Select Committee on Science and Technology Minutes of Evidence

Examination of Witnesses (Question number 800-819)




  800. Sir William?

  (Sir William Stewart) No, I think it has just been answered, that 30 per cent of our current grant goes on R&D. We have got that, we will continue to have it and what we can also do is bid to the Department of Health for additional funds.

Baroness Emerton

  801. There has been some concern expressed that the PHLS labs which are transferring to the NHS will prioritise clinical microbiological work and, therefore, cease to play such a major role in public health. To what extent do you share that view and that concern and how would you ensure that it does not happen?

  (Dr Troop) If I could just put the context, as we were saying earlier, our aim is to strengthen microbiology across the piece and if we want to have comprehensive surveillance, we do want all the laboratories, those transferring and the NHS laboratories, to be active in surveillance, to be submitting samples for reference laboratories and supporting local outbreaks and of course many of them already do to a variable level. To develop that, we have appointed a new post called the "regional microbiologist" who will be working across the whole region, working with laboratories to develop into strong networks, and again some of these are already there and some need to be stronger, so that we do encourage that kind of development across the whole region. When I was talking with the laboratory people who will be transferring, I was encouraging them to help to support some of those networks and that work. The other thing we are trying to do to strengthen all laboratories working is we have established 42 local teams of health protection now across the country either at county or at strategic health authority level and we are asking the head of those teams to bring together all those working in health protection, whether they are in trusts, whether they are in local authorities, to try and strengthen a much stronger co-ordination of health protection and, in so doing, hopefully encourage all local laboratories to feel a part of that system. That is the direction we are going in and we also have a strong regional team where the regional microbiologist would work with the network of regional epidemiologists and so on, so that is where we are driving, to try and get as full and comprehensive a system across the whole NHS and local authorities. In the short term what we have tried to do is build in all the safeguards that we could to make sure that in that transfer things did not happen in the way you describe. First of all, funding for public health work is coming directly from the HPA against a service-level agreement. We have agreed sessions of consultants transferring so that they will continue to oversee and ensure that work is done. Nigel Crisp, as the Head of the NHS, has written to all the trust chief executives requiring them to make sure that they do not change the work and they have had a very strong message from him that they should do so. We are working with the strategic health authorities who have responsibility for performance management, as part of their performance management, to make sure that does not change and we have also set up monitoring so that we can monitor where surveillance is coming from and where samples are coming from so that if we start to see any change, through those various mechanisms we will be able to go in there and say, "We have given enough funding for this. You have to deliver". So we think we have brought in sufficient safeguards, but we are very closely monitoring it and very closely working with the trusts.

  802. Is it the HPA itself doing the monitoring or is it delegating?
  (Dr Troop) We are doing the monitoring of our surveillance and our reference laboratories, but also we are engaging with the local teams and the local strategic health authorities to make sure that they make sure it is happening at a local level as well.

  803. So there is performance management—
  (Dr Troop) There is performance management and I hope also by the involvement of a wider base across the local team where they are part of a wider team locally, that will encourage them to feel very actively part of a public health network as well as their network of laboratories.

  804. I wonder if I could supplement that by saying a letter has gone to the Chief Executive, Sir Nigel Crisp. Has there been any effective programme for the NHS boards because to date I think it would be true to say that possibly microbiology has not formed a high priority?
  (Dr Troop) I think you are right there. What has happened is that the negotiations with individual trusts, there has been more at the chief executive level rather than with the boards, but there have been a lot of discussions with them on an individual basis. The next stage then, as I say, we have appointed interim regional microbiologists and we will be encouraging them to be raising the profile of microbiology across that region. I think it will also come, as I say, with the local teams where we are encouraging them to come up with a local health protection plan with the trusts, with the primary care trusts, with the local authorities, and again if we can do that, we can start to raise the profile of these issues. I think you have to come at it from a number of ways. I think, finally, because now of antibiotic resistance and healthcare-acquired infection, these are now indicators for performance management, so they have to demonstrate that they are creating change and we have set up surveillance mechanisms to look for that change. Therefore, the interest in these, because it has a major impact on that hospital, I think is being raised because they are monitored now to require them to change what is happening there. I think that a number of different ways are coming together to try and increase the profile for local boards.

