Select Committee on Science and Technology Minutes of Evidence


Examination of Witnesses (Questions 260 - 279)

TUESDAY 1 NOVEMBER 2005

Ms Rosie Winterton MP, Dr David Harper and Dr David Salisbury

  Q260  Baroness Sharp of Guildford: This brings us back to the question of PCTs and GPs and the role they will be playing. You have assured us that PCTs and health professionals will get very specific advice but can we raise some specific questions to reassure us as to how you see these things playing themselves through? Will the PCTs and GP targets on patient access be suspended in the case of a pandemic? What steps are you taking to expand the critical care facilities in the event of a pandemic? How far will patients gain rapid access to antiviral drugs in the event of a pandemic? What information would someone, for example, ringing up NHS Direct with flu-like symptoms be given in those circumstances? I wonder if you could give us a little bit of advice on these things.

  Ms Winterton: Again, I hope the Committee might find the information we are going to pass round helpful. In fact we can pass that round now. (Documents circulated) It is quite important to remember that in terms of information dissemination what we really need to do is make sure we disseminate the appropriate information at the appropriate time, and I think there have been some people who say, ­We want the answer to XYZ now", and quite frankly we might get very confused messages if we started to do that. What we have done at the moment through the information and through the websites is at the moment send out to GPs what they need to do now and essentially that is about understanding pandemic influenza in the first place. I am sure it would be highly unlikely, if not impossible, a GP would be confused about that, but obviously we want to be absolutely clear everybody is able to explain the difference between bird flu, seasonal flu and a pandemic. We want them to ensure they are keeping a very close eye out obviously because as frontline professionals they are able to assist, if you like, the surveillance and reporting. We want them to liaise with Primary Care Trusts about their plans so that the two of them they are aware. What is important is that at the moment we establish the relationships between GPs and those they would be working most closely with in the event of a pandemic, so that it is quite clear what would happen and who is doing what. I can understand that some people would say, ­We want to know everything now", but quite honestly we have to give out the information depending on the circumstances of the moment. I can assure the Committee that we do have advisory groups, and Lady Sharp has mentioned particularly the issue of intensive care and we have an intensive care working group with Professor Menon who has joined that and is able to give us advice on those various issues. So we are trying to pull together the relevant professionals, stakeholders and others to make sure we can effectively communicate, quite rightly, the issues people want to know about.

  Q261  Chairman: Would you consider suspending the targets that PCTs and GPs normally have if there is a pandemic?

  Ms Winterton: We have to respond to the circumstances of the moment. There is no doubt we do have to look at what would be the effect perhaps on elective surgery if there were a very, very severe outbreak. It would be ridiculous to say we would not look at that. Again, I would say those are decisions which are not only being looked at in terms of the implications of all sorts of areas, in terms of how hospitals, PCTs, GPs operate, of course we look at that, but the message we have to get over very clearly is that there is not a one-stop answer because it absolutely depends in a sense on first of all the severity of any virus but also on the age group which might be affected. We know that the 1918 flu affected people of working age more than older people, so again there may also be issues there in that if somebody had lived through those outbreaks certain age groups might be more resistant, so we have to look at all those implications and make sure what we are not trying to do is set in stone something which will need to be flexible depending on the circumstances of the time.

  Q262  Chairman: Do you think we could get into a situation where people would have to diagnose themselves? If that was the case, how would we cope with the distribution, for example, of antivirals? It could get to be a very large problem.

  Ms Winterton: What we are being very clear about is that PCTs and others have mechanisms in place for distribution. In terms of self-diagnosis, part of our obvious communications strategy would be for people to look out for symptoms in themselves and their families, certainly that is what we would hope but obviously we would want health professionals being involved in (a) confirming that and (b) distributing any antivirals or treatment as was appropriate.

  Dr Harper: We are looking at a whole range of scenarios and if it developed into a situation where it was necessary for people to confine themselves at home, we would look at Primary Care Trust level to have in place arrangements to get the antiviral to the people who needed them. That is the sort of consideration we are looking at right now.

  Q263  Baroness Finlay of Llandaff: I think we understand that when you are dealing with an unknown you cannot give hard and fast answers for X number of people who are going to be affected, but it sounds as if a lot of this planning is going from the centre out in terms of distributing whatever stock of Tamiflu there is or having algorithms to decide at which point people trigger their ability to have the drug. My concern is, in a changing situation how are you going to get the information back into the centre from the ground to know over 24 hours how rapidly stocks are being raided and therefore how much is left and whether the threshold has to alter so the information going back out to the periphery is altered. Whilst you can have information going out there is the feed-back loop coming back into the centre and I am not clear from the way people have been talking how that really grassroots information is going to go rapidly back to the centre to alter policy. There may come a time when we have to say to GPs, ­Forget your targets, just treat that, don't worry, you will be paid, your staff will be paid" and it will be important to do that to maintain the morale of people who are still working. Similarly, you may have to say, ­We suspend all NHS targets" and have a decision taken rapidly, and you can only do that if you have information coming into the centre.

