Examination of Witnesses (Quesitons 260-279)
MRS DAWN
PRIMAROLO, MR
JIM FITZPATRICK,
MRS SANDRA
WEBBER, DR
RAY JOHNSTON
17 JULY 2007
Q260 Lord Paul: Would you encourage all
airlines to adopt the procedure of this particular airline that
you are not naming?
Dr Johnston: Yes, I think clear communication
and information allays anxiety and to prepare for travel, if you
have a medical condition, is very important and I think wider
information is disseminated by a number of airline websites. I
mentioned one in particular but there are other airline websites
which are also helpful. I think the individual has a responsibility,
if they have an illness, to do a risk assessment, in their own
mind to say, "I have this condition. Let us seek advice whether
it is going to preclude travel", because the majority of
medical conditions can be carried on airlines.
Q261 Chairman: A lot of people do not
use the Internet, surprisingly, but they do not. Is there literature
placed in the waiting rooms of surgeries?
Dr Johnston: Luckily, my Lord Chairman, I have
not been to my general practitioner for some time, but, yes, there
are hard copies of pamphlets on safe travel, etcetera, that are
available, although, as we have said before, the majority of information
is moving towards the Internet and I think a number of people
one would think would not use the Internet do use it quite successfully
at all ages of maturity.
Q262 Lord Haskel: I wonder if we could
move on to the question of seating and the seats on aircraft.
In 2001 a CAA funded study was published into the relationship
between aircraft seat dimensions and passenger size. It seems
that the impact of this study was that it was studiously ignored.
For instance, the study found that "the current requirement
does not provide enough space for taller passengers to adopt the
`brace' position. Seat pitch would have to increase to at least
35 inches to provide an optimum safe brace position". Is
it rather irresponsible to have a minimum seat pitch requirement
of 26 inches?
Jim Fitzpatrick: I will ask Dr Johnston to comment
further in respect of your secondary point, your Lordship, but
I can say it was in response to your Committee's recommendation
in 2000 that the CAA funded research study into the relationship
between aircraft seat dimensions and passenger size was published
in 2001. This was submitted to the joint aviation authorities.
Although the seat spacing issue is not currently on the European
Aviation Safety Agency rule-making programme, it will need to
be addressed by EASA once it assumes responsibilities for regulation
of operations, expected early next year, as we discussed earlier.
The CAA is the only regulatory authority to have made regulations
on seating which relate to spacing on safety grounds. The UK is,
thus, the only country to specify a minimum. The UK minimum seat
space criteria require that the minimum distance between the back-support
cushion of a seat and the back of the seat in front, as you mentioned,
is 26 inches in the upright position, and most airlines give information
on their websites, but I am not sure if Dr Johnston wants to add
some more information to that.
Dr Johnston: I think that has been well summarised
in relation to EASA. Looking at the current European and, indeed,
Asian airlines, I could find no airline which operates a 26-inch
pitch, and also in that report, my Lord, it said the seat pitch
should be increased to 28 inches, and every airline that I have
researched has a seat pitch greater or equal to 28 inches, and
that includes scheduled carriers, charter carriers and, indeed,
low-cost carriers.
Q263 Lord Haskel: Who is responsible
for laying down a minimum seat pitch?
Dr Johnston: At the moment in the UK we have
a minimum seat pitch, but until EASA examine this when European
operations come in, in 2008, the data to which you allude is with
EASA at present.
Q264 Lord Haskel: So at the moment any
airline can put any seat pitch that they want?
Dr Johnston: I think that if an airline produced
a pitch that was less than 26 inches, that would be a problem
in the current legislation and, since no airline is near 26 and
the minimum I found was 28 inches, I do not think that situation
would arise. If one got down to 26 inches, I think the public,
who are becoming increasingly selective in how they travel, would
vote with their feet.
Q265 Lord Haskel: Current minimum seating
spacing leads to passengers being unable to change posture and
seating position at will. Also, you do not have much room to move
your legs to assist the venous flow that you were telling us about.
Do you think the Government should do more to encourage airlines
to provide seating as a standard which meets the health needs
of the passengers?
