Select Committee on Science and Technology Minutes of Evidence

Examination of Witnesses (127-139)




  127. Thank you very much for coming along. Would you like to introduce yourselves, and if you would like to make any opening statement, either collectively or individually, now is the time to make it.

  (Dr Crook) I am the Clinical Director of Clinical Microbiology at the John Radcliffe Hospital, which is one of the hospitals of the Oxford Radcliffe NHS Trust. I was appointed to do this to oversee the withdrawal of PHL from Oxford some three years ago. Presently, I am in the United States as part of a leave fellowship from the Wellcome Trust doing research into the evolution and transmission of antibiotic resistance. I have as other responsibilities membership of the Hospital Vaccine Group, where I am very active with a number of other people from Oxford. I am a member of the Tropical Medicine Steering Committee, which oversees the multiple overseas Wellcome Trust units for Oxford University. I am Programme Director of the Joint Training Scheme for Microbiology and Infectious Disease, and I participate on a number of college committees contributing to the development of a curriculum and college exams.
  (Dr Kelsey) I am Mike Kelsey. I am a Consultant Medical Microbiologist at the Whittington Hospital, and have been for in excess of 20 years. I am President of the Association of Medical Microbiologists, which is a broad organisation representing more than 400 medical microbiologists in the United Kingdom and Ireland.
  (Dr Spencer) I am Bob Spencer, Consultant Medical Microbiologist at Bristol Public Health Laboratory and also a member of the Medical Advisory Group for CAMR at Porton Down. I am Chairman of the Hospital Infection Society and a member of Council for the Royal College of Pathologists and I also act as an advisor on various microbiological subjects to various government departments and agencies.

  128. Thank you very much, gentlemen. I will ask the first question as usual. We have had evidence that there are relatively few infectious disease physicians in the United Kingdom compared to the US. I wonder if you can say a little about the role of microbiologists, what the role of microbiologists is, and how microbiologists interact with the infectious disease physicians and other clinicians in the United Kingdom.
  (Dr Crook) I am in an unusual position because, as you said, I did my specialist training both in general medicine and in infectious disease in the United States, and came to the United Kingdom following that to follow a career in microbiology. In a sense, I am fully trained in both, and am registered with the General Medical Council as a practitioner both in infectious diseases and microbiology. I think around the country there is a variation in the extent to which microbiologists and infectious disease groups work together. In Oxford we have a coalescence of those practitioners into a single working group, and my colleague is here today, Professor Peto, who is the lead person in infectious disease, and we work as one. But that contrasts with other parts of the country. In fact, at St George's it is a bit further away than ourselves, and the Hammersmith in a sense is closer than ourselves. So there is a great deal of variation. ID as such is a small sub-specialty, and its great strength has been its academic development and prowess, and really they have carried the banner for research and the academic development of the subject, whereas I think the Academy of Medical Sciences recently held an investigation into the role of academic bacteriology, and it was clearly recognised that there had been a substantial decline in academic bacteriology, but that has been balanced by infectious disease. In a sense, in Oxford, the Royal Colleges, and I think Lord Patel is part of that at STA, we are seeing through a joint training scheme, which is an effort to redress the degree of imbalance around a lot of the country and bring into clinical microbiology through joint training a good deal more clinical appreciation for practice, yet not losing competence and expertise in laboratory medicine.
  (Dr Kelsey) I would just add a little to that, whilst being in major agreement, that, of course, the function of the medical microbiologist differs slightly from that of the ID position, in that we are responsible for the management of the medical microbiology labs. The laboratories in the NHS are on the whole medically managed. We also take on the function of the control of infection, which is a difficult function at the moment; it is fraught with problems. So we tend to manage groups and departments. We have biomedical scientists, scientists, nurses all working for us, and it gives us a broader role. To some extent, we tend to confine our activities more to the hospital, and where we consult outside the hospital it is mostly with general practitioners. It is often telephone consultations. We occasionally see patients, but the role of the microbiologist I think is more confined to in-patient work and infection control. As well as doing clinical consultation, most microbiologists do ward rounds. I probably do more ward rounds than most consultant physicians. I do one every day. I see 10, 15 patients a day. So we combine everything. Although there is a move, as Dr Crook said, towards combining training for ID and microbiology, I think there is some distinction still to be made in the line of activity. Of course, microbiology is nationwide; we are represented in every reasonable-sized hospital in the country, where we provide the bulk of the infection services. It does not mean to say we do not welcome working with ID physicians, of course.
  (Dr Spencer) There is very little for me to add. My two colleagues have summed up the situation. I think it is worth remembering that in the 1970s the United States Surgeon-General said infection is dead, we do not need to do any more research, we have got antibiotics and we have got vaccines. Of course, this has been shown to be total nonsense, with the resurgence of antibiotic-resistant organisms and, of course, the threat of infectious diseases in the shape of tuberculosis, and West Nile fever, which is sweeping the United States and also sweeping up through France, and it is only a question of time before it lands on our doorstep. There was a decline in infectious disease physicians following the closure of the large fever hospitals in the 1940s-1950s. How we interact is an interesting concept, because there are relatively few centres in the United Kingdom that have both ID physicians and clinical microbiologists. On the whole, I would say that they get on quite well. Their role is somewhat different, in that ID physicians may have beds, they have may units, they have out-patient clinics, whereas, as Dr Kelsey said, the role of the clinical microbiologist is that he has to run a laboratory, to make sure that results are accurate and produced in a timely manner. They undertake surveillance—I expect we will get on to that later. They also do rounds on in-patients, mainly on intensive care units, and also they are the connection between the hospital engineers with regard to decontamination of re-usable surgical instruments, which of course has hit prominence in England with the advent of variant CJD.

