Examination of Witnesses (Questions 60-79)
TUESDAY 29 OCTOBER 2002
PROFESSOR SIR PETER
LACHMANN, PROFESSOR
JONATHAN COHEN AND
PROFESSOR HUGH PENNINGTON
60. The discussion has been limited mainly to medical education,
but what about involving other health professionals in terms of
public health and infection and so on?
(Professor Cohen) I think that the notion
of multi-professional education is something which is very much
being embraced certainly by the new medical schools and something
which we very actively try to incorporate into our training.
So, for example, just the other day we were talking about the
teaching of basic hygiene to our first year medical students
and that is going to be delivered by infection control nurses;
they will be the lead people for delivery of that part of the
curriculum. I think there are opportunities there which need
to be built upon. I guess the other way in which one might think
about it is at the other end of the curriculum when students
are emerging and in their early years of training and whether
it would be possible to incorporate experience in public health
as part of the early post-registration PRHO equivalent type
of training. After all, we allow young doctors to spend some
time in medicine, in surgery, in general practice. Would it
not be possible to say they could actually do one of their house
jobs in public health medicine? That would be an innovative
and interesting way of trying to not only increase the man power
but more importantly to encourage young people to see it as
a career in its own right.
Baroness Walmsley
61. That sounds like a very good idea. Why is
it not done? Are there any practical difficulties? Or are there
career disadvantages? Why is it not done now?
(Professor Cohen) I have absolutely no idea.
Baroness Emerton: When I was a nurse in training—some
many years ago—we went and certainly did a spell in public
health and it slipped from the curriculum. I think it is probably
the same in medicine. I think it needs rejuvenating.
McColl of Dulwich
62. At some hospitals one of the HP jobs was
half HP and half resident pathologist. Those people often went
into pathology and often into bacteriology but that was scrapped
for some reason or another.
(Professor Cohen) I think that is right. I think that
would be very unusual these days.
63. Is there any reason why we could not go
back to that? It was a great method for recruiting people.
(Professor Cohen) None that I am aware of.
Chairman
64. Could we now move on to question number
five which I think Professor Pennington might be interested in.
In your written evidence you describe how surveillance systems
need to be flexible and innovative. Do you think that this is
the case for what is planned in Getting Ahead of the Curve
and, if not, what steps should be taken to achieve flexibility
and, I would add, integration and responsiveness.
(Professor Pennington) Yes, Getting Ahead of the
Curve is fine as far as it goes. It describes the sort of
systems that will strengthen the quality of the information that
has been collected passively. So, for example, on page 137 it
talks about the duty of care of microbiology laboratories to report
what they find; better case definitions for reporting; co-ordinating,
analysing and reporting on different systems; integrating information.
It is all about collecting information and also having good systems
of accreditation and laboratories. All this is necessary but it
is not sufficient for a surveillance system that is going to catch,
for example, new and emerging pathogens. What it will deal with
are the ones we know about using the procedures which are well
established and it will make sure that all laboratories are operating
to a common standard. There are even problems with that in the
sense that unless those standards are kept continually under review,
unless those standards are taking account of new developments,
they will always be out of date. I think there is almost an inevitability
that if you are going to have tests that will satisfy a legal
requirement, that have been validated (and this was one of the
issues, for example, in the foot and mouth outbreak using tests
that had been validated) this takes a long time and by the time
the test has been validated very often better tests are on the
horizon. This is why flexibility is very important in terms of
surveillance. For the ordinary, small district general hospital
laboratory what Getting Ahead of the Curve says is absolutely
right because many of these laboratories are not accredited yet
and they need to be so that we can be certain that the quality
of the data they are sending—and certain that they are sending
in the data that they are collecting—is done properly. Looking
for the real problems, the new problems for example, this will
not be sufficient. I think part of the answer to the question
about the key steps taken to achieve flexibility and responsiveness
comes down to the Research and Development side. For example,
to do surveillance it is not enough just to passively collect
the data that has come in generally speaking because of a general
practitioner or a hospital consultant requesting a particular
sample; it will require active surveillance by surveys in the
community and it will require active work on samples that have
been collected to do detailed typing and so on. Very often this
requires more than just the basic funding that a laboratory requires
for doing its ordinary day to day service work and also just sending
in information and collating that information. At the end of the
day, I think Getting Ahead of the Curve addresses a significant
problem but it does not take it far enough in terms of us being
"ahead of the curve" in a sense. We need to be aware
of new developments and new pathogens because—as I think
we put in our report—one of the essential features of microbes
is that they evolve in real time. Using tests of the past is not
going to be enough to identify the problems of today, never mind
the ones that are just round the corner.