  Ms Winterton: We have the experience for example of what we have done during severe winters, and we have set out what I think are very good information reporting systems. Over the last few years we have been able to get very quick advice on what was happening, for example in accident and emergency services or ambulance services. We do have very good systems of reporting now, including on winter flu as well. So I think we have those structures in place but, through the communications programmes we are distributing at the moment, we are making it very clear we want the connections to be made between different health professionals. If you have a look at the letter we sent out to GPs, it is saying, ­Make sure you are in contact with your PCTs in terms of distribution and so on, that we work through Strategic Health Authorities." We do have quite clear ways of being able to set this up. I take absolutely your point that that needs to be a two-way system but I think in terms of what we have set up not only have we built-up expertise over a number of years in terms of communicating with the service through those structures, which I think have been very effective, but also in emergencies as well. I know that we can at the centre get information very quickly about what is happening in individual service areas.

  Dr Salisbury: You make a very important point about the need for information to be coming back both in terms of burden of disease and on issues such as how many people have been given Tamiflu, how many people are going to hospital and what their outcomes are. We have already been working to raise the sensitivity of all our existing flu surveillance systems so that the Royal College of General Practitioners' central surveillance system is increased in its scope and sensitivity so it reports more often and we get better coverage across the country. So some of this is being done. We are also putting in place a means of bringing together a whole lot of the surveillance work including real time data from general practitioners on the number of people they are seeing daily, the number of people they are treating daily, what they are treating them with, and all of this will come into a gateway which can be accessed by the Health Protection Agency so that they can be doing the epidemiological surveillance, and the modellers can be taking data and making projections on the pattern of the pandemic which will then allow informed policy decision-making and we can look also across the whole country.

  Q264  Baroness Finlay of Llandaff: Does that work across the four countries? I say that living in Wales. If it starts with us, is it going to work across all the borders?

  Dr Salisbury: All I can tell you is that the meetings I have been chairing have all four countries represented and they are working together on surveillance.

  Q265  Lord Patel: Is this not an important point because in the evidence that we heard from the General Practice Research Unit, their anxiety is their ability to do this surveillance. I agree that the surveillance we have through the general practitioners in Primary Care is very efficient but we have to maintain that, particularly in a situation where a pandemic is about to start or has started when we need it. The evidence we have had from the General Practice Research Unit suggested their contract runs out with the Department I believe in April and there are no current plans to renegotiate this contract. Is that right or wrong?

  Dr Salisbury: I have to say that is probably wrong in that we have already been having discussions with the RCGP about their central surveillance scheme, including expanding the scheme to take in parts of the country which were not previously covered. One of the considerations which has been paramount in this whole concept of expanding surveillance has been resilience. Whatever we put in place has to work at a time when Primary Care could be extremely busy.

  Lord Patel: I am pleased Scotland is included.

  Q266  Lord Howie of Troon: Chairman, I would like to apologise for my late arrival, I thought the Minister was arriving at 3.30 and I apologise for my discourtesy. I have a somewhat naïve question arising from something you said, my Lord Chairman, about self-diagnosis. If it has been answered in my absence, just tell me to go away and read the transcript. Suppose you are taken ill and you think you might have something, is there some kind of general public guidance which says, ­You have got  .  .  ." whatever it is? What I have in mind is a year or two ago I had a flu injection and I became ill a couple of days later and I had pneumonia. Can I distinguish between pneumonia and this thing? Is there guidance to help me so I do not burden GPs unnecessarily?

  Ms Winterton: I suppose we have to be quite clear as to what we might be talking about at this stage.

  Q267  Lord Howie of Troon: Which I am not.

  Ms Winterton: Obviously if you were talking about avian flu which you might have caught from a bird -

  Q268  Lord Howie of Troon: No, from a person, that is what I am thinking of really.

  Ms Winterton: Okay. I think there are two things because to a certain extent there may well be, and I will have to ask my colleagues to help me out here, particular symptoms we would be very clear about.

  Q269  Lord Howie of Troon: I would like to know what these are.

  Ms Winterton: I will ask them to explain them. Obviously there are symptoms of seasonal flu that will differ from that and in a pandemic if the virus had mutated into something which was passing very quickly between humans I suppose it might be different again. There might be some similarities but I think one would be, in the latter situation, having to issue, if one could issue, much more detailed guidance at the time when it was known what the real symptoms were so as not to worry people about other symptoms which may not be related.

  Dr Salisbury: The public information material which we have prepared has been done so each stage of our preparation matches the WHO levels of building towards a pandemic. So we have got in preparation public communication materials as we get towards and have a pandemic. Included in those materials, which we have already market-tested with the public, are descriptions of signs of symptoms, so the public will be receiving information that not only tells them what sort of things to look out for in terms of flu-like symptoms but tells them what to do about it and also tells them where they can get more advice. Much harder is telling them about everything else which is not influenza. During the times when you do not have a pandemic, clearly you are going to have to take great note of people who think they have got pandemic flu to see what they have got. At the time of the pandemic, most people with flu-like symptoms will have influenza, and the routes through which they can get advice will be made clear to them and we will have advice which is made to them through NHS Direct. All of this work is well advanced in terms of communication materials.