Dr Johnston: I am passionate about evidence-based
medicine or evidence-based changes and until there are data which
suggest the current seating pitch causes a health problem, I do
not feel this is an urgent issue. In the previous reports we have
talked about dropping the title "economy class syndrome".
It is not an economy problem. One can get a deep venous thrombosis
in a business class seat and, indeed, a first-class seat, and
one could almost argue that if one had more space one might adopt
a policy of not moving at all, plus a little alcohol to help the
relaxation. So, I do not think there are data there to substantiate
a health risk in the current seat pitch, and I have sat in a 28
inch pitch on a ski flight and I could still move my feet in the
appropriate manner.
Q266 Lord Haskel: So on what basis did
the Government decide to levy a higher rate of air passenger duty
on the premium economy seating? After all, the premium economy
seating is not necessarily a luxury; it is the space which is
in line with the findings of the 2001 research?
Dr Johnston: I will pass that on to my colleague.
That is not my area of competence.
Mrs Webber: I have to say that air passenger
duty is a Treasury decision, but I can say that I believe that
health and safety were not relevant to the decision, it was taken
on economic and financial grounds, and, indeed, as Dr Johnston
was saying, had no health or safety impact because there is no
link, and I believe, as some of the airlines mentioned when they
gave evidence here, they were not happy about where the borderline
fell in the Treasury decision and they are still discussing with
the Treasury whether they can persuade them to make any change.
Q267 Lord Haskel: So is that one of the
things that you will take to the European Aviation Safety Agency
when it assumes responsibility for regulations in 2008?
Mrs Webber: They will not have any responsibility
for tax collection. The air passenger duty is a tax, and that
will not come into it.
Q268 Lord Haskel: So are you going to
make any other representations to them apart from this matter
of seat spacing?
Mrs Webber: EASA is developing its competences.
It started out with aircraft registration and I think the next
phase it is moving on to is the pilot licensing area, and it is
looking to take on health responsibilities in the future. They
have asked us to go and visit them, which we will be doing in
the autumn, to talk about what we would see as the priorities
we would want them to pursue, and one of those would undoubtedly
be, for example, to contribute to the WRIGHT Phase 2 or to ensure
that there is a European contribution to the WRIGHT Phase 2. So
I do think that we in the UK do have a good opportunity to influence
the way EASA develops its programme, because the UK is renowned
amongst European countries as being one of the more advanced in
terms of the whole history of the aviation industry and aviation
regulation, and I am sure we will have as much influence as anybody.
Q269 Lord Haskel: So you would see passenger
health as one of the top priorities when you go to see them?
Mrs Webber: They have asked us to come and talk
to them specifically about that. They are already dealing with
a lot of safety issues, because they have started their work already
and they are gradually accumulating responsibilities, but they
know they have got to take on health and they have asked us to
come and help them develop their programme.
Q270 Lord Colwyn: In the answer to question
one, or it may have been the introduction, Mr Fitzpatrick said
that the UK is actively involved on the EU-led Ideal Cabin Environment
Project. I wonder if you could actually say what the goal of this
research is and what impact do you think it will have on government
policy?
Jim Fitzpatrick: If I may invite Dr Johnston
to respond to those questions. He is the medical chair of the
ICE project, so he is ideally suited to give you what you need
by way of an answer.