65. In your submission on paragraph three you
are somewhat critical of the service not being joined up. Of course,
you might expect me to mention the Veterinary Laboratory Agency
where, indeed, similar work is being done. What is your opinion
about the two getting together much more?
(Professor Pennington) I think there have been movements
in terms of having committees which are looking at zoonoses, for
example, which, by definition are linking the veterinary and the
human medical scene from the microbiological point of view, but
we still have laboratories which are working in quite different
environments which, generally speaking, will only be talking to
each other formally on fairly infrequent occasions. There will
obviously be a network behind the scenes and those work well sometimes,
but I do not think you can rely on those as a management tool,
as a systematic tool to make sure that everything is being done
that needs to be done. I think there is a real need to have a
look—whether it is veterinary or human—from a pathogen
base, look at the outcomes of what you want from surveillance.
I think we draw E coli 157 as an example where there are
different efforts going on looking at this organism which are
not sufficiently co-ordinated in terms of having a full understanding
of what is happening in real time in terms of the organism being
in animals. Animals are the source, but it produces its major
health problems in people because in animals it does not cause
disease. It only causes problems in people when it spills over.
So it is not a veterinary pathogen; it is a human pathogen but
the main source of the organism is in animals. I do not think
we have yet solved the problem of how we address that particular
complicated situation as well as we might. It would not do just
to rely on informal contacts between Colindale and Weybridge,
and so on, in terms of solving that problem, or by committees
that meet relatively infrequently.
66. A good example of what might be proactivity
is the question of the West Nile virus infection and what are
we doing to co-ordinate the various groups such as the VLA and
yourselves to monitor that and its entry into and spread in this
country.
(Professor Pennington) It is partly a missed opportunity
that the Health Protection Agency does not use that as an example
where the West Nile virus needs not just people interested in
diseases in wild animals, diseases in humans, but also entomologists
as well, for example, and the mathematical modellers bringing
all these people together (which we alluded to in terms of talking
about the public health aspects of infectious disease control).
We still have not cracked the problem of bringing all these people
together. I think that was shown remarkably well in the foot and
mouth outbreak where the people were brought together after the
outbreak had started; they should have been brought together long
before the outbreak was started with a role in contingency planning.
I think it does come down to the contingency planning argument
that we need to have a system which brings all these people together
and, in a sense, bangs their heads together, if you like.
67. Has that happened in North America where
the West Nile virus is causing quite serious problems? Have entomologists,
veterinarians, virologists, et cetera been brought together effectively?
(Professor Pennington) I think it is quite difficult
to make a comparison, but CDC Atlanta obviously has a very broad
range of experts either in the organisation itself or on tap.
They have a slightly different tradition. Their shoe leather epidemiologist—and
I am not being rude to our epidemiologists I hope—is not
sitting in an office crunching numbers, but he is out there with
a field role as well as a office role. We do have field epidemiologists
in this country, but they have made a virtue of it rather more
than we have. It is a very attractive career option for doctors
to go into this kind of epidemiological activity. I would sincerely
hope—and this is just a personal view—that we go down
that same road ourselves. I think that some of the state health
authorities in the United States—which we do not really
have an equivalent of here—also play an important role in
this. Again in the United States I think one has to be careful
when making comparisons in that in some states their system is
working extremely well and is well funded. In other states—and
I am drawing on my E coli experience—in the western
United States there was a significant lack of co-operation between
the different states which led to a very large outbreak going
unrecognised for a long time because of downsizing and so on.
There are advantages in the American model, but they have to be
looked at with a degree of caution, I think.
Lord Oxburgh
68. Could I ask Professor Pennington,
when you say "people getting together" do you mean there
should be some kind of new physical institute containing these
different disciplines, or are you talking about someone organising
funding and maintaining some sort of network of activities?
(Professor Pennington) I think I am talking about
both, essentially. I think our infection centres would be a very
good way of working towards this. We would still need the networks
as well because there would be a very small number of infection
centres. There will be a requirement in other parts of the country,
for example, to have a network of people who are formally linked
so that they do know what is going on. We do have very good networks
of information. We have weekly reports and so on going out. But
I still think that we do miss tricks on this, that we do not have
it quite right. There is a British disease of disciplinary compartmentalisation
which, we have already heard, has been addressed in terms of infectious
disease physicians and medical microbiologists. We have a way
forward in addressing that problem (although I think you heard
that our optimism was guarded in how long that would take) and
we need to move faster not just on that but in getting other disciplines
(for example the mathematical modellers) and bringing them into
the house. I do not have an answer how that could be done any
better than it is being done now.