  Q270  Lord Howie of Troon: What I have in mind is this: when many years ago you got the Black Death, you had a fair idea you had something pretty serious. Are there clear guidelines so you can be sure that what you have not got is a broken ankle?

  Dr Salisbury: Again most people in the course of a pandemic who have got flu-like symptoms will have influenza.

  Q271  Lord Howie of Troon: Ordinary flu?

  Dr Salisbury: No, the pandemic flu.

  Q272  Lord Howie of Troon: They will be much worse then.

  Dr Salisbury: They may be much worse but we do not know how the virus will manifest itself. We do not know until it starts. We can have general ideas of the signs and symptoms based on seasonal flu but what we cannot tell is whether there will be different presentations affecting different age groups differently. For that we have to wait and see. We know in 1918 the signs and symptoms and the age groups affected were quite different from ordinary seasonal flu. We just do not know. The population distribution in 1918 was very different from now when the number of people over 65 was of the order of 1 per cent at that time, and now of course it is very much higher.

  Q273  Lord Howie of Troon: Happily.

  Dr Salisbury: Absolutely. So there are many differences which we will have to wait and see before we can get advice on some of those narrow specific points.

  Q274  Lord Howie of Troon: So you are very unlikely to know if you have really got it unless you panic?

  Dr Salisbury: I think most people will know what they have.

  Q275  Lord Howie of Troon: Will they?

  Dr Salisbury: Yes, they will, and the advice we are preparing will help them both look after themselves and know where to go to seek further advice.

  Lord Howie of Troon: Thank you, Chairman.

  Q276  Lord Mitchell: I wanted to take Lady Finlay's question a little further, and that is the issue of communicating data from the ground level up to the central point. It is not an unfair comment to say that despite the spending of huge amounts of money in the NHS, information systems have not quite become a beacon of best practice. I know an awful lot is still cooking and due to happen but I am an information technology person and anything to do with the NHS just fills me with horror, and I have a degree of scepticism when I hear in the case of a pandemic suddenly there will be this magical information flowing to you in Whitehall. I would like to be reassured if I could.

  Ms Winterton: I can only reiterate what I have said about the experiences we can build on in terms of recent passing of information when it has come from our winter plans. During the winter we look very closely at the information that goes from the frontline back to the centre; we have had a lot of experience building that up and I think that is effective. We need to expand that, that is what part of this is all about, because it is in a sense making sure we can cascade that further down to GP and frontline health professional level. That is why we are using the PCTs and the Strategic Health Authorities to help manage that. I certainly am clear that that kind of exchange of information can happen effectively and, as I say, certainly through the winter planning it is almost built into the NHS that it is possible during times when we know there will be extra pressure on accident and emergency services and others and we are very clear when that is going to happen and we can set in place mechanisms to ensure the centre is aware of where there are particular pressures. This will happen and it is necessary to happen very much for example in terms of accident and emergency departments and ambulance trusts, when there will be times when if there is severe pressure on an accident and emergency department it will divert ambulances to other areas to deal with that. There is some very good joint working which happens already because we understand the problems there have been in the past when, during times of heavy use such as winters in the past, the NHS have found it very difficult to cope. What we have done is set in place communication mechanisms now so when those pressures are there the NHS is able to respond very quickly. That is why in a sense during last winter at a time when there was heavy pressure, it was possible for the NHS to achieve for example the four hours' maximum wait for people in accident and emergency. It is quite a feat to do that in the middle of the winter when there are all those extra pressures on the service. So we must build on that and that is exactly what we are doing, but we do have a mechanism we can use very effectively I believe.

  Q277  Lord Paul: Has any assessment been done as to when one has the symptoms how quickly one needs help before things really deteriorate?

  Ms Winterton: What I do know is in terms of Tamiflu if the symptoms develop, it is important to get the treatment there within 48 hours.

  Dr Harper: That is the answer. The quicker, the better between the on-set of symptoms and Tamiflu. It is 24 to 48 hours. The current evidence is that within that 24 hours the quicker you receive Tamiflu the better it is.

  Q278  Lord Paul: So it is very essential to make sure you know that.

  Ms Winterton: It is the ASAP scenario.

  Q279  Earl of Selborne: I was going to ask about guidance on contingency planning. The Government's own revised contingency plan says that, ­local authorities, education establishments and businesses will wish to consider the likely effects of a pandemic on their organisations." One would rather hope they would do more than that and produce co-ordinated contingency plans, and I wondered to what extent the Department can get guidance and indeed encourage such co-ordinated contingency planning?

  Ms Winterton: We are doing that not only through cross-government meetings of top officials to ensure that all departments are aware and are making proper emergency preparedness plans, but also through the ministerial committee DOPIT, rather curiously named, which does look at public services resilience so we can make sure at political and official level -


 
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