Cynulliad Cenedlaethol Cymru

Yn ôl i Chwilio

Y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon

Health, Social Care and Sport Committee

04/03/2020

Aelodau'r Pwyllgor a oedd yn bresennol

Committee Members in Attendance

Angela Burns AC
Dai Lloyd AC Cadeirydd y Pwyllgor
Committee Chair
David Rees AC
Helen Mary Jones AC
Jayne Bryant AC
Lynne Neagle AC
Rhun ap Iorwerth AC

Y rhai eraill a oedd yn bresennol

Others in Attendance

Dr Peter Saul Coleg Brenhinol yr Ymarferwyr Cyffredinol
Royal College of General Practitioners

Swyddogion y Senedd a oedd yn bresennol

Senedd Officials in Attendance

Amy Clifton Ymchwilydd
Researcher
Claire Morris Ail Glerc
Second Clerk
Lowri Jones Dirprwy Glerc
Deputy Clerk

Cofnodir y trafodion yn yr iaith y llefarwyd hwy ynddi yn y pwyllgor. Yn ogystal, cynhwysir trawsgrifiad o’r cyfieithu ar y pryd. Lle mae cyfranwyr wedi darparu cywiriadau i’w tystiolaeth, nodir y rheini yn y trawsgrifiad.

The proceedings are reported in the language in which they were spoken in the committee. In addition, a transcription of the simultaneous interpretation is included. Where contributors have supplied corrections to their evidence, these are noted in the transcript.

Dechreuodd y cyfarfod am 09:29. 

The meeting began at 09:29. 

1. Cyflwyniad, ymddiheuriadau, dirprwyon a datgan buddiannau
1. Introductions, apologies, substitutions and declarations of interest

Bore da a chroeso i gyfarfod diweddaraf y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon yma yn y Senedd. O dan eitem 1: cyflwyniadau, ymddiheuriadau, dirprwyon a datgan buddiannau, allaf groesawu fy nghyd-Aelodau o'r pwyllgor yma at ei gilydd y bore yma? Croeso i chi gyd. Gallaf bellach esbonio bod y cyfarfod yma yn naturiol ddwyieithog. Gellir defnyddio clustffonau i glywed cyfieithu ar y pryd o'r Gymraeg i'r Saesneg, ar sianel 1, neu i glywed cyfraniadau yn yr iaith wreiddiol yn well ar sianel 2. Dylid dilyn cyfarwyddiadau'r tywyswyr os bydd y larwm tân yn canu, achos dydyn ni ddim yn disgwyl bod y larwm tân yn mynd i ganu oni bai fod tân yn digwydd. Felly, gyda chymaint â hynny o ragymadrodd, gwnawn ni symud ymlaen.  

Good morning and welcome to the latest meeting of the Health, Social Care and Sport Committee here in the Senedd. Item 1 is the introductions, apologies, substitutions and declarations of interest. Can I welcome my fellow Members of the committee this morning? Welcome to you all. Can I further explain that this meeting will be bilingual? You can use the headsets to hear the interpretation from Welsh to English on channel 1, or to hear contributions in the original language amplified on channel 2. You should follow the instructions of the ushers if a fire alarm sounds, because we're not expecting a fire alarm practice this morning, so it would be a real fire, if it sounded. So, with that much of an introduction we'll move on. 

09:30
2. Sepsis: Sesiwn dystiolaeth gyda Choleg Brenhinol yr Ymarferwyr Cyffredinol
2. Sepsis: Evidence session with the Royal College of General Practitioners

Eitem 2: sepsis. Dyma ein harolwg tymor hir ni fel pwyllgor ar sepsis. Dyma'r sesiwn dystiolaeth gyda Choleg Brenhinol y Meddygon Teulu, ac fel bydd Aelodau'n gwybod, dyma'r ail sesiwn dystiolaeth yn ymchwiliad y pwyllgor i sepsis. Mae'n debyg y buasai'n well i mi ddweud yn y fan hyn, fy mod innau hefyd yn aelod o Goleg Brenhinol y Meddygon Teulu, jest wrth basio.

Allaf groesawu i'r bwrdd felly, i roi tystiolaeth y bore yma, Dr Peter Saul, cyd-gadeirydd Coleg Brenhinol y Meddygon Teulu? Gyda llaw, Peter, mae'r meicroffonau yn gweithio'n awtomatig. Does dim angen cyffwrdd dim byd. Diolch yn fawr iawn ichi am eich tystiolaeth ysgrifenedig sydd wedi cael ei chyflwyno ymlaen llaw. Yn ôl ein harfer, awn ni'n syth i mewn i gwestiynau yn seiliedig ar y dystiolaeth yna a hefyd ar sail tystiolaeth arall rydyn ni wedi ei chael hefyd. Felly, mae'r cwestiynau cyntaf o dan ofal Angela Burns. 

Item 2: sepsis. This is our long-term inquiry, as a committee, into sepsis. This is the evidence session with the Royal College of General Practitioners, and as Members will be aware, this is the second evidence session in the committee's inquiry into sepsis. I should say, in the first instance, that I am a member of the Royal College of General Practitioners. I'll just say that in passing. 

Can I welcome here to give evidence this morning, Dr Peter Saul, who is joint chair of the Royal College of General Practitioners? By the way, Peter, the microphones work automatically, so you don't need to touch them. Thank you very much for your written evidence that was submitted beforehand. As usual, we will go straight into questions based on the evidence that you've submitted and also on the other evidence that we've received. So, the first questions are from Angela Burns. 