Lord Quirk
69. Would this networking—and indeed any
new institution that might be set up—be better on a European
basis or an individual national basis? You compared our situation
in this country with the United States. With BSE you were obviously
greatly involved with work in other countries.
(Professor Pennington) I think the UK has a very good
opportunity here to set a European lead. If I may say so, there
are many European institutions being set up to address this particular
problem, a formal network is being set up. For example, on the
IT side and certainly on the public health side, certainly on
food safety, there are European initiatives which will drive this.
I think if we get our house better in order we could continue
the lead role that we have been taking in Europe on this because
in terms of most European countries I still think we have a better
system. Although we are drawing the disadvantages to the fore
here, I still think we have a better system than many European
countries and they are eager to learn from us. Clearly, if European
networks are going to be set up, it is to our advantage to be
in on the ground floor as well with that.
Chairman
70. I am just going to ask about the World Health
Organisation rather than European people. Is WHO well schooled
in this and operating along the lines that you would wish to see?
(Professor Pennington) It acts as a forum and as a
support and has particular interests as well and can facilitate
in particular areas. At the end of the day I do not think it has
a particular interest in British problems. We have a particular
interest in WHO rather than the other way round.
(Professor Sir Peter Lachmann) WHO is very focussed
at the moment—and quite correctly—on problems of the
third world. Can I just mention to you that there is a new body
called the Inter-Academy Medical Panel which brings together all
the world's academies of medicine and medical science who had
their inaugural meeting in Paris last March and have just published
their proceedings in a book Confronting Infections: Antibiotic
Resistance and Bio-Terrorism Round The World. Their work is
going to be developed much further with financial support from
the United States, but is concerned essentially with the problems
of the third world. Because of global travel we are not isolated
from the infection problems of the third world; but compared to
their problems, ours seem rather small.
71. Could we have a copy of that or will you
leave it behind for us?
(Professor Sir Peter Lachmann) We will leave it behind.
Baroness Walmsley
72. What you have just said, Sir Peter, brings
me neatly on to something that struck me very much in your evidence,
that you were somewhat concerned about the limitation of the brief
we have imposed upon ourselves to focus on UK health issues. Although
we do not have five years to do this report, we have had to restrict
ourselves to some extent and we are perfectly aware of the fact
that infectious disease is a global problem. Could you suggest
any area of our brief that we might particularly emphasise in
order to address your concern about the limit of our brief, this
sort of networking, for example, that you have just been talking
about, or something else?
(Professor Pennington) Could I respond by quoting
an example where international collaboration has worked well and
if you could give support to that kind of collaboration and that
kind of enterprise and working, I think we would all benefit from
it, not just in this country but elsewhere, and that is tuberculosis
where there has been a very successful international collaboration
in terms of typing the tubercle bacillus so that one can work
out the source of the organisms. This has been done by countries
in North America and Europe and Ethiopia; it has been a truly
international effort. You can type your organism and look at its
profile on the World Wide Web, for example, because the scientists
have got together and agreed a typing system. Anybody who knows
anything about the typing systems for bacteriology knows that
this is one of the most fertile sources of dispute amongst bacteriologists,
which system to use. The paradox is that tuberculosis is one of
the most difficult organisms to work with—it is very slow
to grow, it is very difficult to handle in a laboratory, it is
very dangerous to handle in a laboratory, extracting its DNA to
do the fingerprinting is very difficult because the organism is
very tough—and these have all acted as a stimulus to people
to actually get their act together and work out an internationally
agreed system which, at the end of the day, depends on good IT.
I think any support that could be given to this kind of enterprise
in other organisms—as Sir Peter mentioned, these are not
organisms which are resident in the UK, we get them from other
countries and we export them to other countries—would be,
I think, a very powerful way forward in terms of protecting the
public health of the citizens of this country, never mind others
as well. It is partly a question of banging together the heads
of the scientists, or finding people who can do that and push
people in the direction of much more collaborative effort in terms
of putting the science to work properly; the science is there
but it has not been put to work properly.
Chairman: Are there any more points on that? If not,
can we move on to question six, Lord Oxburgh?
Lord Oxburgh
73. The Academy's evidence and comments upon
the proposal to transfer the research funds from the PHLS to the
central NHS on the budget is fairly clear and not very supportive.
