Select Committee on Science and Technology Minutes of Evidence

Examination of Witnesses (Questions 369-379)




  369. Good morning ladies and gentlemen. Thank you very much for coming along. Could you please introduce yourselves for the record and after that, if you have any opening comments to make either collectively or individually, now is the time to do that before we get onto the questions.

  (Mrs Howard) I am Janet Howard. I am a health protection nurse working in Shropshire. I am also the Co-ordinator of the Community Network of the Infection Control Nurses Association.
  (Mrs Perry) I am Christine Perry. I am Senior Infection Control Nurse at the United Bristol Health Care Trust. I am Chairperson of the Infection Control Nurses Association.
  (Professor Little) I am Paul Little. I am a GP and professor of primary care research at Southampton University. My area of interest is in the management of acute infections. I do not pretend to be an expert on surveillance.
  (Mrs Williams) I am Gini Williams. I am a lecturer in TB and Public Health at City University. I am a trustee for the charity TB Alert and I am nurse consultant to the International Union of TB and Lung Disease.

  370. As there are no opening comments to make I will take the first question. You are aware of the document Getting Ahead of the Curve which identifies under-reporting of infection as a barrier to effective surveillance. What, in your opinion, are the problems in the primary care setting that need to be overcome to ensure high quality, comprehensive reporting?
  (Mrs Williams) In terms of tuberculosis most of the reporting is done by specialist centres as TB is actually diagnosed most often in a chest clinic. It is not necessarily an issue for primary care; the issue is for primary care to recognise potential symptoms of TB and then refer them to the specialist services.
  (Professor Little) I suppose I want to go back a step. I personally found the arguments in Getting Ahead of the Curve not very convincing. One of the problems for me is the understanding of what we mean by surveillance. There are a whole range of potential ways that you can perform surveillance. There is passive surveillance which occurs at the moment when the GP or the nurse will send a sample of somebody they are particularly worried about, but generally things are managed syndromically. There is also passive surveillance in terms of syndromic surveillance. By that I mean the sort of information that we are getting from NHS Direct about the pattern of symptoms. That information has only just started to come on line but it is incredibly useful, in my opinion. Then there is the type of sentinel system that the Royal College has where specific spotter practices will perform syndromic surveillance but when there is a rise in influenza like illness there will be targeted sampling as well. Going further on there would be structured clinical and microbiological surveillance with GPs sending a lot of specimens routinely according to defined protocols. When the CMO advises us that we need an effective surveillance system I am not quite sure what he is talking about. I think there are advantages and disadvantages in all those systems, but in my view, using syndromic surveillance actually is extremely promising. For example, we can use the information from NHS Direct on a daily basis; we can target when there is a peak in influenza like illness in the south of England. That could then be fed into the local CCDC and there could be targeted microbiological surveillance if necessary. You have a trigger system. Is anything odd going on? If there is some odd can we target sampling there? That would seem to me a very efficient use of resources. Whether we should augment the other forms of surveillance I am not quite sure; it depends on what you want surveillance to do. I did not find the arguments for why we should augment surveillance—if that is what was intended by the CMO—very convincing. The arguments were about antibiotic resistance, spotting outbreaks and new infections. I could deal with each of those briefly if you would like me to.

Baroness Walmsley

  371. You mentioned NHS Direct and things like flu. We are all very used to flu. Do people actually ring NHS Direct about flu because people know what to do about it and I would have thought it might be rather under-reported to NHS Direct. Or is that not the case? I am genuinely curious.
  (Professor Little) You are right. And this is one of the things we have to bear in mind. The situation from a primary care perspective is that most people do not report the common infections because they self-manage perfectly happily. That will apply to flu, sore throats, tonsilitis, chest infections, urinary infection, you name it. We cannot actually afford for all those people to be reporting their acute infections. We see about one in nine; something like that, one in nine or one in ten. We cannot afford to do anything to the system that is going to bring all those people into medical care and medical advice. We would just be swamped.

  372. Has some research been done so that we know what the multiplier is? Do we know the level of under-reporting?
  (Professor Little) Not terribly recent. Most of that is old research. I do not think we know currently. It might be a matter of one in five rather than one in ten, but most people manage their own things themselves perfectly happily. We do see the things that are more severe. The chest infections we see will be more severe than most chest infections managed by people themselves, but there is huge overlap and we cannot afford to be seeing all the people who have flu and chest infections and sore throats.

Lord Patel

  373. Do we want to know that accurately?
  (Professor Little) I think that is a very good question. I am not sure we do need to know. I think the question is: what are the arguments for enhancing surveillance? We need to be very careful that we are not going to bring people who are happily self-caring into the system.

Lord Oxburgh

  374. It sounds that the combination of sentinel practice observations plus NHS Direct make a really rather powerful combination, useful for most purposes.
  (Professor Little) I personally believe that is true. You would probably spot an outbreak fairly quickly with that system. You will see rapidly whether there is an increase in gastro-enteritis in Truro, so let us ask the GPs for a week or so to send samples in from all the acute gastro-enteritis or food poisoning patients.