Dr Johnston: Thank you. The Ideal Cabin Environment
is a pan-European project which addresses the European Strategic
Agenda to a highly customer-orientated air transport system and
really arose from the concern about health, well-being and comfort
of passengers. It is unique in its approach, looking at health
and well-being, and the concern has also increased with the changing
passenger demographics in that a larger proportion of more elderly
passengers are travelling. The figures from Stansted show that
from 2000 to 2006 the number of passengers over the age 60 has
increased from 11% to 17%; so a significant increase in the older
passenger. My particular role is to ensure the total integrity
of this project, to provide guidance to the project teams and
to ensure that the consortium takes account of other pertinent
research and to chair the stakeholder workshops. What we want
to look at, the key objectives, are the impact of cabin pressure
(ie altitude) on aspects of well-being and health, the interaction
of the environmental comfort factors, their variation over time
and their relative contribution and sensitivity to changes that
we might make. The population that we looked at was approximately
1,500, equally divided, 50% male and female, in three particular
age groups, 18-34, 35-50 and 50 years plus. In addition, because
of the perception of cardiac and respiratory problems causing
a risk in travel, we had a subset with cardiac and respiratory
disease. A number of environmental conditions were examined—temperature,
relative humidity and a range of cabin altitude from ground level
to 4,000, 6,000 and 8,000 feet. Psychological well-being was also
assessed by questionnaire and, in addition, heart rate variability
and monitoring of skin electrical changes to address the stress
issues. This work was done on two ground-based facilities, firstly
in the UK at the Building Research Establishment in Watford and
the Fraunhofer test facility near Munich. Both these rigs consisted
of a forward fuselage of an Airbus wide-bodied aircraft which
can be configured to a variety of seating pitches to replicate
either economy or business class, and this study was done in an
economy pitch. However, the test rig in Germany is unique within
Europe in that one can change the pressure within the rig to simulate
altitude. The ultimate aim of this project is to set a new European
standard once the data are analysed. The study was completed approximately
eight weeks ago and the data are currently being put into the
database and the study will report formally towards the autumn
2008.
Q271 Lord Colwyn: That sounds very comprehensive.
So, could you be confident and say that, in your opinion, this
study will go some way or will it completely put an end to the
current concerns about cabin air quality, humidity and cabin pressure
that is raised by passengers and crew?
Dr Johnston: I think it will produce some excellent
data. I mentioned earlier I was passionate about evidence. I think
we will have evidence on humidity figures, we will have evidence
on altitude, ie cabin pressure, and we will have evidence on heath
and well-being; and getting all those parameters together for
the first time, I think, will be a major step forward. The other
concern you mentioned, cabin air, will be addressed in further
research we will talk about perhaps a little later in relation
to measuring in a real aircraft, not an artificial situation,
what exactly is in cabin air.
Q272 Lord Colwyn: So you are confident?
Dr Johnston: I am extremely confident. I think
it is a world first, it is innovative and it is a privilege to
work on this project because its pan-European, people are coming
from a lot of different directions, but they are all passionate
about saying, "Let us get the evidence and then work on the
evidence and not anecdote, because only with evidence can we move
forward."
Q273 Earl of Selborne: Dr Johnston has
said that vulnerable passengers have a responsibility to take
advice before they travel, and I imagine that most would seek
advice from a GP. Could you tell us what has been done to enhance
GPs knowledge of health implications of air travel and to what
extent have the medical royal colleges and other medical groups
been involved in disseminating such advice to GPs?
Dawn Primarolo: Clearly Dr Johnston has touched
on the research that is published and that doctors have access
to and read, but there is more information online to advise particularly
GPs on this issue, and for members of the British Medical Association,
the BMA produced a document and circulated it on the impact of
flying on passenger health. So there is a great deal of information
that is disseminated to GPs to make them aware (if they are aware
that their patients are travelling) of what advice should be given
vis-a"-vis their conditions.
Q274 Earl of Selborne: To what extent
have the medical colleges been involved in disseminating this
and consulting particularly on some of the specialities? You might
be able to give special advice on particular conditions.
Dawn Primarolo: I believe that that advice is
available, but I will double check and give you a note on that
with specifics. The GP, particularly where their patient has a
condition that would make them high risk, should already, one
assumes, be aware of this and have flagged it up to their patient,
whether or not they know they are travelling, in case they are
travelling, but I will certainly go back. Forgive me; I do not
have that information before me on the particular role of the
royal colleges. I do not know whether Dr Johnston might know that.
Dr Johnston: Things have changed, as your Lordships
may be aware. The content and standard of training in relation
to physicians is really now the responsibility of the Postgraduate
Medical Education and Training Board (PMETB) and the General Medical
Council has the particular role of ensuring that students and
newly qualified doctors are equipped with the knowledge, skills
and attitudes essential for professional practice. As regards
the Royal College of Physicians in London, myself and my colleague,
the Chief Medical Officer, Sally Evans, are talking on aviation
issues to the college in October and the college sees this as
an area of interest.
