situation that is not rapidly reversible either
because where there are few who have career posts, there will
not be many people in the training programmes. Giving trainees
confidence that they are going to have jobs at the end of training
is very important if there is to be a good cadre of doctors able
to fill infectious disease posts when they are made.
46. Would it help if there were more intercalated
BSc's in certain fields, specifically microbiology? Perhaps a
number of intercalate BSc's over a certain period?
(Professor Cohen) I think it would help in the sense
that it would encourage individuals to see the interest and excitement
in the field and might lead them in that direction. It tends to
be the case that young people who are enthused at an early stage
in their career will then tend to follow that through subsequently.
It would certainly be something that would assist, I think.
(Professor Pennington) There are problems in that
area in the sense thatas the Academy has already shownacademic
medical microbiology, academic bacteriology in particular are
in serious difficulties. Without that running and offering intercalated
courses is difficult. That is not to say that there are not some
centres which can do this extremely well, but it is a limited
resource unfortunately at the moment. Until we solve the problem
of academic medical microbiology, that is going to be just one
route that one can get people interested in the subject: through
showing that it is intellectually interesting as well as practically
interesting, professionally interesting and so on.
(Professor Cohen) The Academy thinks an intercalated
BSc is an essential part of training. We would be very happy about
any encouragement you can give it.
- Is it a fair inference from what you have said
that there is no body within the UK at all that takes an overall
view of the appropriate numbers and their availability in essential
but possibly non-mainstream medical specialities of this kind?
If one may draw a comparison with the University Funding Council,
in its addition to supporting disciplines across the field, it
will have a special care that minority subjects are present somewhere
because if it were simply left to the market they would disappear
through a series of unco-ordinated separate decisions. Perhaps
this is the case which you describe here. Is that correct?
(Professor Cohen) I think that is absolutely right
and I think it is particularly a problem now where much of the
development funds or the opportunity to derive change resides
primarily within the PCT's of course, and inevitablyand
understandablytheir priorities are seen as more local or
regional than national. That oversight aspect, the ability to
deal with areas which are, as you say, core but not immediate,
I think is exactly what is missing.
48. Is it not true that a high proportion of
infectious disease consultants are university academics, employed
mostly in academic departments and the number of NHS employed
physicians in infectious disease is quite small. It would be interesting
to know what the numbers are. But is it not also true that there
is no problem with attracting people into the discipline, that
it is an attractive discipline for many academically able people,
and it attracts very bright young men and women. The difficulty
is in finding posts for them.
(Professor Cohen) That is exactly the case. Albeit
the numbers are now very smallI mentioned the figure of
70 or 80that represents a substantial increase over, perhaps,
15 years ago. Virtually all of that increase has been driven by
academic developments funded by largely the Wellcome Trust and
the Medical Research Council. That is absolutely a correct analysis.
The NHS itself has put very little resource into this area in
terms of NHS funded consultant posts. It is also true that it
is an attractive speciality; we are fortunate in that extremely
bright people want to come into it, but they are put off if, for
obvious reasons, there does not seem to be an exit.
49. The paradox is that microbiology, which
is very closely related, has a big problem in attracting people
and maintaining people in the discipline. I wanted to ask you
a question later, but perhaps we can deal with it now instead
of later, is there no way of bringing the training of microbiology
and infectious diseases together because you would then cancel
out the problems on each side?
(Professor Sir Peter Lachmann) That has largely happened.
The two colleges (the Royal College of Physicians and the Royal
College of Pathologists) agreed on joint training about 10 years
ago, but it has taken rather a long time to get going. One of
your specialist advisors runs a joint training program for microbiologists
and infectious diseases physicians in a leading London teaching
- Do you think it will then answer the problem?
(Professor Pennington) In the fullness of time, yes,
but it is a question of how long that will be.
Lord McColl of Dulwich
51. Is the problem not much more deep-seated?
Given that young people go into some branch of medicine and although
the senior training posts are matched to the number of consultant
vacancies, at the lower level no-one has ever accused the system
of matching anything. There is just a great hoard of people with
no future at all, no security, and is it not time that we followed
the line of most other countries where if somebody wants to go
into, say, surgery or medicine or obstetrics or microbiology,
if they go into it and they are of a reasonable standard they
ought to have a reasonable chance of reaching trained status at
a reasonable age in their early thirties, not forties as so many
of them are today.
(Professor Sir Peter Lachmann) That is certainly true.
We are very much in favour, particularly for academic trainees,
of shortening training. NHS training has got shorter in recent
years. A report is pending on the future of the SHO grade which
proposes a seamless transition from the moment of leaving medical
school until becoming a consultant. That entails a lot of inflexibility
in training and a lot of inflexibility in career pathways which
will certainly have a serious downside. We have not yet responded
to this consultation, and I do not wish to pre-empt what our working
party will say, but it will certainly be worried about the academic
consequences of this seamless approachyou can call it a
"seamless treadmill", if you like. Many people, when
they come out of medical school and do their pre-registration
jobs have no very firm views of what the practice of medicine
is really like and change their minds as they go along. Again,
particularly for those who are going to have academic interests,
it is important that they have the ability to move sidewards and
to do interesting and unusual things. Therefore these are difficult
52. They manage to do it in other countries
and have done for half a century. That is my point.
