Select Committee on Science and Technology Minutes of Evidence

Examination of Witnesses (Questions 660-679)



Lord Oxburgh

  660. Dr Wake, your explanation was very clear, but within a PCT, if you spend money on health protection units, you do not spend the same money on other things. What are the tensions here and how are the priorities set?
  (Dr Wake) At the moment, I would not say there are tensions in all honesty. Money which has been spent on health protection is protected and will continue to be spent. Money which is in a PCT's baseline I would not say generally at the moment is under great threat. The difficulty is when one is faced with new infections or enlarging problems of infection control. Hepatitis C is a very good example. It becomes quite hard at PCT level to see where the new investment will come from, so my concern is not about maintaining those services, although they are about to change with the formation of the Health Protection Agency, but is rather about understanding how we do all that is necessary for infection within our existing budgets which grow at a certain pace.

  661. When you say expenditure is "protected", do you mean it is protected by you or is it ring-fenced before it comes to you in your allocation?
  (Dr Wake) My understanding—my colleagues might want to correct me—is that there is no money now which is truly ring-fenced. The best example of that which I am aware of was around HIV, which was ring-fenced. The ring-fence from that has recently been removed. I might suggest that the issue we may face there is that we continue to give money we have traditionally given for HIV, for example, to a trust. It becomes difficult for us to enforce ring-fencing on the trust, so I think in all honesty one cannot be sure that HIV money is spent within each trust on what it was originally meant for.

Lord Patel

  662. Mr Brogan, you said that there is under-reporting of infectious diseases by general practitioners. Are general practitioners given guidance as to which infectious diseases they should notify and is the under-reporting related to that?
  (Mr Brogan) They are given guidance and they are regularly reminded by our director of public health and the CCDC, but they tell me that in fact it is widely recognised that there is under-reporting across the country. I cannot prove that to you and I am just repeating what they have told me. What they also say is that the under-reporting is consistent, so at least you know the trends are whatever the trends are, they are not due to artefacts of the reporting system.

  663. If I understand you clearly, this under-reporting is in seriously notifiable diseases. What would the PCTs do about it?
  (Mr Brogan) There is not an awful lot we can do about it. The danger of fiddling with the thing too hard is that you would then cause a blip in the disease allegedly, which would actually cause a problem with the reporting system, rather than the actual incidence of the disease.

Lord Turnberg

  664. You said at one point that PCTs will work with the HPA. Do you want to enlarge on that?
  (Mr Brogan) We will have a memorandum of understanding with the HPA, which will set out our relationship with them. We work together now because the CCDCs are part of the PCT in my particular office building looking after the health protection of the four PCTs, including my own, in the Vale of Aylesbury, South Bucks and Chiltern and Wycombe and Milton Keynes PCTs. We shall continue to have the same relationship, at least to begin with, but over time we shall have to work hard to maintain that relationship because there is always a danger when people are in different organisations that they will gradually drift apart. We shall have to be very careful to ensure that does not happen. It is not the only area where we have to collaborate with other people across a wider area. We are doing this all the time with our neighbouring PCTs. It should not be too difficult and people recognise the importance of this subject and our public health team are very committed to continuing to work with the CCDC as the CCDC is very committed to working with them. I do not see a major problem here.

  665. Is there a contractual relationship? Do you have to fund them to do something for you or vice-versa, or is it simply a collaboration?
  (Mr Brogan) It will be a contractual relationship but it will not be a contractual relationship where money changes hands in the sense of having a contract. As I understand it, the money for the CCDC or health protection team, will be taken from us and put into the HPA. The money will go with the people and the money for the desks and computers and all the rest of it.