  805. And are you quite confident that there are enough microbiologists?
  (Dr Troop) No.
  (Sir William Stewart) I just wanted to make a single point about the transfer of some of these labs into the NHS from the PHLS. I think the point which has to be made is that there are about 300 already managed by the NHS and there are no complaints about the data that they provide. Why should the extra 40 that go into the NHS be any different?

Lord Lewis of Newnham

  806. I think this is a point you have touched on from the point of view of general interest in development and interaction between various groups, but can we just take a specific example. How do you envisage the role of the HPA in relation to vaccine developments, evaluation and assessment, so you have got development, evaluation and assessment?

  (Dr Troop) I think there are different levels of this. First of all is the assessment of where we need vaccines, which is future development and future thinking and I think particularly as we are now looking more to the life-long approach to vaccines, we have been trying to encourage people not just to think of childhood vaccines, but particularly influenza and the meningococcal vaccine in older people, and in other age groups things like HIV we should be looking for and so on. I think there is work in looking at priorities and ways in which to develop vaccines in all the work that we do around infectious diseases. I think there is work around where there could be some joint research and I do think it is looking at joint research because there is expertise in the HPA, but there is a lot of expertise in other sectors, industry and so on, and I think there could quite often be a partnership because of the capability within the HPA. There can be work looking at the accelerated introduction of vaccines. When the meningitis C vaccine was introduced, the research was done collaboratively with the PHLS and the industry to help with Department of Health funding and, as a result, we introduced the vaccine ahead of any other country, so I think there are relationships there. Some of the work about cost-effectiveness is also important in this context because, from my time at the Department, the Department would not be willing to fund a new vaccine unless it could be demonstrated that it was cost-effective and we did sometimes find people coming forward for vaccines when we discussed them with the industry which were ones which were not necessarily the priorities and that is why, as I say, the research needs to be clear about the priorities which I think is very important. We sometimes got the ones which might have been interesting for the company, but would not necessarily be a priority. I think we have a major role in the evaluation, monitoring and surveillance. You need very large numbers, you have to do this on a very comprehensive basis and work internationally with government on this basis. I think for each of the stages for thinking through which vaccines we might need, some of the collaborative research and then the long-term surveillance, I think we have an important role right through and it was a highlighted area in CMO's report, so obviously it is one of things we take seriously.
  (Sir William Stewart) Dr Troop touched on the evaluation and assessment side of things. In relation to development, basically the UK currently has no assured, dedicated and readily available capability to develop and supply vaccines for use in combating an emergency. Yvette Cooper in the Commons debate on vaccination policy on the 16 May last year said, "Where there is a military need, which is usually a low-volume need, or a capacity to respond rapidly, there remains a need for the Government to fund R&D for vaccines". Now, that is pretty clear stuff to me. The question then is to ask why is that necessary. Because we are a population of 55 million people in the UK, the pharma companies are usually large, global companies and they are not going to switch their vaccine production for 55 million people. Their interest, quite rightly, is in their shareholders, and it is not necessarily in the health protection of the people in the UK. I think that there is a need for that to be done bringing in experts from industry when they can be of help to the public sector. For example, when I did a review of anthrax vaccine production capability at CAMR when we were thinking about it, one of the key people we brought in was somebody from industry. My point really is that the UK currently has no dedicated and readily available capability. The Netherlands and Finland, I believe, have this, so why should we not be having it for the UK. Do we really believe that the large pharmas are going to do it for us? Large pharmas are multinationals. Which country are they going to provide the vaccine to if there is a conflict of interest?


