Select Committee on Science and Technology Minutes of Evidence

Examination of Witnesses(Questions 264-279)


Professor Brian Duerden and Professor Angus Nicoll


264. Gentlemen, thank you very much for coming along. I see you are not accompanied by any public, I am not sure why that is. Would you like, for the record, to introduce yourselves, please, and if you have any opening comments to make now is the time to make them, before we get on to the questions?

(Professor Duerden) Thank you. I am Professor Brian Duerden. I am the Director of the Public Health Laboratory Service.

(Professor Nicoll) I am Professor Angus Nicoll. I am Director of the Communicable Disease Surveillance Centre, at the PHLS.

265. Any opening comments?

(Professor Duerden) I think, two opening comments. We welcome the opportunity to meet with your Committee to discuss areas of infection, and we are pleased at the high priority that this gives to infection and communicable diseases. Obviously, one of the main areas that we are concerned with at the moment is the implementation of the Health Protection Agency, with the Department of Health, and that features obviously in your considerations and featured in our submission. We want to stress from the outset that the PHLS is committed to implementing the Health Protection Agency, and we are putting all our efforts into doing it and doing it properly. And any concerns we may have raised, and we did raise, in our submission to you is purely about getting it done properly and effectively, not in any way to be taken as being opposed to or trying to prevent any of this happening, quite the opposite.

(Professor Nicoll) I have nothing to add to that.

266. In a way, Professor Duerden, you have answered the first question, but if I could pursue it just a little. In written evidence you expressed concern about the pace of change, and is this a concern about (a) yourself and (b) the staff of the Public Health Laboratory Service, the apparent speed at which this is being done?

(Professor Duerden) The speed with which it is being done we are still concerned about, because from the publication of the strategy, in the middle of January last year, to implementation, on 31 March/1 April in 2003, it was a very short time to take the outline that was in the strategy into a proper plan and implement it, so that things have been going on in parallel with the implementation, even before some of the details of the strategy have really been worked out, and that has created some difficulties. In particular also, the fact that it is being linked with the transfer of the majority, 31, of the Public Health Laboratories in England into the NHS. This is quite a major exercise to do, and it was only last Friday that we had the definitive guidance document agreed with the Department of Health and published in order to guide that process. And although we had been able to start some things in advance, that leaves only three and a half months in which to implement that part of the activity. And that has meant that the staff have been concerned about where they are going to be, who their employer is going to be next year, and also then the negotiations with our partners in the NHS to make the transfers. So the whole of that has been a somewhat tight schedule. As far as the Health Protection Agency itself is concerned, again, the timing, we learned only at the end of November the decision that it would be a special health authority, in the first instance, and not an NDPB, and that it would be a two-stage process to move to an NDPB. This again has meant that appointments have been delayed into the new organisation; currently there is a shadow Chairman in place, Sir William Stewart, but he is the only person actually appointed to the Health Protection Agency yet. The appointment of the Chief Executive Officer is going on at the moment, and it is anticipated that they hope to make that appointment at the end of January. But it means that we have nobody to discuss and negotiate with on the organisational front, other than the implementation team at the Department of Health. So that is a short timescale. As far as that is concerned, we were very pleased, last week, that the Chief Medical Officer and the Deputy CMO did say to us that they would be making interim acting appointments into the Health Protection Agency, so that people would have the authority and the responsibility to carry forward from 1 April 2003 the activities, because it is quite clear that there will not be the executive officers in place, other than the Chief Executive, at that time. We do now have the reassurance that people will be appointed very shortly on this acting, temporary basis.

267. These interim acting appointments, is that another way of saying You are going to be in a position that you are interimly acting, appointed to," or could it be that different people will occupy that position?

(Professor Duerden) We understand that it will be generally people who are in post in the existing organisations that will go into the Health Protection Agency that will be given roles in the new organisation, without prejudice and without commitment as to what their future will be, to ensure continuity.

268. But the fear of redundancy does not arise, does it?

(Professor Duerden) The fear of redundancy does not arise, because all staff in the bodies going into the Health Protection Agency have been assured of employment through until 31 March 2004; the first year is guaranteed.

(Professor Nicoll) But there are some key posts, they are new posts, which have to be filled, where it is not simply a question of people continuing doing their jobs, and so it is going to be important to attract people in, which is quite difficult if you are saying to somebody, Well, you're acting and you're interim," and also you have got to persuade their employer that that is the case. But I would add, My Lord Chairman, I would not want you to get the idea that the PHLS is necessarily slow, we are used to moving very fast in things, but part of our worry is that it is not as though there is a static world outside, with all the change that is going on in the Health Service, and you have somehow to get the attention, let us say, of a Trust chief executive, to say to him, Look, this laboratory needs to transfer into you by April 1, everything's got to be sorted out; these are the things that we feel it is important to continue to do, and here's the money." Now that is not necessarily something that a chief executive is happy to sign off very quickly, especially at the moment. So there is a lot of detailed negotiation which people are working on very hard, but actually to get that done by March 31 is a tall order.

