TUESDAY 3RD DECEMBER 2002

DR DAVID BROWN, PROFESSOR PAUL GRIFFITHS, DR DEENAN PILLAY AND DR MARIA ZAMBON

  220. Do you feel that you have adequate academic time to develop advances because there are two aspects, one being the service provision for the disease burden that is out there now, and the other one being the thinking time of looking ahead and trying to be more efficient. From what Dr Pillay said about having to go out to get grants, to get in people, it takes time just to look at the data you are already collecting, let alone having thinking time to generate new ideas.
  (Professor Griffiths) I think I speak for us all when I say we do not have enough of that thinking time. What we have said from the network point of view is we want to employ appropriate people, non-medical scientists, grade C and grade B, in each of the 20 centres whose specific job is to take that best practice from other laboratories and apply it in their particular setting. Those people will be kept busy doing that and rise to the situation where everyone has validated assays nationwide.

  221. What about rolling out into primary care, how much of it is bedside assays?
  (Professor Griffiths) It depends on the type of technology. At the risk of being flippant, we have talked today about bio-terrorism and there is a small potential advantage of bio-terrorism and that is the diagnostic systems being improved as a result of new technologies coming through to pick up infectious agents. That could be rolled out possibly to general practice and possibly also to pharmacists. We have plenty of work and we are not looking to retain all this in the laboratory. We will support the developments as they go forward. Somebody will have to do quality control and quality assurance of those particular assays.

  222. Thinking back to surveillance that may be a problem in terms of getting the data in.
  (Professor Griffiths) Yes.
  (Dr Zambon) The generic point about the introduction of new technologies could mean the introduction of highly specialised, highly skilled technologies such as some of the molecular technologies that Professor Griffiths mentioned where the hospital laboratory is the clear place for those. Then there are other technologies which could be defined as new which are more suitable for use at the bedside or in the GP office. The introduction of such technologies is only limited by the absence of information about how useful they are in practice certainly but also a clear understanding of how they are to be paid for within the health system. For example, with the introduction of a near-patient test for flu, if we leave aside the question of sensitivity and specificity, that may take 30 seconds of hands-on time to do but a total of ten minutes to read. Somebody in the health service who is already over burdened has got to be designated to do that. I think there are some questions about how to introduce new technologies, where is the funding for that? In hospitals in particular, as I have already mentioned, if you introduce new technologies using a pathology budget it is the clinical budget and management that will benefit but clinical budgets do not translate into pathology budgets. The introduction of technologies is limited by a number of different factors but virologists have traditionally shown themselves to be very forward looking in trying to introduce new things. There is plenty of scope for that and loads of things coming.
  (Professor Griffiths) One business plan that David mentioned earlier on is that of a pharmaceutical company making a new treatment for flu or another virus which may subsidise the cost of the test and make it available in pharmacies so people can come forward and purchase their own antivirals, saving Lord Rea some of the work he would otherwise be doing diagnosing. You can see that as a potential route forward. We would not want to hold that back, but we are building up the question of what that might do for antiviral resistance for those particular viruses and also inappropriate treatment. So there are quite a few hurdles and quality control checks that have to be put in that somehow.

  223. That information is disseminated, how do you get the information back to the centre to do that monitoring?
  (Professor Griffiths) Potentially you could get the information from the machine in every Boots shop on the corner.
  (Dr Brown) Obviously that is something that has been thought about. If you think of the influenza diagnoses being made in primary care, you can say there is a case for that but what we want to know is what virus caused that. We have done studies to see whether you can characterise it from the near-patient testing. These are issues that are being looked at.
  (Dr Pillay) Coming back to cost, there is no doubt—and Paul has talked about the molecular techniques that have increased costs tremendously within our own limited budgets—for those of us here who use commercially available assay systems the cost is even higher. There is a potential through the network that has been outlined by Professor Griffiths of laboratories that are specialist enough to enable the innovation to occur but also that evaluation could happen through a UK-wide network for tests that are actually developed using our own skills. That provides huge cost advantages over the alternative, which is waiting until the diagnostic company has produced a kit, and, to be honest, to fleece the NHS. We need to provide the evidence base to convince clinicians and PCTs to pay for this but that is in our hands and I think we should be encouraged to go down that route.