  807. One of the supplementary comments which follows from what you say is of course that CAMR did apply for funds to build a rapid vaccine development centre and this was rejected. Following on from what you have said, Sir William, that seems an unfortunate decision if we do not have that capability in this country, despite the fact again, if I can refer to Getting Ahead of the Curve, there is a very firm statement here that programmes for new vaccine development create opportunities, et cetera, so all the evidence and your evidence would seem to go in that direction and yet somehow or other we have pulled back from that position.

  (Sir William Stewart) I have to say that I was Chairman of CAMR at the time that bid was put in, but I was not involved with CAMR at the time it was rejected.
  (Dr Troop) I have to declare an interest in being the person in the Department who headed the team who asked for more work on the bid.

Lord Lewis of Newnham

  808. Do I take it from that statement then that it has not been totally rejected, it has just been sidetracked?

  (Dr Troop) No. I have gone back to check and the door is not closed, but I think there needs to be more work jointly to agree what is needed and how it might be funded, so it is not totally closed, but I have to say I was involved in that.

  809. This does point out the dilemma which I think was implicit or even explicit in Sir William's statement, namely of course that you have got the large drug firms which are multinational in nature who are quite clearly concerned more with producing something which is going to give their shareholders a return rather than necessarily dealing with what could be a significant problem, so you have now got this dilemma there that their interest, and they are the people who to a large extent have been developing many of the things in the drug industry as a whole, is coming this way, so how do we deal with it if the Government actually is not prepared to accept this type of responsibility?
  (Dr Troop) My advice is that we can go back, that we need to develop the case perhaps in a different way or with other partners, but the door is not closed for it. The principle that we need was agreed. I think what we need to do is go and work with the Department to make sure that we come up with a proposal that they will support rather than say it is something they do not agree with in principle. Certainly, when I was at the Department, I agreed with it in principle.

Lord McColl of Dulwich

  810. I was interested in your comments about determining whether a vaccine is cost-effective. If there is only one vaccine that is developed and it prevents a lethal disease, how do you determine whether it is cost-effective?

  (Dr Troop) If we take, for example, when the meningitis vaccine came about, it is looking at what the morbidity and mortality is from that particular disease and the cost of a vaccine and any potential risk from that vaccine. The costs of vaccine programmes may be £30 million to £40 million a year, so they are not cheap programmes and therefore if the Department of Health has a finite set of resources it has to decide how best to deploy those resources and if it turns out that that would save a very small number of people whereas spending that £30 million on something else would save a lot of people, those are the decisions that it has to make. It does that not just for vaccines, it does that for treatments and services and for every aspect of its health care. If you make a bid for funding you have to demonstrate that this is the best value for money for that piece of work. I am talking here about the big vaccine programmes. It is not the same as the issue we have just been discussing which is the rapid facility, it is more about the wider vaccine programmes.

  811. If you have a disease and there are a million people going to die and there is only one vaccine and it would prevent the million deaths, I do not understand how you determine whether it is cost-effective. It is certainly effective.
  (Dr Troop) If it was going to save a million people then it would come out as cost-effective, but some of the vaccines that we have been offered for other things maybe cause half a dozen deaths a year. It depends what the vaccine is for. If it is for something which is, as you say, a lethal disease, that would kill a lot of people, it does not matter if there is only one vaccine, that is not the issue, the issue is whether a vaccine is the most cost-effective way of handling that problem. In some instances it may be not the best way of handling that particular health problem. It is those kind of broad decisions we have to decide, not just that if we had a lethal disease of large numbers we would not necessarily think a vaccine was worthwhile.

Lord Oxburgh

  812. I think we are returning now to one of the perennial problems, that is the interface between the Central Government Agency and local authorities, and certainly as we have gone round the country talking to different groups and taken evidence, the Environmental Health Officers have indicated that they have felt a little bit left out. Would you please describe how you plan to interact with the Environmental Health Officers because this does seem to be very important to much of what you do?