(Professor Sir Peter Lachmann) I think the American
system is one which should be carefully looked at. It is shorter
and it achieves a slightly different objective, and people often
go on academic training afterwards. Americans also go to medical
school when they are rather able. Training in this country, particularly
for academics, is certainly too long.
Chairman: I think this will have to be the last question
on this matter. Lord Haskel?
53. I was interested in what you said about
appointments being linked to targets. How can we make sure that
appointments are linked to priorities? We know about the weakness
(Professor Cohen) I suppose it is by correctly identifying
the priorities and making sure that those who have to implement
them have the resources to deliver them. I think that the difficulty
is that unless the trustsand it is largely down to the
PCT's nowcan be persuaded that something like infection
in this context is a core function, unless this is adequately
addressed and dealt with, understandably they are reluctant to
put resources into it. While, at one level of course they understand
that, in terms of all the other pressures on them I guess it simply
does not have sufficient priority. That is exactly the problem.
54. The next question is about a possible structural
change so it may not prove very popular with Sir Peter. Do you
think there is any merit in establishing designated infection
centres and could they take over the training function of the
PHLS and improve the situation you have just been describing?
(Professor Sir Peter Lachmann) Yes, I do see merit
there, it shows how inconsistently these Centres of excellence
were proposed in the Academy's report on Bacteriology. It would
be a very good idea to have multi-disciplinary centres of excellence
in microbiology, infectious disease and epidemiology, where all
these strands come together presumably in an academic environment.
They would provide valuable training in the whole area. We very
much hope that some way of funding these Centres of excellence
is found. They are not a major change in structure; it is just
bringing the threads together which we do believe would help.
The Centres would have tentacles reaching out to the peripheral
laboratories so that these laboratories would have access to multi-disciplinary
centres. Indeed, it is the Academy's view that this is exactly
the way we ought to go. There should be a limited number of these
centres. They would be the focus for developing new techniques
and maintaining excellence in this area and would bring together
all these different specialities, not just the infectious disease
physicians and the clinical microbiologists, but also the public
health doctors, the epidemiologists and all those who are necessary
for the control of infectious disease. They should all be able
to work together. This should be facilitated and we think it would
be facilitated particularly by having a centre of excellence.
I would refer you to our report on Academic Medical Bacteriology
in the 21st Century which outlines these suggestions in some
55. How would they link with the universities?
(Professor Cohen) I guess most of them would actually
be based on an academic department or even several academic departments.
56. Are there any other points on this question?
(Professor Cohen) I entirely agree. The only addendum
I would make is to say that one has to be careful in doing this
not to forget that the coal face, particularly in aspects of surveillance,
for example, is still going to be at the periphery. You still
have to make sure that you have the means to pick up the events
where they are occurring on the ground. In a sense I think one
has to have both. I absolutely agree with the merits of an infection
centre, but it should not be at the price of losing the radar
tentacles, if you like, around the edges because that is where
you actually pick up the events that are occurring on the ground.
57. So this would be extra.
(Professor Cohen) I think it is a different emphasis
and it is simply making sure that you have both. Neither can work
on their own, essentially. I think you need both bits of it to
make the system work properly.
Chairman: Lord Turnberg, you partially asked a question.
Are you happy with it or do you want to press for a further answer?
58. You talked about joint training between
microbiology, epidemiology and physician training. Is there a
public health element in that? Has it been agreed that there should
be a three-way training program or is that still not quite there?
(Professor Sir Peter Lachmann) I am not sure I am
the right person to answer that. Does public health come on board
in the training?
(Professor Cohen) My understanding is that they are
interested in that possibility, but it has not been developed
to the state that it has between microbiology and infectious diseases.
Lord Turnberg: I think we have dealt with this question.
You obviously feel that this is an important way forward, but
it will take time.
Chairman: Are there any other points? Baroness Emerton?
59. You have touched on medical schools and
I wonder if I could ask Professor Cohen to describe how, within
the crowded medical curriculum that there is today, public health
is adequately covered.
(Professor Cohen) It is, of course, the case that
GMC do expect that public health is part of the curriculum and
I am sure that all medical schools will incorporate that within
their curriculum not only because of that but because they think
it is a good thing to do. It is, of course, very crowded and that
is a problem. Public health, it is worth remembering in this context,
covers not just infectious disease epidemiology but all the other
aspects of public health as well. Inevitably, again, to some extent,
the same pressures arise. For example, in the public health part
of our curriculum, quite rightly, issues around smoking and heart
disease will figure. Those kind of pressures mean that the infectious
diseases aspect of public health inevitably finish up with a rather
small slice of the cake. I think we do try to cover it but it
is probably a pretty small part of the curriculum inevitably.