Q275 Earl of Selborne: The British Thoracic
Society has published excellent guidelines on managing passengers
with respiratory disease planning air travel, and this is clearly
an excellent example. Do you think that the Aviation Health Unit
should encourage other specialist organisations to prepare similar
guidelines?
Dr Johnston: My Lord, I think that would be
interesting and I think it is again getting more evidence. The
particular meeting to which I allude in October is being organised
by cardiologists, and I think that would be an excellent window
to raise this. I agree with you that the BTS guidelines are a
significant way forward.
Q276 Earl of Selborne: If you get these
specialist groups such as producing reports on respiratory diseases
together and then you get the cardiology, orthopaedic, psychiatry,
why could you not get them all, together, to produce eventually
a comprehensive guide for GPs so you have got the whole lot there
in an accessible form?
Dr Johnston: One of my future aims in the Aviation
Health Unit, but it is no mean task, which does not mean to say
I do not accept the challenge, is to try and bring this disparate
information into one area, ie the Aviation Health Unit, and somehow
give serious consideration to it. I think it is an excellent suggestion.
Q277 Lord Paul: What is your assessment
of information available to passengers and general practitioners
on fitness to fly? How does it differ from what it was in 2000?
Dawn Primarolo: I would hope, through the progress
of this morning, that you would agree with our assessment that
the quality and availability of information is much improved,
both through the Department for Transport, the Department of Health,
the CAA, plus the excellent work of the Aviation Health Working
Group, and, of course, during this time (and I heard the point
that was made) not everybody would have access to the Internet,
but, nonetheless, we have seen enormous growth and development
as the main method of transmitting advice to travellers. I have
touched on this before, the Department of Health website is clearly
sign-posted and there are links to the necessary other sites now
that the Department of Health has transferred the function of
providing travel health advice to the Health Protection Agency
in 2003, but the Health Protection Agency is working in partnership
with the National Travel Health Network Centre and, likewise,
Health Protection in Scotland and, of course, the Aviation Health
Unit provides links to websites for travellers as well, as does
the Foreign and Commonwealth Office website. So, there are a large
number of places where that information can now be got. The information
would be, if you have these conditions, you should consult your
GP and, as we have explored through the session this far this
morning, that needs to be improved, to join together more information,
making sure that GPs and travellers are aware of potential risks
and the right questions to ask and, therefore, the solutions to
mitigating that risk.
Q278 Lord Paul: Given the change in the
demography of the flying public and the prediction that by 2030
older people will outnumber younger adults by a fifth, should
the Government take the lead on recommendations on fitness to
fly?
Dawn Primarolo: I think that actually Dr Johnston
touched on some of that when he talked about the demographics,
the travellers in terms of different airports, different carriers
and the changing age profile and, therefore, the need to have
the evidence associated with understanding the composition of
the travelling public. Therefore, yes, given that we would follow
the evidence, you could see it emerging that there would be specific
advice for a particular age group but, let us be clear, risk exists
across all the age ranges. We are healthier, Lord Paul, even though
we may be older and, therefore, age may not be the determining
factor, I think, certainly in my case anyway. So, in short, yes,
we have got to keep looking at the evidence, where it directs
us and making sure that the appropriate advice is available to
the traveller through all the different websites and, of course,
to the medical profession on what would be appropriate mitigation
of any risk.
Q279 Lord Paul: Should the National Institute
of Health and Clinical Excellence be involved in recommending
best practice with regard to travel advice and fitness to fly?
Dawn Primarolo: I think not, Lord Paul. I think
the Health Protection Agency is the appropriate body and has the
remit to do that. The remit for NICE is quite different and, therefore,
I do not think it would be appropriate to ask NICE. If the Committee
has observations about how the Health Protection Agency might
improve what it is doing, then of course we would take those comments
on board.
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