  (Dr Troop) I think there are interactions both locally and nationally and I have described what I would hope for with the local teams, that is, we pull everybody together to produce a local health protection plan and we have had a lot of encouragement from the Environmental Health Officers themselves. As a group they have anxieties about their work at the moment. Many of them think that they have just been going down the regulation role recently rather than some of their wider roles and working in the community, and the Chartered Institute has had a working group to try and look at the future role of Environmental Health Officers and I was discussing that with the authors of that report a couple of weeks ago. We were talking about how we might work together to try and help them as well as us, how that role might be developed more, to go back and to draw on what they see as their wider skills and then how we might work in partnership to make sure that we use all the skills. As I also explained, we see our role as helping drive much of the training and development and we would want to encompass all disciplines in that programme.

  813. Thank you. Are there significant variations in the level of resource applied to environmental health by different local authorities?
  (Dr Troop) Yes, there is quite a lot of variation and their roles also vary quite a lot now.
  (Sir William Stewart) I am not concerned about the extent of consultation in the past. The HPA has been with us for ten hours now and we will make sure that there is consultation in the future. I believe that the Field Services Division of the HPA will be crucially important, because its interactions will be at the coal face. That is where it actually happens at the end of the day. To that end we have certainly been meeting with HEPAs and the CCDCs and we will go out and about to meet them. When I last saw them I suggested to them that they ought to bring a group in to an early meeting of the board to talk about their problems and, in addition to that, we are going to have some of our meetings outside London in the regions where we will meet with various groups at the coal face. I should say in passing that our meetings will be open to the public so that anybody can hear what goes on at the board meetings and, also, we will put board meeting minutes on the web.
  (Dr Troop) We are trying to base our regional teams in partnership with the government offices of the region and along with the regional directors of public health and that gives a good opportunity for working alongside all the other people in government offices who work with the local authorities, and that is the first time that we are going to have that kind of combined approach at a region, looking not just at the NHS but the regional development agencies and the local authorities and so on. That opens up an opportunity for looking across a much wider picture as well.

  814. Do you feel that you will be in a better position, for example, than the authorities in the Eastern United States where West Nile fever arrived and the first evidence in retrospect was crows dropping out of the sky? How would you look after that? Will this be environmental health? How would you pick that up with the new system?
  (Dr Troop) Some of that will come through the veterinary system as well, that is where some of it was picked up there. I think local authorities could very well be the first people to pick this up. Then there is the veterinary side of things and the laboratory side of things. What we are looking for is very strong local, consistent teams working to the same standards. I hope that after working with the local authorities there we could expect in each of our teams the same ability to be working with the local authorities and picking things up. It is building those stronger teams and links that I hope will do that. I also think that there is work to be done in strengthening the veterinary side of this as well. When I have been discussing it with them it has been in relation to veterinary pathology and so on which I think needs developing quite a lot to be able to answer the West Nile fever problem.

  815. So your regional teams will have veterinary connections?
  (Dr Troop) They will have connections, but I think their side of things needs strengthening as well if they are going to have the capacity to handle some of these issues.
  (Sir William Stewart) I would like to go back to this point about the contacts and the relationships we have. We are developing good relations with the environmental agencies, with the vets, the HSE, the Food Standards Agency. What we need in this country that we do not have at the present time as effectively as we might is national standards and protocols. What has happened is that you say Mr Joe Bloggs actually is the expert on such-and-such a thing, but when he dies or moves on they reinvent the wheel. Basically what we need to put in place are protocols so that you can take something off a shelf or electronically and say this is what has happened, this is what you do under these circumstances. You have to try to be aware of everything, even things like crows. May I say just in passing, Lord Lewis once told me a story about a canary falling unwell but perhaps he can tell you that outside of this meeting.


  816. There are concerns at the local level that moving the CCDC from health authority PCTs to the HPA will weaken the local areas. How will you ensure this does not happen?