Lord Lewis of Newnham

269. Can I just ask you, Sir, I am sorry, I am slightly confused, you used the word `interim' post; it seems to me that the interim post carries with it, for me, the connotation that you may not continue with that person in that particular post. Is not this going to provide you with difficulties actually in getting people to accept these type of appointments?

(Professor Duerden) The proposal that there would be interim acting posts was made only last week, and I share the concern that in some areas people may not be happy to take these on, particularly if they have other options, in other areas, other jobs they could take on. It is vitally important that we have people in place to run the organisation from 1 April onwards and that they do need perhaps quite quickly some longer-term security.

Baroness Emerton

270. May I pursue that just a little bit further. Does that mean then that the interim post-holders are going to be the ones that are actually formulating policy and formulating a new structure?

(Professor Duerden) I cannot say that at the moment, because that will be for the Department of Health to determine, but the Chairman, Sir William Stewart, has created an interim Advisory Board that is helping him, and that is separate from this; these interim posts are operational posts.

271. I see. It is really to carry on the business?

(Professor Duerden) Yes. May I mention one thing I missed about the change. The fact that it becomes a special health authority means also that there is a residual PHLS proposed for the first year, which would retain the PHLS Board, but purely with the role of overseeing the production of bacteriological media for the laboratories, which is a function that the PHLS does currently for all its laboratories. This is fraught with complications and the PHLS Board is unhappy that this is something that is feasible, certainly as far as retaining any people employed by the PHLS. It may be that the remnant of the PHLS Board has to commission such activities, but it will be very difficult to retain any employees within the PHLS, because if it was for only one year that would be seen very much as an end stage with no future.

Lord Lewis of Newnham

272. We have had some concern given to us about the fact that some surveillance activities will be carried on on a regional basis and that this may affect the coherence and overall co-ordination on a national basis. Do you have any problems with this, and how should the organisational changes proposed in Getting Ahead of the Curve be implemented so as to avoid any form of fragmentation of these type of services?

(Professor Duerden) It is certainly essential to avoid that fragmentation, to ensure a coherent national picture. Professor Nicoll is Head of the Surveillance Centre.

(Professor Nicoll) I will try to deal with that, Lord Lewis, combining surveillance and response, because I think that it is best always to look at the two together. I am worried but I am not desperately worried. I am concerned, when you look at countries like Spain and Italy, which have moved towards regionalisation, and you get bizarre circumstances in Spain where Madrid is the last place that Barcelona will tell about the local problems and they would feel that they ought to be telling Brussels first, rather than Madrid. And, there, I think, you have an example, that we must not repeat, of a country that is less than the sum of its parts, in terms of its surveillance and response, because infections are not very forgiving of that kind of fragmentation. But to give you an example of why it would be crucial in this country, at the moment we are in the midst of the largest resurgence of egg-related infection that we have seen since the time of Edwina Currie, and part of the way that that has worked, to get the information, has been that they have been referring up specimens and information in real time to, the Central Public Health Laboratory, and to the Gastrointestinal Disease Division of CDSC. And I think as long as it is understood that there must be that transparency and the flow of information, and as long as there is somebody who is overseeing—and this is what CDSC does—the response mechanisms and the surveillance mechanisms, to make sure that they work together, then we will be okay. That is why I think we are having very frequent meetings informing the Agency, and it is why I am very keen to keep the excellent team of people that I have because I am lucky in that I have got both staff in Colindale but as many medical staff now out in the nine regions, and also in Wales and Northern Ireland, who work together. I think we need to be using some of the electronic mechanisms better, so that when there is a substantial incident in the North West or the North East I can get to know about it very quickly; equally that when there is something occurring nationally that I can communicate this to field staff. Now we have those mechanisms at the moment for some of the people who will be in the Agency but not necessarily all of the people. So I have got some concerns, and if we discovered that a particular region was doing something which was totally incompatible with national strategy or a national investigation I would have no hesitation in saying to Sir Liam Donaldson, Look, I think this is potentially dangerous, can we sort it out?" And he has been very supportive to us all the time in saying, Yes, we will sort it out." But I think you raise a bigger issue, which is how one keeps UK plc together, where there is more of an issue there, which is not something which the technical people, like myself or the Chief Medical Officers, want to see happen. There is pressure, I would say, from the politicians in the devolved administrations, saying, What is the added value in Wales, what should we be doing that is different in Wales?" Or Scotland, or Northern Ireland. And that is potentially dangerous. We had an interesting example of this two years ago when the Scottish politicians very nearly did something different on MMR and saying, We should make single vaccines available," and it took quite a lot of work by their officials to say, No, you must do the same and consult with England." But I think that is a tension. I am more concerned about that fragmentation than I am about fragmentation within England.

