Select Committee on Science and Technology Minutes of Evidence

Examination of Witnesses (Questions 380-399)




  380. You were saying you were disappointed there was no feedback of the information. At the very local level to whom do the practices report and what happens to that information at the beginning of the reporting situation?
  (Mrs Howard) The practices would phone into us and tell us they were seeing a lot of patients with whatever. Or we have an informal reporting system via the local education department and they send in a form which tells us they have so many children off with chicken pox or flu like symptoms. We also have other information that is coming across directly from the microbiology laboratory. It is possible, on occasions, to marry that information and to have a very good idea of what is happening in a particular part of the county (I work in a very widespread geographical area in a particular part of the county) and then to see if there needs to be some sort of intervention such as information sent out on particular issues. That is how we work.

  381. You mentioned the lack of feedback. Is that a detraction for making this system as effective as it should be?
  (Mrs Howard) I think the lack of feedback tends to be from the surveillance perspective when specimens are sent. Obviously there is feedback directly to the GP who is caring for the patient to guide the management of the case, but there sometimes tends to be a lack of feedback from the overall picture back out to primary care. I think that probably is one of the big problems. There is no incentive to report. The relationship with the general practices and the CCDC team is built up by networking in a particular area.

Lord Oxburgh

  382. Can I ask whether there are any privacy issues that arise in pursuing this perfectly sensible course, namely the information that comes back on patient samples being distributed more widely?
  (Mrs Howard) It is distributed it an anonymous way in terms of: "We are aware of x infection and you may possibly see cases". That is how it is distributed.

Lord Turnberg

  383. Continuing the surveillance theme, we have had evidence suggesting that surveillance should be thought of in general terms as providing information for action. But should it better be used to identify clear objectives and targets for disease reduction and collect information to be used for those specific ends? I am thinking particularly of things like sexually transmitted diseases, chlamydia, TB, food poisoning.
  (Mrs Williams) I would like to say that my area of expertise is TB. In terms of TB surveillance we have a very good surveillance system. We have had enhanced surveillance annually for the last 10 years now which collects information about ethnic breakdown, travel and different aspects according to each case in a very clinical sense which has been very helpful to show which groups are most affected. We have also now started to collect information about treatment outcome which is obviously very important for measuring the quality of the service that you are giving and making sure that people are completing treatment. We have, however, tended to focus very much on clinical surveillance and have not been so good at collecting data on social aspects which are obviously very key to the group of patients that often suffer from tuberculosis. The London TB Nurses Steering Group has already piloted one case load profile aimed at producing a snapshot of social information about the patients on the case load. Although the data in the first round was not particularly rigorous, it did give us much more information about homelessness, incomes, statistics, immigrant status of people on the case load, which would be very useful information in terms of planning services according to the patients' needs in any particular area. There are issues about increasing the levels of surveillance and changing the type of surveillance. Feedback is a very important aspect as has already been mentioned. If people are asked to fill in more forms and take time to provide information it is very important that they get feedback on their local statistics in relation to the overall pattern both in their region and probably nationwide. What we want to do this year—if we get the resources to do this in London at least—is to repeat the profiling exercise with an improved pro forma so that we can collect the social data again on a broader range of aspects. If we then keep that cohort of patients, we can review the treatment outcomes on those patients in the following year. We will get an idea of what aspects are related to problems with compliance. All of this together will give us some very useful information in looking at the make up of services that we provide for helping patients with TB, both to come into the services and also to remain within the services and complete their treatment.

  384. From what you say, so far as TB is concerned, you are sold on the idea that surveillance is specifically targeted at disease reduction in TB.
  (Mrs Williams) Yes. In terms of microbiological surveillance we do have mycobnet so that every positive culture we have is tested for antibiotic resistance which is, in fact, the way we found the outbreak in north London.

  385. Do you have targets? Disease reduction?
  (Mrs Williams) In the action plan it has been suggested that there should be some disease reduction targets. The problem is, if we put more resources into something like TB you are bound to have more cases initially but they would eventually go down. If we are looking long term it is perfectly realistic to have these disease reduction targets. In terms of using more social profiling, it is very important so that we can target screening effectively in order to find our cases much sooner to prevent delays in diagnosis and prevent infection in the community.