Would you care to elaborate on this and really say how you think
that research into infectious disease and public health should
be funded?
(Professor Cohen) I think the way into this, in a
sense, was to identify that the PHLS in its current role has,
I suppose, two very broad functions. One is that around surveillance;
the other around serving as reference laboratories as centres
of expertise. Focussing on that second part, clearly a reference
laboratory is only going to be effective if it is able to continually
develop new procedures, evaluate new tests and so on and validate
them. I think the reason we flagged this up as a concern is that
quite properly the role within the PHLS of this kind of work focusses
more on D than R; it is a more developmental than basic science
role. I would say that I do not think we are talking about very
basic science aspects of research; we are talking particularly
about the D part of R&D. It is certainly true that by and
large funding for development is seen as less of a priority than
funding for research. It is always generally more difficult to
get funding for D than it is for R. Yet without that adequate
funding the very important role of the PHLS in being the forefront
of developing new tests—as Professor Pennington was talking
about earlier—is going to be threatened. I think our concern
here was to point out that if all that resource (not just the
resource which is currently allocated to the central PHLS laboratories
in Colindale and so on, all the amount of R&D support which
currently is associated with the peripheral centres which would
be lost then because they would not exist as part of the revised
HPA) were to be moved into a central NHS pot for research, our
concerns would be that inevitably the call on those funds would
again be driven by things which were seen as a higher priority,
things which were perhaps more pressing in terms of the priorities
being set by others. Particularly given that D is traditionally
funded rather poorly, our overall concern was that this would
mean that the admittedly already rather limited resource the PHLS
has for R&D would be further weakened and this would be at
the expense, therefore, of the public health function because
the ability then of the PHLS to develop new tests and to respond
to problems in relation to public health would therefore be severely
weakened. That, I think, is the point we were trying to make.
74. Are you really saying that experience suggests
that the NHS R&D directorate would give insufficient priority
to this kind of work? Is that what it amounts to?
(Professor Cohen) I think what we are saying—as
we were saying earlier, indeed—is that throughout the NHS
(not just the R&D directorate) this is seen as an area which
is of less pressing importance than some other areas, yes.
75. Do you have an alternative suggestion? Or
would you simply say we should retain the status quo?
(Professor Cohen) I think that it would follow inevitably
from what we have said, that we would see it as important that
a mechanism be found to ensure that there are adequate resources
to support particularly R&D (and particularly D) within the
public health arena. Whether that means that the Health Protection
Agency should retain a specified R&D budget or whether other
means should be found to ensure that within the general NHS budget
there was a mechanism to ensure that public health was protected—there
are a number of different models—I think we would recommend
that there is adequate means of ensuring that there are funds
to ensure development of public health R&D.
(Professor Pennington) Could I just illustrate what
Professor Cohen is saying by two examples of what the PHLS did
in the past using its own internal funds, work which would have
been quite difficult to fund in terms of putting in an application
to a body. This was the original work looking at Campylobacter
-the commonest bacterial cause of food poisoning—which was
done in PHL laboratories like Worcester. This was done as part
of their routine diagnostic work developing culture media and
so on. The same sort of work was done more recently in Sheffield
in terms of E coli 157, developing a medium in which you
could grow the organism successfully. This is extremely mundane
work in terms of putting it down on paper and saying "I want
to modify a culture medium" which was invented by Robert
Koch in about 1890 and has not moved technically very much since,
but is absolutely crucial if one was going to get a good return
in terms of sampling faecal samples for the pathogen. It sounds
trivial when you write it down, but it is so important in terms
of surveillance and in terms of diagnosis. My preference would
be for some kind of fraction of the budget to be allocated—not
to salaries or to consumables—but to this development fund
where people could do the kind of work where, if you applied to
the MRC, it would not get past the office (and rightly so). The
MRC is not in the business of funding that kind of work. Somebody
has to fund it. The PHLS has funded it in the past; somebody has
to fund it in the future.
Chairman
76. Are you suggesting some ring-fencing?
(Professor Pennington) I think there are problems
that not every laboratory in a network of laboratories—whatever
the Health Protection Agency network develops into—is going
to be fit and suited to do that kind of work. There is an argument
for having some kind of central control over it. But at the end
of the day I think it is very difficult to predict where that
work is going to be needed; it will depend on local circumstances.
Local outbreaks might throw up a problem which would require somebody
to exploit that particular material, that clinical material. That
is something we have not discussed so far this morning, but that
is another aspect of the R&D that laboratories do have a very
rich resource of material which we neglect at our peril if we
do not do R&D on it. At the end of the day, some kind of ring-fence
money, yes.