(Professor Duerden) And this is particularly the case with the fact that the PHLS has served both England and Wales as an integrated whole for the 50 years, and now there will be two distinct Services, in Wales and in England, and we have to ensure the proper links between them.

(Professor Nicoll) We have set up a structure to overcome that informally, which is called the Five Nations Group. In case you are wondering who the fifth one is.

(Professor Duerden) It is Ireland.

(Professor Nicoll) This is because our colleagues in Dublin felt that they had something to contribute, and Northern Ireland is now working so closely with the Republic. This is a meeting of the technical heads of the surveillance and response centres, like myself, and we meet on a four-monthly basis and have teleconferences when issues arise in-between that time. It is rather like the way, actually, the Chief Medical Officers meet on occasion. Indeed it is a technical version of that meeting.

Lord Turnberg

273. Can I just follow up on this fragmentation. You have talked predominantly about the epidemiological function, but the question refers also to the laboratory fragmentation. I wondered if you would like to comment on that?

(Professor Duerden) There are two aspects of the laboratory fragmentation. One is the split between England and Wales in relation to reference laboratories, in that there are three of the National Reference Laboratories and one of the regional Mycobacteriology Centres based in Wales, that will have to continue to provide services to England as well as Wales, and similarly Wales will need access to the reference services in England. So we need to have strong agreements there so that nothing gets held up, for example, with the question as to who pays for any particular aspect at the time, because these services need to be provided without question when they are needed. So the reference laboratories are one aspect. The other risk of fragmentation is the PHLS laboratory network around England and Wales. Currently, 47 laboratories cover England and Wales; in England, this will come down to one nominated Health Protection Agency regional laboratory in each region, with two in London, for north and south. In order to maintain the very necessary network of public health microbiology activities, the Health Protection Agency will continue to fund activities in the laboratories that have transferred from PHLS into the NHS, and will pay for consultant medical staff and scientific input and support. But what we have to ensure is that it works. At the moment, it is a direct line of accountability; the Director of the Service can instruct, if necessary, and certainly require, any of the laboratories to do what is necessary immediately, and we have to maintain that immediate response capability in a situation where it will not be a managerial accountability line.

Baroness Walmsley

274. I am rather concerned about your suggestion that there might be difficulties in getting paid because of the regionalisation. There are paper chases in other areas of the Health Service, like drugs rehabilitation, for example, people have to chase invoices all round the country. So is anything being put into place to avoid the concern that you expressed a few moments ago happening?

(Professor Duerden) I understand that there are discussions between the Welsh Assembly Government and the Department of Health to ensure that the cross-border flows between England and Wales for reference services are maintained and are not subject to individual pricing blocks or cost blocks. As far as the laboratories in England are concerned, the ones that are currently Public Health Laboratories and will become NHS laboratories, the funding stream that goes in from the Health Protection Agency will need to have with it a very carefully drafted service level agreement to show what the laboratories will provide in return for that funding. And I would be very keen to see that that was not prescribed in such tight detail, in terms of saying numbers of samples that had to be examined, and so on, that there could ever be a time when somebody turned round and said, Oh, sorry, we've used up all our allocation." When there are big outbreaks, we know that funds have to be provided for extra testing, and so on, but that should be done after the event and should not get in the way of the immediate response.

Lord Lewis of Newnham

275. I realise this may not be your area, but could I just ask, what about Scotland and Northern Ireland, are they stand-alone, or do they have any form of interaction with the system in England and Wales?

(Professor Duerden) At present, we have good relations with Scotland. They have their own system, they have the Scottish Centre for Infection and Environmental Health, SCIEH, which relates very closely and works closely with CDSC. They have some of their own reference laboratories, and again we work in co-operation with them, and we provide services to Scotland from the PHLS in areas where they do not have their own services. In Northern Ireland, we provide the communicable disease surveillance function under an agreement with them, so there is an outpost of CDSC in Northern Ireland, and they have their own Public Health Laboratory in Belfast.

