Select Committee on Science and Technology Minutes of Evidence

Examination of Witnesses (Questions 880-896)



  880. Perhaps I could just explore a little more about standards. I am interested to hear about the Regional Microbiologists and the Inspector. How are we going to ensure that standards are levelled up rather than down? Are we going to have a sort of Ofsted for microbiology? How is it going to be done?
  (Ms Blears) We are not going to have an Ofsted because we have already got at the moment the Commission for Health Improvement and following our legislation we are going to have the Commission for Health Audit and Inspection. So the Inspector of Microbiology I think initially is going to start off in public health and then he is going to go across, or is planned to go across, to the new Commission for Audit and Inspection. So we will have very much an inspection role within that existing framework.


  881. I understand that in the past there were NHS Trusts that did not report to public health and the laboratory service. What will the Department of Health do if there is a Trust that does not report in this way in the future?

  (Ms Blears) I understand that the vast majority of laboratories actually did report through the system. I am not aware of what the proportion was. I do not know if your Lordship has had any figures around the proportion. My information is that the vast majority did.
  (Dr Wight) I think the current figures were around 90% of laboratories currently report. Those are the latest data that we have and that is in consultation with the HPA I got those figures.
  (Ms Blears) But the Regional Microbiologists will be working with all the laboratories and that I think will probably be quite a big issue for their agenda; how do you get all the laboratories up to the same standards? And they will be on the ground in those regions working with the Regional Directors of Public Health to try and make sure that we do draw in as many as we can.

Baroness Finlay of Llandaff

  882. If I can just carry this on a little bit because the laboratory is dependent on the quality of specimens and the appropriate specimens that come to it. So no matter what standards or levers you have on the laboratory, it is actually dependent on the clinicians. I am not clear where the joined up answerability comes in and at what level it is going to come with the Regional Microbiologists, on the hand, responsible for the laboratory side and monitoring that perhaps and auditing that with the problem that occurs now on wards where patients do not necessarily get their temperatures taken regularly, or they do it with these ridiculous little blue ear things which are sometimes incredibly inaccurate and you cannot find an old fashioned mercury thermometer anywhere in the hospital, even though it is actually quite an accurate way to measure temperatures. And unless you have got that very sensitive and important clinical pointer to systemic infection, you are not going to get the right specimens at the right time from the patient to inform the whole process and that has to be the early warning system where new organisms, particularly resistant organisms, are emerging.

  (Ms Blears) I think the collections at local level are going to be very much the responsibility of Directors of Public Health in Primary Care Trusts working in their networks with their Regional Directors of Public Health as well, because these are the people who are actually on the ground at local level working with the primary care teams, not just inside Trusts but in primary care as well in terms of GP referrals. So I think the system does have connections both across the laboratory side through the Regional Microbiologists, and then if you like through the public health clinical side, through the Regional Directors of Public Health, the Directors of Public Health in Primary Care Trusts and their relationships with their NHS Trusts. And increasingly the NHS Trusts will be performance managed by the Strategic Health Authorities as well. So they will be keeping a very close eye on what their performance measures are like. But again, you can have those mechanical levers in terms of the connection, but what we have to make sure is that the people who are out on those wards and the GPs and the primary care professionals really feel that what they are doing is making a contribution to reducing infection and promoting good health because if they feel that that is what is happening, the samples will be better, they will be sent properly and you will get good proper data coming forward. Therefore I think it is quite an education and teamworking role to try and make sure that all of those clinicians are brought into why they are doing it. If you just have a top down system that says "You must do this" then my experience is that people do not respond to that kind of management organisation. It has got to be why you are doing it and what contribution that you are making.
  (Dr Bickler) What you could add to that, as part of what you are describing, is the issues that underpin clinical governance really, the details of what individuals do and how well they do it and I think we will be looking to those clinical governance processes to also be contributing to that quality improvement as well.


  883. Just go back to the question I asked about NHS Trusts reporting to PHLS, and I think it was Dr Wight who said 95%—

  (Ms Blears) Ninety per cent.