  129. You mentioned West Nile virus infection, and in the recent outbreaks of both West Nile in the USA and anthrax, they were recognised early because of the unusual clinical syndromes that they presented. These were identified by clinicians with training in infectious diseases. Could we have controlled it as rapidly as they did in the USA?
  (Dr Spencer) In actual fact, if you look at the history of the West Nile fever, it was the vets that actually found the cause. People had already died from some bizarre neurological disorders in New York state, and at the same time the vets found there were these crows falling dead, and it was they who made the connection. As regards anthrax, following 9-11 CDC increased central observations at various A&E departments throughout the United States, and it was really that that triggered the diagnosis of meningitis in Mr Robert Stevens, who was the photographer down in Florida, and when they saw the anthrax bacilli in the CSF. Following that there was more intensive surveillance, because if you look back, by the time Stevens had been diagnosed with pulmonary and anthrax meningitis, there had already been at least half a dozen cases of cutaneous anthrax seen in New York which were unrecognised, undiagnosed. They were treated with antibiotics that perchance happened to have activity against Bacillus anthracis. Would we recognise it today? I have talked to A&E consultants, and I have said, "How many cases of unusual illness would you need to see before the penny dropped?" and it was quite a large number, and of course, if, for instance, you carry on with the deliberate release scenario, say, at Waterloo station with everybody disappearing to their home in the south-east and also in the north, and one or two cases here and there, it would be quite difficult, but that is when, of course, surveillance would hopefully kick in.

Lord Patel

  130. Coming from a hospital which has recently had a rabies death, would the public be better served if all infectious disease specialists also trained in microbiology, recognising that some of them would then end up running microbiology labs and doing infection surveillance?
  (Dr Spencer) I think that is probably what will happen eventually.

  131. Why eventually?
  (Dr Spencer) It will take time because the examination for the Royal College of Pathologists has somewhat changed. There has been change, for instance, in the Senior House Officer grade in pathology. When Dr Kelsey and I am sure Dr Crook came into microbiology, we would serve a year as a resident clinical pathologist or SHO, and go through four different departments of pathology before you decided "I like that" or "I don't like that." So you would be trained in that. Those have disappeared to a large extent, so what we are getting is people that have done a general medical training, and one of the criteria for coming in to be an SPR in medical microbiology is possession of the MRCP. Most of the good postgraduates who are coming into the discipline already have MRCP. The reason they want to come into clinical microbiology is to treat infection but they also like interacting with patients. So I think it will probably go that way eventually, but of course, it takes time for people to come through the system, to be trained in both, and to become consultants, because there is quite a few of us who were still trained in the old way.

  132. So if the Royal College of Pathologists and the Royal College of Physicians were to take the initiative and talk together now, it might come sooner?
  (Dr Spencer) They are already doing that anyway. We have two joint training scheme placements in Bristol, and I think there are some in Cardiff, and I know there are in Oxford. I am sure Dr Crook can address that.
  (Dr Kelsey) I was just going to make the point that there are joint training schemes in London as well now.
  (Dr Crook) If I could briefly add to that, I agree very strongly with what Lord Patel is saying, which is that there is great virtue in bringing a coalescence in the training between what is essentially a physician in clinical practice, seeing and ministering to patients, and a pathology, laboratory-based practice, which historically has been very strong in the UK, while infectious disease has been stronger in the United States, as was implied earlier, and bringing in a hybridisation of those two. As you imply, I think that would be a particular strength for the specialty of infection in the future. How one accelerates that, which would be very desirable, is quite difficult, in that the number of competent individuals to train is in the order of 44-50 infectious disease clinicians in the country. It might be as many as 70. That is quite restricting in the extent to which one can promote joint training. Whether there is some way through the Royal College of Physicians to expedite that and give further support and give greater emphasis to that scheme I do not know, but it would be very welcome.