(Professor Nicoll) And to cover those two, to give you tangible examples, because a month ago there was the rabid bat problem in Scotland, and, although that was rather sprung on both Scotland and England, in that nobody realised what was going on until four days after the initial diagnosis had been queried, we were then very rapidly able to give to our Scottish colleagues the experience we had gathered with two previous cases of rabid bats in Lancashire and in Sussex. And then I was visiting Northern Ireland, as I do regular visits to all of the CDSC regional offices, two weeks ago, and they are identifying one of the crucial things for them is that the laboratory in Liverpool still continues to deliver brucella serology testing, because they have a particular problem there of rising rates of brucellosis in people in contact with cattle, in Northern Ireland. So things have to hang together, and it is those details which I think are worrying me, that as labs move over into the NHS the things that we now take for granted, that individuals do, or that laboratories do, which do not seem to be that vital on an overall scheme, actually become very important suddenly. So what we are doing is getting all the bits of CDSC, national and regional, to list These are the things that individual laboratories do now and we would like to see preserved as they move over into the NHS." I would not want to give you the impression though that there are NHS labs who do nothing, we get a lot of work done by NHS laboratories as well, in terms of reporting and helping in some parts of the country where there are not a lot of Public Health Laboratories. The difference will be as Professor Duerden says, that when a laboratory finds something odd and they have to do something because of that odd finding, some further work, some tracing of notes, etc. there is not the managerial relationship. In the middle of the egg-related outbreak, we were getting the hints from one or two laboratories and hospitals that they were saying Why should we look out the notes, that's not our job?" While CDSC was saying, Well, the fact is that you're the only people who can do that." When we spoke to the local public health people and they spoke to the people in the hospital, it was not a problem. But we talked about fragmentation on a regional level, I am concerned also about fragmentation of different bits of the Health Service. And I was wondering what was the implication of foundation hospitals. I have nothing against foundation hospitals per se, but when somebody said they would be removed from some of the shackles of the NHS administration, I was wondering whether CDSC was one of those shackles. Because we do ask people to go the extra mile when they have got an outbreak that is related to them; equally, we provide a lot of support and expert advice when they have got an outbreak. And I would point out one of the reasons CDSC was set up was following two disastrous outbreaks that were poorly co-ordinated in hospitals, and I do not want to get back to the time where the first time you discover that there is an outbreak in a hospital is when there are deaths and it appears in the local paper. That is not the case at the moment, but I could see that, if you had these hospitals which were rather stand-alone, that might become the case.


276. Before we move on to the next question, could I just ask, as well as co-ordination of existing structures, is this an opportunity to bring in other structures to the body of the HPA that could with benefit be brought in?

(Professor Nicoll) Absolutely. It is partially that you have got the new partners, in CAMR, NRPB and the chemical service providers though it is worthwhile recalling that this is something that, in part, was happening already; not with the radiological, but after the American anthrax releases and September 11 we were already getting to know the other people. But there is a larger family, and one of my hobby-horses is to say that health protection is too important to be left to the Agency alone. At the local, regional and national levels there are other partners who one gets to know through experience; in foot and mouth we got to know the Environment Agency very well and reinforced our relationships with the Food Standards Agency. With the bioterrorism we got to meet all sorts of people that we had heard of but we had never met before properly. So there are opportunities there. I suppose my worry is to ask will the Agency be given the authority to pull these people together, how will that work?. When we are dealing with the foot and mouth report, (we do a report on what were the implications for human health of the foot and mouth disposal campaign process, which is done with a number of agencies,) when CDSC says can people come from these different agencies, they are busy people, they do not necessarily come. When Dr Troop or Sir Liam Donaldson says I'm convening a meeting," they are more likely to come. So I am hoping that the Agency will have that same sort of authority that the Department has.

(Professor Duerden) Can I just put into that, that is one of the reasons why we believe strongly it should become a non-departmental public body, as the PHLS is now, in due course and that the special health authority is not the appropriate long-term type of body for the Health Protection Agency.

Lord Oxburgh

277. In your evidence, you describe the need to use information technology intelligently to modernise surveillance, and can you describe what the major deficiencies of current IT management might be, and what the potential benefits would be of doing things better, and what is stopping you doing it anyway?