  884. Nineteen?
  (Ms Blears) Ninety. Nine O.

  885. Nine O. What happens to the other 10% that do not? What would you do with those?
  (Dr Wight) I think it is very much building on the exactly the approach that the Minister has just outlined and I think the regional teams, the Regional Microbiologists or Public Health Microbiologists and the Regional Epidemiologists are going to have a crucial role although they will be HPA employees, they will be the interface, if you like, between the HPA systems and the NHS. And there will be local Public Health Microbiologists as well, around 30 or so, scattered around the country. And I think putting together the local and regional public health microbiology function that is really provided through the HPA will be absolutely crucial in winning hearts and minds. I think it is very much about this culture change and dialogue with the local clinicians and giving feedback as well from the centre, from the seat, from the HPA back to the local teams so that they know what the outcomes are, what the impact is going to be.
  (Ms Blears) I think what I would want to know as well is why do they not do that now and what are the hurdles, what are the obstacles, what are the reasons and then—

  886. You took the question from my mouth.
  (Ms Blears) — to pursue with them what we can put in place to encourage them to be part of the system. I would want to know why they are not.

Lord Oxburgh

  887. Because you are funding them.

  (Ms Blears) Indeed. That would be my answer. That is after the culture change.


  888. It seems to be a very substantial part of surveillance in any case. For 10% not to be participating is not really acceptable.

  (Ms Blears) Indeed.

Chairman: Can we go on to question nine? Lord Rea?

Lord Rea

  889. This concerns the issue of targets to encourage desirable aims and activity. I am sure that you are now quite wary of targets because they can sometimes be more of an incumbent than a spur. How do you feel that they apply to raising the profile of communicable disease control and setting priorities in primary care and hospital trusts in that area?

  (Ms Blears) Targets in general I am a supporter of because I do think that you need to stretch the system to get results. I think the most disappointing part about targets is when people perhaps miss a target by one or 2% and their perception is that they have failed completely. There is nothing that annoys me more than when staff work incredibly hard and get 73% as opposed to 75% and there is no recognition for the tremendous progress that they have made. So I think targets are useful but the way that we seem to interpret them in the public sector is that you have to meet them in their entirety. Whereas in the private sector they are something to aim for by which you can measure your progress. So I just think that we use targets in a slightly odd way, or the perception in the public sector is not always helpful. I think target setting is useful but it is not the sole tool of performance management and again it is about what I was trying to explain that you can have targets, which is a bit of a top down approach, but you have got to get buy-in in order to get those targets to mean anything at local level. We already use targets in this field quite a bit and it has helped to kind of raise the profile, focus minds, focus people's attention in these areas but again I think targets have to be in an area where you have got some control. It is pointless setting a target over which you have got no levers so you cannot do anything in order to meet it. All you succeed in doing then is disempowering people because they know it is a completely unrealistic target. So from the areas for targets around here are around screening for specific diseases and immunisation coverage levels, because we can do something about that and people can work hard to try and achieve those. We have got a couple of examples which we are already using around the HIV testing for pregnant women where we brought in the idea of having a universal test for all pregnant women. That was a bit controversial at the time because in places where HIV prevalence was quite low, people questioned was it really realistic, was it needed, was it necessary? And our target there was to increase the uptake of it, first of all, to 90% and try and identify 80% of HIV infected pregnant women during ante-natal care in order to offer them advice and treatment. I understand the 80% target has been met in London two years in advance of when it was supposed to be and my latest figures for the rest of country indicate that it is already met there as well. Which is fantastic news because the number of babies who are now being born as HIV positive has gone down dramatically because once we identify people, then we can use appropriate treatments and appropriate methods to ensure that the children are safe when they are born. And that is a real positive outcome, I think, for anybody involved in that particular area. So that is where a target has had a real effect and what it has done is it has mainstreamed the public health agenda because it is now a mainstream ante-natal service that people are offered the test. In terms of the sexual health and HIV strategy generally that we have just published and that I gave evidence on to the Commons Select Committee, there is quite a lot of targets in that strategy where again the rise in sexually transmitted infections is something which I think worries all of us enormously around chlamydia, gonorrhea, syphilis, all of those diseases now re-emerging in quite horrifying numbers. So we have got targets in there to achieve a 25% reduction in the number of newly acquired HIV infections and gonorrhea infections by 2007 and to reduce the prevalence of undiagnosed HIV and STIs. And we set a national standard that all GU services should offer an HIV test to clinic attendees on their first appointment so that we are trying to make sure that people get the test on their first appointment and also that we get waiting times down because the waiting times in GU services are now too long. So we have got to get people seen quickly and urgently. We have also got quite good surveillance systems to monitor how well we are doing. The unlinked anonymous surveys that we do in relation to HIV are a good way of seeing whether or not we are making progress because again it is no use setting targets unless you are prepared to measure what you are doing. And I think in the Hepatitis B area we have set some targets again for people to be offered immunisation, to get immunisation uptake to 90% by the end of 2006 and we have commissioned a survey to monitor progress in increasing the uptake of the Hepatitis B vaccine. In the longer term we want GU clinics to collect this data as a matter of routine so we that will have an ongoing way of measuring how the Hepatitis B immunisation programme is going. So in the areas of screening and immunisation uptake, I think targets are appropriate and we are certainly keen to move on that level. But again, people have got to know why the targets, what they are designed to achieve, what can I do to help them become a reality and how can I make a contribution? So it is top down and bottom up.