Baroness Walmsley

  386. Are the health care professionals on the ground involved in the setting of the targets with an understanding of the resources that are going to be provided and able to pass an opinion on whether these targets are appropriate and achievable.
  (Mrs Williams) There have been a number of targets which have been set for London over the last few years because there has been an acknowledgment of the serious problem of TB in London. The increase in London accounts for the increase in the UK as a whole. We have been doing some work on London and a lot of the concerns that have been raised by people in London have led to certain targets being set such as the nurse ratio should be one to forty notifications of TB. That has helped to put quite a lot of pressure on PCT's in order to commission additional staff. Not everybody agrees with me, but I find targets very welcome; you can use them as levers for local commissioning. Essentially there has been very little additional resource linked to these targets. There seems to be some additional resource attached to the action plan although it is very unclear. The resource that has been made available most recently at very short notice is not TB allocated money, which is one of the big issues. There is no specific money allocated to TB. We have to scratch around to try to get it very locally. It is very intensive work to try to get local commissioners to put the right things in place to meet the targets.

Lord Oxburgh

  387. When statistics are collected do you distinguish new arrivals in this country—who presumably arrived in this country with TB—from indigenous occurrences? My second question is, roughly what sort of percentage do you have of full completion of courses of treatment?
  (Mrs Williams) The answer to your first question is yes, on the new enhanced surveillance form there is a section which asks how long somebody has been in the country. It is fairly clear that a large percentage of people will develop the disease in the first five years of being in the country which usually suggests that they have been infected in their country of origin but only developed the disease after being in this country for a few years. We have only just started measuring treatment outcome and I think the last figures are all between eighty and ninety per cent, which is reasonable but not good enough.


  388. Is this with directly observed therapy?
  (Mrs Williams) Directly observed therapy is very intensive treatment because it needs somebody to be observing treatment either daily or three times a week. Probably about ten per cent of our patients are on directly observed therapy and they are usually assessed for risk. One of the pieces of information we want to collect in our case load profile is how many people should be recommended to have direct observed therapy and how many are actually offered directly observed therapy according to the resources available.

Lord Turnberg

  389. Can we move on to other infections. Chlamydia is of particular interest. Is there a target we should be setting and is there a way of getting there? Can we use surveillance better in this area?
  (Mrs Howard) I have very little expertise but I am aware of the work that is happening within the Public Health Laboratory in the area where I work. We do not have targets at the moment for reduction in the area. The problem is that to meet many of these targets it requires a huge input of funding which is not available at the moment. It is not just a question of meeting the target, but also the funding of the other health promotion services around overall reduction in sexually transmitted diseases et cetera, and the funding of the action plan that came out of the sexual health strategy. I am not an expert and I do not know a great deal about it, but there are these big funding issues. It is not only a question of the surveillance. It is how we target the risk groups, where the funding comes from for the public health promotion needs assessment type work. All these things interplay.

  390. It is a neglected area at the moment.
  (Mrs Howard) Very much so.
  (Mrs Perry) I would like to echo Janet Howard's comments about setting targets without the resourcing that goes with it and also awareness of how setting one target impacts on other targets that are set as well. The difficulty between balancing the many targets that we are set and making those a priority for funding with the very limited resources that are available, very often it comes down to who is the champion of a specific target that has been set as to where the finances are led towards.

Lord Patel

  391. Do we know how common asymptomatic chlamydia infection is? Before you set the target you have to know what the incidence of the disease is and chlamydia is one of these infections that is quite asymptomatic.
  (Mrs Howard) I cannot answer the question directly. The question asks about whether we would provide information for action or whether we have clear objectives and targets. There are issues around looking very objectively at what is the public health gain if we set an objective and a target. That is not an answer essentially to the question, but it is on the periphery of the answer. Certainly there are issues around setting clear objectives for targets and about promotion of safe practices in terms of preventing chlamydia infection or preventing food borne disease or what have you. They place an enormous burden on the public health and on the economy.
  (Professor Little) I cannot claim to be a sexually transmitted disease expert, but chlamydia does strike me as a case where you could target providing you had the resources for the implementation. As you are no doubt aware, GP's are a fairly over-stretched demoralised bunch at the moment so telling them to do yet more things will not go down well and they will not do it properly. It does strike me that there is a potential. Smears are an obvious time in which to take a chlamydia sample. I know our practice does that routinely but I do not know how many other practices do. There is an opportunity; it is happening anyway; piggyback it on to what is happening anyway. The other thing—and this would be an example of targeted surveillance—is that you can do chlamydia tests on urine. There is an argument for anonymised testing so that there is the information in the public domain about how common it is in particular areas. I think the business of actually counselling somebody about the fact that they might have a chlamydia test brings in a whole set of thorny issues. People do need counselling. Just like counselling for an HIV test you need counselling for a chlamydia test too. If you are going to do it on a patient identified basis then patients need counselling prior to doing the test. It is an extremely thorny issue and brings in the issue of resources. I think if it could be piggybacked on what is going on already, plus or minus using some anonymised testing on the urine samples which are being collected anyway, you will get useful and efficient information. You may then want to do some particularly targeted patient identified sampling.