  375. The thing about NHS Direct is not actually whether you are seeing true levels but you are looking for perturbations of pattern.
  (Professor Little) That is right. You are looking for: "something funny is going on". It may not be very representative but actually there is something different going on now and does it need to be investigated.
  (Mrs Perry) I would agree that we need to separate out the differences between the different types of surveillance. Certainly we do need that on-going surveillance to look for the peaks and the trends, but there may be times that we do need that increased surveillance that picks up on the risk factors so that we are able to target our actions on those risk factors to be able to prevent infections. The on-going surveillance will not necessarily pick up those risk factors. That is where you would need the further information on where people have been exposed to infection and be able to target your action.
  (Mrs Howard) I would like to build on what my GP colleague is saying. Initially there will need to be a change in legislation to allow other professionals to actually notify and report. That is the first issue. I think there needs to be a big involvement with colleagues in primary care and other colleagues about how we plan the notification and surveillance systems. We need to be able to give clear evidence as to why we are particularly asking people to report. Do we really need to know some things? We need to understand that there is a trend happening. If we do not give clear evidence my feeling is that we will end up with reporting fatigue whereby the very important ones that we require enhanced surveillance for—such as TB, ecoli 0157we will not actually find out about. We want to get the information that will help us investigate them properly. The other issue for primary care is, I think, that there is no really prompt system for feedback. There is no encouragement to tell us about things. The other big issue for the future I think will be expert backup within the primary care trusts for the IT systems. When we have IT systems that will talk to one another we are going to need real expert prompt and on-going backup for the systems. I think those are the key issues if we are to make things work as they talk about in Getting Ahead of the Curve, certainly from my perspective.

Lord Turnberg

  376. Can I just come back a little on the surveillance business and what it means. It obviously means different things to different people. It would be a shame to throw out bacteriological or microbiological surveillance on the basis that we do not know what to do with it and there is too much of it. Those are obviously practical reasons, but it would be a shame if we did not pick up TB or ecoli 0157 simply because we were relying on syndromic surveillance. I just wondered where you see microbiological surveillance fitting in. I am aware that amongst the myriad of patients with diarrhoea and vomiting there will be a small proportion of ecoli 0157 and unless you do the test you will not know, and yet you may be spreading it around if you do not know. I just wonder where you feel that biological backup is needed in the surveillance system.
  (Professor Little) I think it is a very important question and there is no easy answer to that. Currently what happens is "passive surveillance": you have somebody you are particularly worried about. Nasty ecoli will give you a nasty disease and a clinically more severe disease and presumably a more prolonged disease. I think it would be helpful for GPs to have guidance about the circumstances in which something unusual and the situations in which it would be useful to send a sample. To do it routinely for all the normal gastro-enteritis and normal urinary or chest infections which can be managed syndromically would seem like a waste of resources. It is not just the fact that it is resources, the question is the opportunity cost and whether GPs would do it properly, but is also the issue that if you give patients the message that these samples are very important you are implying that they need to come to see the doctor to have samples when they have an infection, so you are potentially altering the threshold of attendance and re-attendance by getting the large iceberg that we do not see into the medical system. I think syndromic surveillance would pick up a lot of nasty outbreaks. The other situation—which happens at the moment but perhaps we could improve the guidance—is to improve guidance to GPs about what constitutes a severe clinical infection and then target the microbiological tests to those individuals.

  377. Not all instances of ecoli 0157 are severe; some are quite mild. It is just the odd one that may be severe. It may not be in your practice but in the practice next door. It is quite tricky.
  (Professor Little) I am sure it is. The question is what are the options, the costs and the disadvantages of all the options.

Lord Rea

  378. Could you just describe a little bit about what goes on in the sentinel practices with regard to sending in microbiological samples more routinely on typical infections, rather than only those which appear a little worse than usual?
  (Professor Little) I think you are going to be speaking to Douglas Fleming and he will be able to give you the precise details. My understanding is that by and large it is clinical surveillance. GPs fill out clinical pro formas and then they will only send microbiological investigations in certain situations for example when there is a trigger or Douglas tells them they need to. They do not routinely send samples. I suppose, again, it depends on what you want it for. If you want general information about what is happening nationally and whether we are getting more reports in routine samples of ecoli then that sort of system would give that information. It will not give you information about what is happening in a locality. It is not a wide enough system or a comprehensive enough system that you are going to find out the problem about the nasty ecolis.

  379. If the NHS Direct or other sources of information shows that there is an increase in symptoms which are unusual, will the sentinel practices then be asked to home in on this and do more testing than usual?
  (Professor Little) At the moment I do not think that information is being fed back. I suppose it is just collecting that information, although I think surveillance has started. The question is how you then act on that information. Whether it would be cascaded to the local CCDC who then contact the practice or whether there would be some other cascading system, you would need to feed it back and have to support the GPs and the practice nurses in the sending of samples. At the moment I do not know how that happens. In principle that information could be provided at a very local level.
  (Mrs Howard) As yet in practice within our unit we do not actually use a lot of the information from NHS Direct because it has not been captured as such. When that type of information comes in from other informal reporting systems that we have, what we then do is we look at it and if it was necessary we would be writing or faxing out to the GPs in the area and saying that we are aware that there are cases of whatever in your area. We would ask them to have a higher index of suspicion, et cetera. We would give them the information to help them when they see patients on a regular basis. At the moment that is how we manage it. That system is in place I would imagine within most CCDC units around England.

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