  890. Do you think that targets would be appropriate to in fact encourage the improvement of surveillance of communicable diseases in general? That is one of the aim of this Committee to try and put the case for improving this.
  (Ms Blears) I think targets for improvement are quite important, as well as absolute targets, because I think that there has to be recognition that different people are at different stages or they are dealing with different circumstances. And that is why the score on MRSA hospital acquired infection is actually an improvement score rather than an absolute target because you have to recognise that some places, particularly tertiary centres, will take people with more compromised immune systems and therefore are more likely to get an infection and the circumstances in which they are operating. So if you like, it is the added value argument; if we can see how far people have come, I think improvement scores are quite important because again you are not hitting people over the head in asking them to reach something that is unrealistic, but you are saying "I want to see you make progress". Now in terms of surveillance, I think where we are at the moment is that we want to strengthen the systems, which is why we are getting the HPA and I think that will be more in terms of strengthening words and making it more integrated rather than specific numerical targets at this point.

Baroness Walmsley

  891. Minister, this is going to sound like a rather negative question, but you mentioned earlier that you were disappointed when "certain things" but are you also disappointed when people skew the system in order to meet the targets? Because in this particular field that could be extremely dangerous and it strikes me that people tend to do that when either their personal remuneration or the money attracted to their unit is affected by not hitting the target. How do you propose to ensure that that does not happen in this particular case?

  (Ms Blears) I would be very concerned if people do skew their activity in order to meet targets. I think all of us as Ministers would be because what we are interested in is a decent health service that serves patients properly and there is no credit in the system if the figures lose their integrity because of certain actions that a small, a very small, minority of people might take. We have a real vested interest in making sure that the targets, the information that goes out to the public is trusted and therefore we would not want to see that information undermined in any way whatsoever. I think particularly in the area of communicable disease, then integrity is overwhelmingly important and that is why I am saying at this stage what we want to do is to create a system which is an integrated system, professionals working together feeling like they are delivering something really important for the community and therefore I think I would be loathe to go into the area of numerical targets when what we are really about is building partnerships and building relationships and getting people to have that trust together. So I think I say I am disappointed when people interpret targets in the wrong way because I think that acts possibly as a lever for people to feel that they are constrained in this way. I will give you one example; in the area of thrombolysis, which is an area I deal with in coronary heart disease, we had a target for people to get 75% patients seen within 30 minutes because early thrombolysis saves lives, simple as that. We are not doing it because it is 30 minutes, we are doing it to save lives. The staff came up from a base, I think, of 39% up to 73%. The target was 75 and suddenly a target was not met. Well, they had done a fantastic job and saved hundreds of lives in doing that and therefore I think we need a more mature debate in this country about how we use targets and what the perception is when they are met.

Lord Lewis of Newnham: But Minister, how do you make a decision between 75 and 73 as a target?