Baroness Walmsley

  392. There is one other thing I would like to ask. From some of your answers it makes me think that perhaps you do think this but perhaps you could confirm or deny it. When we were in New York we talked to the health commissioner and he was very, very keen on programmatic work on specific infections. TB in particular is what we were talking about. This had specific objectives and ring-fenced money and particular resources, professionals, training, public information and the whole thing. What potential do you think there is to that kind of approach? Probably to TB your answer will be yes, but are there any other diseases such as chlamydia and other things which you think are not addressed in that way in this country currently, but do you think there is potential for it and are there advantages?
  (Mrs Howard) I think there is the potential there but there is also the danger in that if you ring-fence money for a particular programme it does not give the flexibility that you need in a low incidence area. I think a better way forward would be to be encouraging the primary care trusts when they are developing the local development plans to have a place for health protection within that—alongside their cancer care and all the other issues they have to address—and to have a system whereby we are able to bid on an equal footing for development monies. At the moment we have to weave our arguments into other issues because there is not a specific line that you can bid for within health protection, if you see what I mean. I can see a case for tuberculosis in London, for example, but it is a very different thing when you have low incidence in particular areas.
  (Mrs Williams) I would share some of Janet's concerns because in TB as well, if you did ring-fence money and give it a programmatic approach, the danger is that you take it out of mainstream services and other people would disengage from it. Having PCTs with particular priorities for health protection and tasking them with coming up with action plans which they are then able to resource for different types of infectious diseases would be helpful. In areas of high incidence obviously you need expert teams and there need to be specialist units. There also needs to be flexibility across organisations and geographical boundaries which I would hope we would be able to achieve without having to do down the programmatic approach entirely. I think it is a kind of hybrid in a way because we still need people in primary care to be very aware of the disease. Patients do not just turn up on the specialist unit doorstep; they have to be identified. I think there have to be specialist units with expertise who can support the general health services and make sure they are kept updated. Specialist units should be ultimately responsible and accountable for managing and finding TB in the community. But it is a kind of balance.
  (Professor Little) I basically support the principle of a targeted approach and I think that if you are targeting something for action you need to identify the resources to go with it. That is the bottom line for me. If you are asking people in general practice to do something that they would not normally do for particular targeting then it would definitely be helpful to provide the resources. How you would specifically target chlamydia, for example, other than in the sort of approaches I have identified, I do not know. How you then provide the resources to general practice needs some working through. But I would agree with the principle.

Lord Patel

  393. I think much of the question I was going to ask has been answered, so you might just address the specifics if you wish to. The question relates to two issues, surveillance systems as they are and the need for the professionals to have information to do their job properly. Do they need information and how does that information get to them? Are they able to influence the surveillance system to make the information they get better?
  (Mrs Perry) Can I give you an example of how surveillance is performed both between primary and secondary care? In the Old Avon area we are currently participating in a research project led by the Central Public Health Laboratory on enhanced surveillance of viral gastro-enteritis. That is based on both syndromic reporting as well as virological data. The value of that has been in preventing the risk of spread to other patients. We now have a link up between what is happening in the community, particularly in residential and nursing homes in an early warning system for patients who have been admitted to hospital with these conditions and hopefully preventing widespread outbreaks which can occur in hospitals at this time of year. It has also been very useful in informing us in making risk management decisions. As many other trusts, we are under considerable pressure to continue admitting patients and maintaining a normal service. Whereas normally we would comply with management guidelines that we have not admitting patients into wards or not—if you have two wards closed you would normally keep those two wards closed and not mix patients—but with the additional surveillance information that we had we knew we had one predominant strain circulating so we were able to adapt our management strategies based on that kind of data. That is a kind of practical approach as to how we use surveillance data to inform our management across both primary and acute care.