Lord Patel

  666. My question relates to performance targets and monitoring. Both PCTs and hospital trusts have to respond to a variety of performance targets and national service frameworks. Do communicable diseases feature within these targets? If they do, how does the control of infection rank compared with other targets such as cancer or care of the elderly or cardiovascular disease or waiting-time targets? How do you make the decisions on how resources are allocated and how much do you allocate?
  (Dr Wake) It is fair to say that communicable diseases do not form a part of a specific NSF or performance targets generally. I had a quick read of the new GP contract, which we are all grappling with at the moment, and there is only one very small reference to infection control in it which relates to the hepatitis B status of NHS staff working in practices. The hepatitis C strategy does attempt to set out certain indicators of success, but they are not performance targets by any means. They are laudable aims really. It is fair to say that infection control does not have quite the same significance for PCTs as those targets which we are really performance managed on, for instance within the NHS plan, or within national service frameworks. That said, it should be remembered that within our contractual framework, the framework we have with primary care contractors, key immunisation targets are set, particularly in relation to children's diseases and also for influenza in adults. Infection control is certainly seen as a core function of the PCT and I think that element of funding is protected and would not seem to me to be at any risk in the way we prioritise care at the moment. You may be aware that resources are allocated from this year via a three-year plan called a local delivery plan, which is an attempt for the first time to plan clinical services in an area on a three-year basis. PCTs do have the freedom to allocate resources to the control of infection and it remains to be seen how well we do that. I can give you an example from our own local development plan or LDP that in London it has been agreed that the control of tuberculosis is a priority for investment and that is certainly reflected as a commitment in our sectorwide LDP. I know that one of our local trusts has also put in a bid for additional consultant time in their chest unit, which will again relate to work with tuberculosis. That is new money, so it is certainly possible for new money to go into infection control. The problem for PCTs is that we are performance managed on other things and they are around access to primary care. We are performance managed on the way that our hospital trusts perform, particularly on waiting times in accident and emergency. We would have to see these as our top priorities, but I would still argue quite strongly that PCTs would see communicable disease control as of high importance.

Lord Lewis of Newnham

  667. When you say "we", do you mean your particular organisation, or could another PCT actually look at it in a totally different way, put a different ordering of priorities?
  (Dr Wake) It would be impossible for me to speak on behalf of other PCTs. I should be surprised if they took a dramatically different view from that since these are resources which we have invested for many years. It would be hard to take away from them. The difficulty is that in certain areas of the country, PCTs and their health authorities find themselves in a less easy financial environment. I would not pretend that ours is easy, but it is not the worst in the country and in areas further south, they may have more difficult decisions to make in relation to that and that is a perfectly fair thing to say.
  (Mr Naylor) I can speak in relation to hospital trusts. First of all, performance targets are numerous for hospital trusts. Communicable diseases, particularly hospital acquired infection, do feature in those performance targets, but I would say only in the last year or so. In particular, the way we are measured through the new star rating system, there are two levels of performance measures which we have to take particular note of. The first level of performance measures has what we call nine key indicators. One of those nine key indicators relates to cleanliness in hospitals. Around cleanliness of course is the major issue of hospital acquired infection. Beneath those nine key targets there is a series of 36 sub-targets which of course are less important than the nine key targets but still important targets to hit. Two of those 36 targets specifically relate to these issues. The first is to ensure that hospital trusts such as mine have quality infection control procedures in operation. The second target is to measure the rates of MRSA bacteraemia which occur within the hospital trust. Both of these latter measures are new measures for this year. Up until this year, it would be fair to say that we have only measured our performance very, very loosely in relation to these targets. The government quite reasonably and rightly, have taken notice of a number of reports, not least of which is the National Audit Office report of February 2000 and more recently the Chief Medical Officer's report Getting Ahead of the Curve, in increasing the number and the weight of these targets which relate to hospital acquired infection. It is now a key issue for us to be measured on and indeed our star rating and therefore the reputation of our hospital trusts and our individual hospitals will be measured by the relative position that we sit within the star rating of hospital trusts in the future.

Baroness Emerton

  668. Could I ask whether the PCTs would welcome a performance target on control of infection or not, in relation to what you have just told us?
  (Mr Brogan) My instinct would be to say no more targets please.

  669. I thought that would be the answer.
  (Mr Brogan) We have about 360 of them already; although I am very committed to this particular target actually. We have 11 key targets in our strategic health authority area and our PCT alone has £2.5 million projected deficit next year. Our local acute trust, Stoke Mandeville, which is joining with another acute trust, has deficits in the order of £3 or £4 million. It is extremely difficult to maintain priorities. I am not saying we will change the financial flows we have going into communicable disease control. We will keep them as they are. Were it to require new money, that would be extremely difficult because we are cutting everything at the moment in order to try to get into balance next year.

Lord Oxburgh

  670. Are you consulted about the targets that you are set? Is this an iterative process or do these just come at you out of the blue?
  (Mr Brogan) They come at us from the NHS plan, not out of the blue. We all know.