Lord McColl of Dulwich

  133. Have you thought of putting the clock back and having house jobs which are partly house physician and partly bacteriologist, infectious disease? We used to have that, and they worked very well.
  (Dr Crook) From my perspective, I am not familiar with that particular scheme. My route of training was essentially coming out of a house job in South Africa, going through the London School of Tropical Medicine in the UK, to the United States, where I trained in general medicine, the usual route in the United States. I think that this applies here these days, as has been touched on earlier. It is at the SHO level, where many of the people going on to do infection are doing SHO jobs in general medicine, and then progress to infection. Our aim should be to catch many of the brightest and most able of those trainees at that level. I think that was quite thoroughly addressed by the Academy of Medical Sciences and they have reported on that. One of the points that they raised was at an earlier stage, SHO kind of level, yet I think there are changes in training at the moment to reorganise medical training which would abbreviate it, and that might be one of the changes that would be particularly attractive in invigorating people in a career following infectious disease earlier.
  (Dr Kelsey) I would just like to add something in answer to Lord McColl's question. In fact, there are a number of SHO training schemes that include microbiology now. There is one at St Thomas's which is an intensive care microbiology and other medical specialty training scheme, as well as some which I think go through paediatrics as well. An awful lot of paediatrics is considered to be infection-related. Can I go back and say something about the relationship between clinical infectious disease and microbiology and the breadth of medical microbiology? We must, I think, be quite careful that not all jobs are the same, and I think it is important that we allow some doctors who may be very bright, but may not wish necessarily to take that particular lead in clinical medicine, to go to a more laboratory-based, more research-based career. I do not think we should exclude them by saying every job has to be the same, every job has to be clinical microbiology with an infectious disease element. We must not restrict good graduates who wish to take a slightly less centre path.
  (Dr Spencer) We must not lose, of course, the vision that we need people to lead on infection control, and of course, we need people to lead on the decontamination of surgical instruments. If we go down the way of being very ID-focussed, we may risk losing that expertise.

Lord Turnberg

  134. Given that we have heard quite a lot of evidence from others, and to some extent from you, that this is the way to go, bringing infectious disease training and microbiology training closer together—no-one is suggesting that there should not be within that proposal, people who specialise one way or the other, but that training should come closer together—is there resistance in the microbiology community to this?
  (Dr Spencer) I have to say yes, there is, with some of the older members.

  135. Older than yourselves, presumably?
  (Dr Spencer) I am quite old actually. My first technician was a technician who worked with Alexander Fleming, so we go back a long way. There is some resistance among the older school, but nature being what it is, they will all drop off their perches and be replaced by a younger generation without fixed ideas. So I think the mood is changing somewhat.
  (Dr Kelsey) May I add a little to that? I am a trainer, as I am sure my colleagues are, and we train the future generation, and I ask them, because ours is a microbiology-only rotation, whether they would not have rather applied for one of the joint training schemes, and although some say yes, an awful lot of them still say, "I can get out of my career what I want from microbiology, because I am not divorced from the clinical side of medicine." I am sure it is true we will gradually move towards a joint training, but not everyone feels that is exactly what they want.

  136. I wondered if one can start, instead of from the point of view of the individuals providing the services, but from what the community would best be served by, then one perhaps might come to a different conclusion.
  (Dr Kelsey) Yes.

Baroness Emerton

  137. There has been concern expressed about the commitment to surveillance which may be lost due to the introduction of the Health Protection Agency and the transfer of laboratories from the Public Health Laboratory Service to the NHS. Do you think that this is a risk, and if it is, how can it be minimised? How can we ensure that the NHS microbiology laboratories will fulfil the public health duties carried out by the PHLS, as some evidence has been given that transferring labs to the NHS will mean that there is more focus on diagnosis than on general public health. Do you have any comments?
  (Dr Kelsey) I would say that actually, once you diagnose the patients, your information on surveillance, of course, is far greater. The problem arises in transferring the information that you have gathered from your material into a surveillance system. I am sure there are some concerns, and a lot of the concerns of my colleagues are about the transfer of funding from the existing PHLS regional network to the NHS laboratories, and there is some fear that there will be retention by the Health Protection Agency of more than is perhaps justified, and that this will leave the NHS labs somewhat short of funds.

  138. Is that an emulation of funding in relation more to manpower availability or to the equipment and the information technology?
  (Dr Kelsey) I am sure it relates more to manpower because you cannot function without people to do the work.

  139. And there is already a shortage.
  (Dr Kelsey) There is a shortage.

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