Baroness Finlay of Llandaff

  892. My question relates, Minister, to the previous question about targets because another concern, quite apart from the one already alluded to where there may be deliberate misinterpretation, is just sloppy practice. Namely that you are below the target in MRSA detection and whereas septicaemia is a classic where if you are really rigorous and take really good blood samples you are likely to correct it. So if you have got very sloppy practice and you do not even think of it, you will not take the right blood cultures to detect it. So a unit may be falsely low because the process of this target setting and the true measurement actually has not been audited or checked and I wondered what you are doing to make the target setting more sophisticated in terms of better reflecting the clinical process rather than being something for the newspapers to use as a headline because it makes a great banner, does it not, on a newspaper.

  (Ms Blears) Yes, it does.

  893. But it is not an accurate headline necessarily.
  (Ms Blears) I think it is quite a complex area in terms of trying to compare like with like and making sure that you have got the same kind of data about different places. When you are at an early stage—for MRSA, I think we are only just beginning to get the data coming through. It is the first time that we have ever kind of measured anything and that is why we want to go to improvement scores because this is quite fragile data and there needs to be an encouragement to people to report and then we can see what kind of progress they are making rather than setting absolute targets. I think also the Commission for Health Audit and Inspection increasingly will have a role in this, as CHI has through its clinical governance inspections as well. So increasingly in the system we have now got some responsibility for making sure that when we do audit, when we do inspect we are drilling down into what their data systems are like and what they are collecting. I say it is an imperfect science, it always is going to be in terms of performance indicators and performance management, but it is a lot more rigorous than it ever was and that is why I am a defender of targets, if they are used appropriately. Because otherwise we have no way of measuring often what is going on in different organisations. If you think about the NHS, I think every Member of the Committee will know that places vary and they vary dramatically, even with the NHS in this country, from organisation to organisation. So trying to get some national framework in, whether it is NICE, whether it is CHI, whether it is National Service Frameworks, you have got some sense that there is a national framework here. Before 1997 we did not have any national standards in the NHS. So it is a very new approach to say that you get your national framework, then you can have your local devolution, but without that national framework people do not have the security that they have got national standards wherever they should be.


  894. Thank you very much indeed, Minister. We have come to the end of the questions that you are aware of. We have one further one. I wonder, if you were to go through the process again of establishing the HPA, what would you do differently? Maybe you should come back in a year's time.

  (Ms Blears) As I did not go through the process personally because I have only held this post since June of last year, so clearly the Chief Medical Officer's strategy was published before I was in this post, I have to say, having read the strategy closely, I think it is one of the best strategies that we have produced in the Department in terms of its focus and its clarity. So certainly I think I would have responded to that strategy probably in the way that we have. I think the establishment of the Health Protection Agency, from all of my discussions with them, is going to be a positive development for this country in terms of bringing together people from a whole range of professional disciplines, giving them the chance to work together, share good practice and really raise the profile of health protection and infection control in this country. So I have got great hopes for it and, as you rightly say, Lord Chairman, perhaps if we come back in a year's time and have a look whether those hopes have been fulfilled, that would be the best way to see.

  895. Because there are other things on the horizon. In The Independent this morning "European Union launches centre to tackle epidemics" and you no doubt will be aware of this. How will this impinge on HPA and your Department? Would you have an input into their planning in Brussels? Or maybe you are already concerned with that.
  (Ms Blears) I think increasingly issues of this nature will be Pan-European, they are global. Infection, there are no national boundaries. So inevitably there will be an increasing need to collaborate. I would say that I think that our agencies, the previous organisations, PHLS, CAMR, all of those, had an incredible international reputation for the very, very high standard of their work. I have no doubt that that places us in an extremely advantageous position to be a major player in whatever European and indeed global institutions emerge in this field.

  896. Let us hope they draw advice from your Department. Minister, thank you very much indeed for coming along. We have had a longish but very detailed session. It is very good of you and may I thank your colleagues too for coming too. If there are any further thoughts, and there are two questions which you are going to respond to, but in addition to those if there are any other points that you feel have not been explored sufficiently and you would like to explore them further, we would welcome an input from you. You will get the transcript, of course, and be able to make factual corrections, if any. But that just remains for me again to thank you very much indeed. It has been very productive.
  (Ms Blears) Thank you, I have enjoyed it too.

previous page contents next page

House of Lords home page Parliament home page House of Commons home page search page enquiries index

© Parliamentary copyright 2003