  394. How do the GPs get that information?
  (Mrs Perry) The GPs' information did go out via the CCDC office. It was a completely joined up working process. When we realised that we were having considerable admissions with viral gastro-enteritis into our trusts we had the normal outbreak meeting and the information went out to the GPs to make them aware of the situation.

  395. Is there feedback as to whether this is an effective surveillance system or not?
  (Mrs Perry) There will be. The surveillance is continuing until April and then there will be a review of whether we do another year.
  (Mrs Howard) I just want to give another practical example that I have recently read about where they have used surveillance within an acute hospital. They have actually looked at the surveillance in conjunction with the admission rates and turnover of patients and patient days, et cetera. They have collated all that data and interrogated it and used it to put a business case forward for a 24-hour domestic service in terms of cleaning on the wards and cleaning the isolation rooms because they found that what was happening was that the majority of patients were actually being moved after eight o'clock at night when, in fact, the cleaning service ended. I read that just recently in a professional journal. That was a very practical way of using it.
  (Professor Little) I think I have outlined how I think surveillance could work with the available information from NHS Direct. It is not beyond the wit of man either to download data from computerised practices for surveillance. Not all practices are computerised and there is the issue of the different systems, but in principle I do not see why some of that data should not be downloaded, anonymised and fed into the system. You might not need it because you have NHS Direct and you could argue that whatever is happening after six o'clock is probably representative of what is happening during the day. I know there is some surveillance of that information at the moment. How that is fed back I honestly do not know, but I think that information could be quite useful. If it could be fed back rapidly with some advice about what to do I think that could be potentially very useful. At the moment we get intermittent communication from our local CCDC which is a two-sided piece of A4 about the samples that are being sent and whether they are resistant samples, unusual organisms which I personally find very helpful. The question is, how should you be acting on that? Some of the information is quite difficult to act on, so the fact that the lab says that twenty per cent of the samples are resistant to trimethoprim does that mean you should not prescribe trimethoprim? Or are they an unusual group of patients who are being sampled. Or are they the difficult and recurrent cases with higher rates than the rates for most people presenting. So twenty per cent to the lab is probably ten per cent in reality. Then there is the issue of whether the fact that the lab says it is resistant will that translate to clinical resistance in practice. You are concentrating an antibiotic in the urine and the lab reporting a resistance is quite sensitive, so do the two match up? The answer is we do not know. I think it is quite useful information for the public domain and it tells you there might be something funny going on, but whether GPs can or should use that information clinically is another matter.
  (Mrs Williams) In terms of influencing surveillance systems what has been quite frustrating over the last couple of years - particularly in the London scene—is that most of the money that was coming into TB has gone on surveillance when we have known that there have been very serious operational issues that need to be addressed. In terms of having control over which part is given to surveillance or operational issues can be a conflict.

Lord Oxburgh

  396. Professor Little, could you just imagine an ideal world. You are a pressed GP. You go into your office in the morning. What sort of information would you like to come up automatically on your screen about surveillance or incidence in your broad area? What would you like?
  (Professor Little) What sort of ideal world are we talking about? Where there are no resource implications?

  397. Let us not talk about resources, but what would you like? I do not think this question has been asked.
  (Professor Little) I would like to know whether there are any particular problems in the locality. I—as a GP managing patients with a sore throat or a chest infection or urinary infection—do not know whether there is a particular problem.

  398. Your locality is a radius of twenty miles, is it?
  (Professor Little) Yes, I suppose that would be nice. You would like to know if there is a particular problem in the Romsey area, for example, or is there an outbreak of something in Southampton. That would be useful. It would also be useful to have some advice on whether we should send samples of people presenting with acute urinary syndromes—even though you would not normally—for the next week. That sort of information and some advice about sampling strategy would be useful.

  399. You would like that to be there on your screen first thing in the morning.
  (Professor Little) It would not have to be there on my screen. NHS Direct would get the information, feed it back to the local CCDC the next day maybe. They would cascade that out by fax or e-mail. It could happen quite rapidly; it might not be the next day.

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