(Professor Duerden) I think one of the overall major difficulties here, and this is not something new because of the Health Protection Agency, this is a general one, is the differences in the IT systems across the Health Service, and, whether they are laboratory systems or patient administration systems, there are so many different types. The need is to be able to extract data, to integrate the information that is held in these systems, to bring it in centrally, to make the analyses, and I am looking forward to the development of the National Electronic Patient Record, which is the next big development coming on stream. Again, we need to be able to harness that sort of information into national surveillance. And, of course, there, without getting across the problems of patient confidentiality, there is a very fine line between getting information about patients for public health purposes, and very necessary public health purposes, without contravening the very necessary and appropriate rules on patient confidentiality. So those are the headline bits of it. Professor Nicoll is more concerned than I with the detail of it, because it is the feed-in to CDSC.

(Professor Nicoll) I always feel, in answering that question, it is sort of like the man being asked, How do I get to Dublin?" who is answered I wouldn't start from here." What we seem to find still to be at the moment is that every system we go to has not really been set up to give the information that is needed for health protection. We need to get into a culture, working with the NHS Information Authority, who we have had difficulties engaging with, is that there should be specifications for each system and there ought to be an output which will do the business. At the moment we feel as though we are going rather like hunter-gatherers, and trying to work out, Well, how are we going to extract the information out of this system?" when clearly it was not set up for that purpose. It would be just so much easier if the systems were set up so that its not the only thing that they have to do, but one of the things they had to do was to produce that information. It is vastly wasteful of time to have to go into every laboratory to work out the intricacies of tweaking the system to give you what it is that CDSC needs. So that is one thought. Professor Duerden has mentioned the confidentiality, and I am sure we will come back to that. There are a lot of systems out there that we are finding considerable untapped potential for supporting health protection. Dr Douglas Fleming's work with the general practitioners has been a beacon for us, and then, building on that, we have found the NHS Direct systems has been particularly useful, for a surprising number of purposes, including responding to deliberate release. So I would not want you to get the impression that it is all doom and gloom out there on the IT side, we are finding that there are some hidden nooks and crannies that are proving to be very useful. I think another development in the future we have to look for is much more secure web-based work. Being part of the Agency and having in the family some of the people who have been making good local developments means that people are beginning to show to us their work: Dr Mike Painter in Manchester, and Dr Ruth Gelletlie, in Yorkshire, which we are now looking at, along with systems from WHO, to see whether those systems have value at a wider level. However a difficulty we always face is that having something that works well in one locality, or even in a region or a smaller country, does not mean necessarily that you can roll it out successfully everywhere. We have had our fingers burned with things that look very good at a local level and then imagining that therefore it will be easy to use them across the country without investment. I think the final point on this topic is that `investment' word, because the idea that you can get IT on the cheap is a non-starter. It has been interesting, when we have been comparing the groups that have been brought together to form the Agency at a national level, in terms of what it does and number of people, the PHLS has by far the least IT investment on a per capita basis.

278. As I understand it then, picking up the various threads of your response, first of all, it is the diversity of systems with which you have to cope, and probably a lack of common interface protocols between your systems and the local system, and clearly that is something that one hopes the NHS IT strategy will tackle. The question of confidentiality keeps coming up in a variety of contexts, not just that of this inquiry, and presumably your requirements and those of patient confidentiality would be satisfied if the information came to you simply in an encoded form that identified a practice from which it emerged?

(Professor Nicoll) Not necessarily. In some instances, the data coming in can be anonymised and we just need to know where things are happening for what I might call the routine purposes. However for quite a bit of our activities indeed some of the most important work, you do actually need patient identifiable data. Infection starts off with individual patients who are ill, spreads to other people, and the public health action that you have to take is to achieve the protection of other individuals. But you have to sometimes come back to individuals to achieve this.

279. Right; but provided that this was an interface through which you could go back, in other words, if you like, the practice was the trusted whole, the key to the individual, that would be satisfied, that would be alright from your point of view? If you could go back to the practice and simply say, Sample so-and-so that has come in is serious and has these implications for the patient," that is the point at which presumably the practice could, say, contact the individual and say, Look, there are major public health implications here"?

(Professor Nicoll) I think it is difficult. We have to do investigations immediately over weekends, that means that all practice would have to be willing and able to deliver a 24/7 service that can de-encrypt. Another difficulty is that you do not know that something is going to be important until the lab result comes. So I cannot say `yes' to that, even though it sounds very reasonable, because my experience has been that there have been a number of complex solutions like encryption which mean that CDSC cannot deliver what we have to to protect health and practice based encryption is one of these. In the circumstances that we face, we do not now get patient names with a lot of our information. What we have been doing in the past two, three years, through our Caldicott Guardians, has been going to each of our systems, saying, Do you really need patient names?" And that has taken out about 70 per cent where we do not need it. But we are left with about 20 to 30 per cent where there is genuine need at the moment that in order to protect people we have to have the names so we can go back to the GP.

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