  671. But you feel you do not have input. If a target were inappropriate, going to be clearly inappropriate and distort what you were doing because of local circumstances, would you be able to negotiate that one away and say it is not sensible for you?
  (Mr Brogan) No, is the short answer. To be fair, it is extremely unlikely that ridiculous targets would be imposed because they do go through an enormous sifting process and national expert groups and so on. That is not something I fear, it is just the weight of the number of targets.
  (Dr Wake) Mr Naylor referred to star ratings which made my ears prick up a bit. Primary care trusts have not been star rated yet and I have not seen what we will be star rated on. In fairness to those who set them, they do consult us about them in general, there is an important process of consultation, it is likely that star ratings would relate to some things which could be related to communicable disease control and that would be particularly around our success in immunising people against the flu and probably children's immunisations as well. That would be about the level of it.
  (Mr Naylor) On the question of setting targets, I think it would be fair to say that a number of people in the Health Service are involved in the development of these targets and for my sins personally, I was a member of the performance management group which advised the NHS modernisation board on the setting of targets which originally led eventually to the star rating system. People such as myself are involved and although individual PCTs and hospital trusts might not be involved, representatives of trusts and PCTs will have been involved in the process. There is a mechanism, either through colleagues or through professional groups, to influence the development of the star rating system, but it is quite correct for my colleague Shaun Brogan to say that the targets do reflect government priorities and they were originally derived from the NHS plan. These targets—as I have already explained in relation to hospital acquired infection—are emerging and developing to take account of reports as they are developed through organisations such as the National Audit Office.


  672. We have heard evidence that CCDCs and hospital control infection personnel have felt undervalued and under-resourced. Can we take it from your comments that this is changing and that it will change in a much more positive way?
  (Mr Naylor) I have no doubt that it has changed. I also have little doubt that it needs to change further. The extent of hospital acquired infection is still much too high. A lot of that infection is preventable within hospitals and a lot of additional investment needs to go in, both in terms of the experts we need on the medical side within hospitals and their relationships with primary care trusts, the Health Protection Agency and so on, but also in the investment in infection control nurses who are the key to controlling infection in hospitals and also the relationship between hospital infection control nurses and their counterparts in the community. You asked a question earlier on about the flow of patients through the system and at the moment the flow of patients occurs in quite discrete ways. Patients are seen in primary care and are referred then into a completely new system which is the hospital system. Once the patient has been through the hospital system, they go back to the primary care system again. The connections between these systems is not as good as it might be. Certainly one of the things we are doing in my part of London in relation to our PCT is talking through the development of joint infection control nurses between the community and the hospital, so that there is a rotation of such nurses, so that they see the problems which occur in the hospital, but also follow the patients back into the community. Bridging the gaps between the systems will become an increasingly important factor in terms of control of infection between the community and hospitals in the future.

Lord Patel

  673. How does NHS Direct fit into this surveillance?
  (Dr Wake) I understand that they provide a good source of high quality advice, both directly to individual patients and to professionals as well. Their website acts as a good source of advice to the public.

  674. I was asking more about the overall picture of surveillance of infections. How do the PCTs relate to it?
  (Dr Wake) I am not aware that they have a role at the moment, although over the next year things will change in that NHS Direct will work much more closely with our out of hours services. I understand that is likely to be one of the routes through which patients receive out of hours care.

Lord Turnberg

  675. There has been an answer about CCDCs being one of the key contacts for you in PCTs and the HPA. I gained the impression you were talking about how it can and should work, but I was not quite sure whether it is and will work in this sort of way. Are we talking specifically about your own experience, which is what you are relating to, or what PCTs in general will feel? The reason I put it like that is because I hear from CCDCs around that they are very uncertain to which PCT they should be responsible and how they must work together. Can I probe you a bit on that?
  (Mr Brogan) I imagine that there is considerable uncertainty amongst CCDCs because they are going through a period of change. They are not the only people in the NHS feeling that way. All of us feel it most of the time now, there is so much constant change. The relationship is being clarified. The Health Protection Agency is being set up. Discussions are going on and there was a discussion yesterday in the Thames Valley Strategic Health Authority, of which I am part, about the memorandum of understanding, about public health doctors, public health consultants and directors of public health and the CCDCs—not all of them but most—getting together to carry on working on the memorandum of understanding which is now in its fifth version. Progress is being made. There will be a new Health Protection Agency; that ought to give those staff comfort in the sense of belonging to a national organisation in the way they have not belonged to one in that sense before. Whilst I can see difficulties ahead, not enormous difficulties but difficulties which need to be recognised and overcome, in overall terms I am optimistic about the future.
  (Dr Wake) I would not dissent from that view. In my own area, where we had a system which we feel works reasonably well and where we understand our relationships, there is some comfort. We are entering into a period of some uncertainty. A lot of reassurance has been given that the PCTs will not feel a loss of the CCDCs to themselves, though it must inevitably result in some loss of control to them if they are no longer locally but are nationally employed. Therefore I think we shall need to work fairly strenuously together to ensure that we get the best of what we want here. I have no argument with the direction of travel. Clearly we need national co-ordinated services. Nobody disagrees with that. Equally we do need to preserve and improve on local services which are directed to infection control. These memoranda must really work quite positively to ensure that local services are protected.

