Select Committee on Science and Technology Written Evidence

Letter from Dr Jon S Friedland, Imperial College School of Medicine

  This letter is in response to the call for evidence by House of Lords Sub-Committee on "Fighting Infection" and is written on behalf of the clinical members of one of the largest Academic Departments of Infectious Diseases and Microbiology in the UK. We are based at the Hammersmith Hospitals NHS Trust and Imperial College London and include nine Honorary Clinical Consultants in Infectious Diseases and Microbiology (Senior Lecturers, Readers and Professors) in addition to a strong non-clinical constituency. Our department is pioneering in many ways including in the development of surveillance with the appointment of the UK's only hospital epidemiologist/infection control doctor who is a trained Infectious Diseases physician (cited in the National Audit Office report). We have made a limited number of comments directed towards specific aspects of infection management in hospital.

1.   Providing the service

  There is a major shortage of specialists in infection in the UK to deal with community- and hospital-acquired infections. This also means that there are few people to educate the next generation of doctors. The demands placed on infectious diseases are increasing for many reasons ranging from the increased global mobility of populations (we see about 100 new cases of tuberculosis at this hospital each year) to the ever more complex problems arising in the face of sophisticated immuno-suppression protocols for treatment of malignancy, in organ transplantation etc. Despite this, there remain Teaching Hospitals in the UK without any infectious diseases physicians and few district hospitals have been bold enough to appoint one. The fact is that there are only about 100 ID physicians in the UK (many of whom are academics) and nearer 3,000 in the USA although their population is not 30-fold greater (The British Infection Society should have more exact figures). The need for more trained physicians to guide treatment and patient management can be highlighted by considering any response to bio-terrorism when there are likely to be relatively few people available to respond to a large scale attack. In addition, there needs to be encouragement to Universities to appoint academic clinical microbiologists who can lead translational research for new methodologies for rapid diagnosis of infection, typing of outbreak organisms, and detection of antibiotic resistance.

2.   Training issues

  In our department, there is close liaison between infectious diseases physicians and clinical microbiologists which we believe is essential in the modern era. We developed the first UK training scheme designed to generate future consultants in infectious diseases and microbiology who will straddle the disciplines. The competition for these posts is fierce yet there are less than 10 such schemes in the UK. This needs overt encouragement for the working pattern found in many hospitals of infection services provided by single-handed microbiologists with inadequate time to visit the wards is no longer tenable. The future is the development of large joint departments of infection including ID, microbiology and infectious disease epidemiology with category three isolation facilities to deal with dangerous pathogens/potential terrorist biohazards in all large centres of population and certainly in Teaching Hospitals.

3.   Surveillance of infection

  The Hammersmith Hospitals epidemiology service is led by Dr. Holmes and is involved in pioneering many schemes (eg antibiotic prescribing, neonatal bacteraemia, dialysis-related bacteraemia and orthopaedic surgical site infections etc). Some projects are based in West London, the orthopaedic study is funded by the Department of Health and the dialysis study involves international collaboration with The CDC in Atlanta. However, country-wide the situation is that little is known about the local epidemiology of infection or even the patterns of bacterial drug resistance (with the decreasing GP surveillance cultures). Better surveillance will lead to improved antibiotic usage and may slow the emergence of antibiotic resistant organisms although ultimately this is often an international problem.

  There are two key problems in surveillance and prevention activities in the UK. The first is the lack of direct involvement of clinicians and clinical ownership of the process. This needs to be embedded in integrated care pathways and within the clinical governance systems in hospitals. There is a need for concurrent fully trained infection control teams and real-time bed management so that isolation rooms can be used to the full. The second major issue is the woefully inadequate investment in the necessary information technology and including personnel.

4.   "Getting ahead of the curve"

  A consequence of the proposed changes is that many PHLS laboratories will transfer to NHS Trusts. A robust system needs to be put in place that ensures the opportunities for co-operation in the gathering of surveillance data is not compromised by this change. Having uniform computer networks that facilitate rapid collection and collation of data is essential.

5.   Co-ordination of health targets

  There is often disjointed thinking between and within government departments. For example, there is great pressure to clear A&E and then admitting wards of patients which may result in considerable patient movement within hospitals and transmission of infectious and possibly antibiotic-resistant organisms.

6.   Educating the public

  The Government needs to educate the public about the real risk and hazards of infection so that the level of alarm in response to each outbreak is more controllable. At present, many patients in hospital believe MRSA bugs will kill them when the truth is that they are often not pathogenic. The UK has a culture of secrecy and we have a lot to learn from the Centres for Disease Control, Atlanta, USA and others about communication with patients, potential patients and their relatives. The information provided about plans for responses to bioterrorism in the USA is a good example of pre-informing the public.

7.   Making the future happen

  A critical issue is that new vaccines and treatments are needed. This requires a far greater development of understanding of disease processes; something which is just beginning in the modern era of genomics and immunology. Whereas there are specific charities directed to raising funds for cancer and heart disease who support large amounts of research, this is not true in infection. A large injection of cash is required in a ring-fenced environment. Although some of this funding may be best directed at focused, near-development large programmes of research, this may be a more appropriate time to encourage involvement with pharmaceutical companies. There is a critical need to allow new ideas about pathogenesis and treatment of infections to develop in smaller groups working on basic science where the clinical output is not explicit. It is known that goal-directed university science does not necessarily produce the best new ideas—a famous example relates to monoclonal antibodies now used world-wide for many different therapeutic and diagnostic purposes which were not developed in Cambridge as part of a clinical project. The important thing is to have the infra-structure to allow promising and unexpected developments that emerge in science to be harnessed, something that did not happen with monoclonal antibodies. It is also necessary for the Government to realise that science is an international not a parochial enterprise and cannot exclude partner countries.

  We hope that these general comments from our department will be of some use to the Sub-Committee.

October 2002

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