(Professor Sir Peter Lachmann) I just want to add
that we are not being critical of the director of R&D in the
NHS; far from it. The point is the regional laboratories of the
PHLS were very well adapted to their function of providing that
local, reach-out public health service which is required for infectious
disease surveillance. This is going to be replaced by asking ordinary
NHS laboratories to take this work on board. That may or may not
turn out eventually to work well, but it will initially be quite
difficult. These laboratories are very heavily stretched. Their
prime function is to provide bacteriology services to their own
Trust not to do infectious disease surveillance. It is not at
all clear that the directorate of R&D and the NHS has the
mechanisms or the authority to make sure that this public health
laboratory work really gets done. This problem extends to other
areas as well. It maybe quite difficult to force Trusts—who
are under pressure from other parts of the Department of Health
to concentrate on service delivery—to engage in R&D
activity. It is not immediately clear to the Academy—as
it says in our report—where is the benefit of destroying
the peripheral PHLS laboratory system in favour of a system which
is untried and which seems to us to pose considerable difficulties
with conflict of duty, loyalty and work.
Lord Oxburgh
77. In a way what you are saying is that what
is a de facto national strategy at the moment would disappear.
(Professor Sir Peter Lachmann) I think that is a fair
way of putting it, yes.
Baroness Walmsley
78. Can I just go back to what Professor Pennington
was saying just now about the sort of development work you were
describing. What is the potential for that sort of work being
done in the private factor and what are the pros and cons of that?
(Professor Pennington) I think there is an opportunity
for the private sector to take part in that kind of work, but
it is really very limited. And, of course, at the end of the day,
the private sector involvement will require it to make a profit.
That restricts its input. I think the private sector comes in,
in the examples I was quoting about development of media. They
then exploit the work that has been done in the NHS laboratories
(under whatever rubric those laboratories exist) or academic laboratories
and then develop the media further in terms of commercial products.
That is the way it has always happened. That is what actually
has happened with the examples I quoted, up to a point. It may
be cheaper to make them yourself or it may be cheaper to buy them
from the commercial sector; it depends on local circumstances
and so on. They do have a role, but they do not have the access
to the clinical material, for example. Generally speaking, the
laboratories that are in that kind of line of business will find
it difficult to get the scientific input to be done in real time.
I think one of the problems is that this does need to be done
in real time. This is not something one should develop over a
period of years. In respect of the examples I was talking about
(which are rapidly evolving organisms or organisms that come to
light because we made some small technical discovery and we find
we have a pathogen which has been all the time but we did not
know about, as in the case of Campylobacter, we were incubating
at the wrong temperature in the laboratory) then yes, the commercial
sector has a role, but not in the initial stage; downstream from
there.
Lord Turnberg
79. Can I return to the R&D business. It
is true, is it not, that the amount of money that the PHLS put
into its own R&D program is relatively small—a couple
of million pounds a year out of its budget of about a hundred
million—and it relied heavily on that bit in order to formulate
bids for more research money. It gained research grants from the
MRC and from WHO and elsewhere in the European community many
times for definitive research, basic research including new molecular
techniques (which was a big program). It did rely very heavily
on that seed corn not simply to do the sort of work you have described,
but also to build up projects, to put forward bids and in order
to provide the sort of philosophical background that R&D was
an important function for the PHLS. It is that which will be lost,
is it not?
(Professor Pennington) Can I just say from a personal
point of view that one always saw the PHLS as a formidable adversary
in terms of bidding for funding in a particular area because it
always started off from a very good position because—as
you have been describing—it had this seed corn, it had been
able to do the preliminary work essential to build up a good proposal
and its proposals were often successful because it had done that
work and then the outcomes were also very successful because of
the fortunate position it occupied in having the clinical material
coming in and the other expertise in other areas of the PHLS.
I am just expressing that from a personal point of view. We always
regretted when the PHLS put in a bid in my area because they usually
won. They had this structure which helped them to structure a
bid for research so that it was successful.
(Professor Cohen) I was going to agree with Lord Turnberg
and say that my personal view would be that the amount of money
the PHLS was able to allocate to R&D was lamentably small
given the importance of the kind of work they were doing. I would
agree with him that without some identified resource to carry
out this kind of work, it would, as we wrote, have a risk of undermining
the public health function quite substantially.
Chairman: Any further points? If not, can we move
on to question seven, Lord Haskel?
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