  676. May I follow that up a bit? You mentioned CCDCs as being a very valuable local part of the HPA. Do you see a relationship with the HPA beyond that in other ways?
  (Dr Wake) I can imagine one and there are areas where we have been much under-involved. I am afraid this goes outside the realm of just infection. Our relationship to chemical incidents, safety in factories and matters like that has been very inadequate, I understand, and our director of public health has traditionally not been involved with global, in the sense of general, environmental health issues. I would see that as a positive influence, if that is what you were meaning in the question.

  677. I am sorry, I did not mention my interest. A year or so ago I was Chairman of the Public Health Laboratory Service. I have to say that for the record.
  (Mr Naylor) In a wider sense everyone supports the development of the national Health Protection Agency. It is clearly very much in tune with the times in which we live at the moment. There are concerns about the relationships between the various bodies. PCTs still have responsibility for the health protection in their population and therefore need to develop relationships and memoranda of understanding between the PCTs and the HPA. Equally, within NHS trusts, where we have a lot of expertise, both in terms of pathology and in particular microbiology services and the strong relationships with the old Public Health Laboratory Services, we need to have relationships with both organisations as well, particularly with the PCTs in the area of managing infection between the community and the hospitals, but also with the HPA through the reporting of microbiological results in major pathology departments such as mine through to what was the PHLS and is now the HPA to ensure that surveillance is kept up to standards so that we can identify diseases as they develop.