  224. How much should that be linked in with public health medicine because I have a concern which was raised before and you did not answer it really which is about the management of the epidemic because it is not clinical laboratory virologists, so who is going to be handling directions that go out to clinicians on managing the information in the long term in terms of policy making and direction?
  (Dr Brown) There are a couple of points there. The first is what is the relationship between the Department of Health and the agency that is responding and I do not think that has been completely established for the proposed HPA in the future. In terms of what happens at the moment then it does tend to be that a group of people representing the different specialties that can contribute to a response to an outbreak do join with colleagues from the Department of Health to try and make a plan, see what information is needed and how that response is to be made. It is often co-ordinated either at the Department or by colleagues in the Communicable Disease Surveillance Centre. Certainly for virus infections for which I have some responsibilities, I have often taken part in those multi-disciplinary teams although usually as a contributor rather than taking a personal leadership responsibility for it.

  225. Professor Griffiths, in some of your evidence you talk about the UK Clinical Virology Network. When was this formed? Is it a statutory body?
  (Professor Griffiths) Not at all. It was formed informally by the virologists ourselves. We had a couple of meetings, September 2000 was the first one and we were working through our protocols when the document Getting Ahead of the Curve was published and we very much agreed with many of those things so we decided to update our document to make it a response to that. Basically we have no funding. It is internal funds from each individual laboratory supporting our own particular website. I think we can claim to have achieved a few things so far. On the West Nile virus, which David mentioned, there is no evidence of West Nile virus in human CSF samples so far. Although it is negative it is quite good and reassuring in that sense. We have talked about bio-terrorism. There is a pox virus proficiency panel which is being prepared now and sent out to the laboratories that diagnose pox viruses. Hopefully we will not find the smallpox virus in the future but it is important to be prepared. We have mentioned standard operating procedures. We have also made some critical decisions on treatment recommendations. There is a particular infection that I am studying, the cytomegalovirus infection, and our American colleagues have completed a treatment trial showing that those children are at risk of hearing loss but, if they are given an antiviral drug, it significantly decreases the loss of hearing. That is quite important information so we put that on our website. We know from our paediatric colleagues that 50 per cent of children in the UK receive that treatment yet the paper has not been published in the primary literature. That shows the advantage and strength of electronic communication. The last thing that David might want to mention is the use of enteroviral PCRs because we are required to continue telling the World Health Organisation that we are a polio-free country, but how do you tell that? Our own laboratories are looking for enteroviruses using the PCR method. That information can be taken and passed on to David to prove that they are not the polio virus, which is our expectation. All of those things are currently moving forward at the moment despite the fact we have had no funding so far.

  226. Is there a similar body in bacteriology?
  (Professor Griffiths) No, but we would suggest to you this is perhaps a potential model of the professions in one particular area getting themselves organised. We would much rather if funds are to be made available for different areas they are spent on the things the professionals need to run the service rather than on bureaucracy.

  227. Would it be better if microbiologists and virologists were combined together?
  (Professor Griffiths) That is a possibility. Of course, where do you stop? We have our immunology colleagues, we have our haematology colleagues, we have our chemical pathologists and our histopathologists. That is another sort of network in the pathology modernisation network. We need to inter-act with lots of different people. Do we need to be all in one group all at one time? Surely you group together in order to achieve a set of aims. We feel a natural affinity for our particular specialty and a certain amount of enthusiasm for it and if we are going to put our soft money funding into getting that going, that is what we would like to run for.
  (Dr Pillay) I would add that one of the pressures on developing this in virology particularly is it is a very, very small specialty. We are quite diffuse geographically and yet clearly we would benefit enormously from the potential to interact much more than we have done to date. Since there are only 30 consultant virologists in the UK there may not be local support to provide all the professional backing required, so it is the clinical governance issue that needs to be addressed as well.

Chairman: Thank you very much. Are there any other questions? My Lords, if not, that brings us to the end of this session. May I thank you very much indeed for coming along and being so open and informative on our questions. If there is any issue which we have not touched upon but the questions and the answers have caused you to think again, perhaps you can let us have that in writing. I know Lord Patel wanted something from you. Thank you very much.