  (Dr Troop) First of all, the people who are given prime responsibility for health protection are the primary care trusts and the role of the HPA team is to work in close partnership with them, to support them and also to do things on their behalf. So we see it as a very close partnership between the PCTs and the health protection teams. The other point is that we are asking them to bring the various groups together so that we develop a much stronger health protection plan for that area, bringing in the local authorities, the PCTs, the trusts and the health protection team and I do not think at the moment we have got this. I think there will be a strengthening of those relationships so that there is a shared understanding of what they are doing. The health protection people continue to be the proper officers with the local authorities as well and part of our standing instructions was that they could continue to do that.

Lord Haskel

  817. You mentioned that you are going to develop some national standards and protocols for IT. This is something that we have been hearing about for years and years and years and indeed it is a problem which a lot of people have been telling us about. Can you tell us a little bit about how you intend to do that?

  (Sir William Stewart) Basically we have to do them irrespective of what we have been hearing. We have got to change from hearing to doing. Basically what we are trying to do and we certainly did it at CAMR, is we evaluated the totality of the situation and said what do you need in your operational plan to do this, what do you need in the next stage if you are going to do something else, what is the protocol for that. That has got to be done more widely than across the HPA. That is one of the reasons, for example, why we are keen to have the involvement of the NRPB. In terms of emergency planning, NRPB has some of the best emergency planning in the whole of Europe, perhaps in the world and we have to make sure that we can use their expertise and their approaches to develop that more generally. My last point is that standards and protocols are important not only within the UK, within our own organisations, but if somebody in France tells you that something has happened or this is the result that you get, how do we know that we are using a similar test in this country to make sure that that is the case. We have to rollout standards and protocols out across Europe as well as doing it internally. Internally we think, for example, NRPB can help us, but we have to do it across the board.

Lord Rea

  818. This question is very relevant in view of Sir William's opening remarks about global bugs. Are there plans for the HPA to become involved in providing rapid assistance to the WHO through short-term and longer-term secondments and laboratory support given the expertise that resides here in England and Wales? Several witnesses, especially in Geneva, suggested it is important that the UK provide more support to the WHO through such short-term or long-term secondments and laboratory support and some other countries do that, they pay for it themselves and we are not, we are rather backward in coming forward in that respect.

  (Dr Troop) I think this is a capacity we should like to develop. There are already a lot of links. I was interested in this because of looking at our corporate plan, I asked people to identify what links they had internationally either with research committees or asking for advice and I got a list of 100. There is a huge amount of interaction internationally. We have a number of WHO collaborated centres and people do go out to those to some extent at the moment and on Serious Acute Respiratory Syndrome we identified people who we can send to China to help with that problem, but I think we could do more. If you take the range of expertise that we have right across the board, I would like to be able to develop the capacity to be able to send people out to support the WHO, to offer training not just in emergency situations but also to help develop people on other programmes and to do that I think you have to involve more dedicated capacity rather than if you have got a smaller number of people and you send somebody because then you may be quite stuck. Part of our plan is to try and work through how we would like to do that, what is needed to have that more proactive role and that is something where I would then want to go and seek support for funding and maybe different parts of Government might be willing to do that. I think it is something that with all our expertise we are wrong not to do and I have had exactly the same comments from my colleagues in Geneva.

  819. I am very pleased to hear that from the Chief Executive of the HPA. I do not know how much the costs amount to, but is there not an argument for saying that we gain from this not necessarily in financial terms but certainly perhaps in health terms and international appreciation for us sending such people?
  (Dr Troop) We do, and there is a lot of interaction. One recent example, colleagues in the now HPA have had a lot of interaction with colleagues in all the different countries who have been involved with the new syndrome and the UK has earned a lot of respect for this. There has been work in the laboratories, there has been work going on at Porton Down all to help support this, so there is a lot of respect there. If we are going to increase that we either need to create some internal capacity or we need to increase funding in order to free up more people to be able to do it in a more systematic way because at the moment it is done on a fairly grace and favour basis. It is all about having a more dedicated resource than we have at the moment.

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