Examination of Witnesses (Questions 260
TUESDAY 1 NOVEMBER 2005
Ms Rosie Winterton MP, Dr David Harper and Dr David
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
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
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
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
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
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
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
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 -