Lord Oxburgh

  678. I ought to express a former interest as a member of the Hammersmith Hospital Trust board and I am occasional adviser to FLE Ltd. May I ask to what extent you regard the arrangements for communicable disease control to be satisfactory, just standing back and taking a broad view? In particular, are there any policy, organisational and/or resource changes which would enable a better service to be delivered? As a rider to that, who do you think should be responsible for R&D in communicable disease control? I am not thinking of fundamental R&D but I am thinking, for example, of establishing best practice in hospitals to control the spread of communicable disease.
  (Mr Brogan) I have a number of concerns. First of all, where the teams are going to be based. There is an idea abroad that they may be consolidated at strategic health authority level rather than at PCT level as we have them at the moment in the Thames Valley Strategic Health Authority area which covers Buckinghamshire, Berkshire and Oxfordshire. That would be a mistake, because it would be putting them too far away. They are already 20 miles from the two PCTs at the southern end of Buckinghamshire, Wycombe and Chiltern and South Bucks, operating from my PCT building. To move them any further away would be to distance them from their clients and I think that would be a bad move. I am concerned about whether or not you can set up this national Health Protection Agency at no extra cost and improve the service. It is extremely unlikely. With the sorts of computer systems I was talking about earlier, modifying GPs' computer systems or whatever is required to deliver that much faster summary of surveillance back down to the troops in the field and so on, you are going to need to spend more money on it, perhaps not a fortune but some more money on it in order to improve things, otherwise you will in effect not be realising the promise of setting up a national Health Protection Agency. There are difficulties with the shortage of staff in the sense that for Buckinghamshire, where I work, we used to have a director of public health and four public health consultants. The director of public health has moved to the strategic health authority as the director of public health in the strategic health authority. One consultant has left and we have three consultants remaining each of whom is the director of public health or the acting director of public health on a PCT. They have corporate responsibilities which, quite rightly, take them away from their public health job and from liaising with the CCDC. There are difficulties here. I am not saying they are insuperable difficulties, difficulties which cannot be overcome, but they are matters which deserve attention and need working on to get right in my opinion.
  (Dr Wake) As we see it at the moment, I feel that arrangements for communicable disease control are certainly satisfactory. I do not experience problems at a local level. That is not meant to sound complacent and that assumes the current level of risk we have locally and nationally and that could change. I am sorry if this is a plug for hepatitis C but it also probably applies to hepatitis B and HIV. I would feel that we are not yet concentrating resources in areas of maximum effectiveness for those diseases and you can take that for an example in many areas. It is well known that one of the biggest risk areas for these blood-borne viruses is within prison and the prison population is a very difficult population to deliver health care to. Nevertheless it is also apparent that we have not got to grips with the level of investment which is required there and it would seem to me obvious that we need to devote resources to those places where the greatest amount of infection exists and arises. PCTs will have a responsibility once again in this area in that although I do not think arrangements are quite clear on this, they will have an increasing role in the development of healthcare services for prisons in their area. I welcome that but it does need a big investment in resource as well. At a local level, PCTs will really need to work with all their employees and contractor services to improve infection control and they are starting to do that. I meant to mention earlier and this is quite important, that the remit of PCTs in the last six months has also come to include dentists, community pharmacists and optometrists and, particularly among dentists, infection control will be quite important. Once again, I see that as quite an integrating move and a sensible direction of travel. It will need quite an improvement in our understanding of the need for screening of health workers and some work has been done nationally which has been published recently about that. We will have to develop a modern approach to the provision of sterile equipment and that will in fact lead on to further expenditure requirements either for disposable instruments or for sterilisation using CSSDs. I am not sure that we have got to grips with the financial implications or the organisational arrangements which we will need to have. I would not regard myself as an expert on the R&D question. There is though, I would feel, an opportunity for the development of teaching PCTs to improve our investment in R&D in this particular area. I think PCTs should form part of it, but clearly that will not be the only area where R&D can take place. R&D is starting to take place at a PCT level and in our own area we have recently appointed a professor of R&D in primary care.
  (Mr Naylor) May I pick up the very last point about R&D, which is something I have been musing on since you asked the question but which is not something I had really thought about until today. It does seem to me that there is potentially a strong connection between the centralisation of expert resources in university hospitals such as mine, particularly in the aggregation of pathology services. If I might just digress for one moment, we are currently in the process of putting together a proposal to bring together pathology services across a whole range of hospitals in north London. This is part of a series of recommendations which has come through the NHS Executive and from government for a number of years. We are really only now getting to grips with the centralisation of pathology services. If these pathology services were centralised in collaboration with universities, universities have enormous power houses of intellectual capability around infection in general, I could see the potential opportunity in the future for the HPA to commission research jointly with PCTs and perhaps through joint academic appointments between PCTs and institutions such as my own. It is a very interesting question and one we need to reflect on further.

  679. I was also thinking of research at a much more applied and practical level. In our travels and visits we have seen very different models for managing isolation wards or intensive care units, where the spread of infection is important. Clearly there are some very good ideas there which are confined locally. On the other hand, there has not really been any very systematic study of how effective these are. People say they have the feeling it would be better like this or like that and it does seem to me that if control of infection is as important as we are now all agreed it is, that is not quite good enough. I do not know whether you have any comment on that from the University College Hospital point of view?
  (Mr Naylor) I agree with you that a great deal more can be done and there are some excellent examples. If I may just tell you about one that we have been working on in my trust over the last year or so, you may recollect that my trust acquired the Heart Hospital, which was a private hospital, from the private sector and brought it into the NHS just over a year ago. One of the things we have been able to do in that new environment, because the environment is so superior, more akin to a five-star hotel than a classical NHS hospital, and there is a very high proportion of single rooms and a lot more space and capacity to be able to develop those services, to put in improved policies to control infection around the organisation because of the greater degree of isolation. Not only that, we are about to publish some research where there is a clear indication that by screening patients who come into hospital prior to surgery, particularly for complex invasive surgery such as cardiac surgery and dealing with their infections before they come into hospital, there is a very substantially reduced subsequent rate of wound infection which can be fatal. There is a great deal of research which can be done in these kinds of areas around screening patients prior to admission, particularly for complex surgery, but also in hospital design. I am personally a great believer in designing hospitals with a much higher proportion of single rooms, moving away from the old Nightingale ward where you might have 30 patients in one area to a situation in our new hospital for example, in Euston Road, where, when it is complete in 2005, we shall have a very substantial proportion of single rooms, therefore our ability to control infection within the hospital environment will be greatly improved. I would welcome further research into that kind of detail within the hospital environment.

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