Thank you, Chair. Good morning. I wonder if perhaps you could just give us an overview of how, in your opinion, successful general practice and primary care is at identifying potential sepsis cases, and getting them to the appropriate medication quickly enough.

Okay. So, I think it's very much a team global approach that needs to be taken. In an ideal situation, we have a population that's educated in knowing when to ask for help when sepsis is suspected; we have pathways for people to get assessed quickly and efficiently so, typically, through primary care, whether it's in-hours or out of hours. Sometimes, obviously, it may be in A&E departments directly, depending on the clinical situation of the patient. We have staff—. I'm talking mainly in primary care here. We have support staff, receptionists, who are trained to be able to identify people who need rapid, urgent assessment and systems within practice that allow them to be seen promptly, whether it's an urgent house call or an urgent appointment in the GP surgery. We have a workforce of GPs and other clinicians who are trained to be able to identify sepsis, which is a relatively uncommon presentation, but an important and identifiable presentation.

So, the role of the GP is to identify where we suspect sepsis to make an assessment, because not everybody with sepsis would need to be admitted to hospital. We're fortunate to have the National Institute for Health and Care Excellence guidance, which helps us stratify patients, but to be able to correctly stratify if necessary to start treatment there and then. So, often, this is giving antibiotics immediately in the clinical situation, such as when we have people with meningococcal septicaemia. There's reason to give antibiotics in other forms of sepsis. And then, where it's necessary, we have rapid and appropriate transport to hospital. So, an ambulance service that we can rely on and that the patient can rely on to turn up quickly and to take them to hospital and then, obviously, we hand over to hospital colleagues where necessary, which is outwith my realm of experience. So, that's what happens in an ideal situation. 

Now, obviously, you can take each part of that and say—. Because, clearly, it isn't—. We still have too many sepsis deaths in the UK and in Wales, and you can deconstruct that and you can look at each part and say, 'How could we do better? How can we better inform the public? How can we make access for patients to a GP and an assessment better? How can we improve the education?' And the college has been, over the last five or four years, which you'll probably see in the report, taking steps to do our best to address many of these issues.

09:35

Can I ask you a slightly more strategic question, because people quite often talk about what are the great challenges facing the NHS in the years to come? Of course, with antimicrobial resistance on the rise, I think from my perspective—and I'd like to hear your take on it—actually, one of the greatest challenges we face is infection. Let's just call it infection. Because, as a society, over the last 50 years, we have got so used to being able to deal with infection with our amazing array of medical interventions that we're concentrating on hearts and cancers and all the other things. But it's kind of come around and bitten us in the back again, hasn't it? Because this whole infection area is now beginning to grow in terms of focus and in terms of, actually, the presentations to hospitals, and how difficult it can be to treat people. Do you think that's a fair assessment—that it's one of the challenges, or not?

I think you're right—it's an important challenge. I don't know if you've got a copy of our document, 'Sepsis Guidance for GPs', which has been sent out to GPs. One of the points in that highlights the conflict between antimicrobial stewardship. So, people not to expect antibiotics when they go and see GPs for common infections, but using them appropriately in serious conditions, such as when we suspect sepsis.

I've been a GP long enough, I'm afraid—and I suspect our Chair can empathise with me—that once upon a time, you didn't really have to worry too much about this, but I'm seeing patients with relatively common infections like urinary-tract infections, which can sometimes go on to develop sepsis, where all the common antibiotics, they're resistant. I get results back from the path lab, and I'm thinking, 'Crikey, they're resistant to all the common ones.' And you get some uncommon one that's hardly ever used, and the lab have identified that it's sensitive to that, and you have to then go and look it up, because you hardly ever use this.

It is a growing problem, absolutely, and something that—. I suspect the answer, really, is in education of clinicians, that we have to be more targeted. We want people to identify important life-threatening conditions, and treat those, but we want them also, when it's not life threatening and it's something that will naturally get better on its own or not be a bacterial infection, not treat it. And it's a continuing thing. It's something that we have to keep—our medical students, our junior doctors, or qualified doctors and nurses, all our prescribers, we have to keep this cycle. It's almost like child protection—you do that every couple of years, you have to renew and get up to date with it.

Just on that point. I appreciate the increase in antimicrobial resistance that occurs, and we want to reduce the use of antibiotics a much as possible. But we've seen so many occasions and there are so many reports where delays in giving antibiotics in a case of sepsis can actually result in death, or even worse in the sense of their condition gets worse and you have a longer term problem as a consequence if you recover from that. You mentioned, 'if necessary, give antibiotics'. Surely, the situation is, if you suspect sepsis, you should give antibiotics, but keep a wary eye on it, and stop doing it once you identify that it's not an issue. Because I would have thought if a suspect—. If it was my family, any of my grandchildren, I'd be saying, 'Why aren't you giving them antibiotics if you think it's sepsis?' Because the longer you leave it, the more likely it is that there are going be serious consequences.

Yes, you're absolutely right. That's why we encourage GPs to carry injectable antibiotics in their bags and have it available at surgeries so that if you see a case where you're concerned there may be acute sepsis, you can give it straight away whilst they're waiting to go to hospital. I think one of the issues is, often, the diagnosis is not clear cut. So, you get somebody who's ill and you're asking yourself, 'Could this be sepsis?', 'Could it be something else?'. Part of that assessment is, 'How ill is this person?', and, 'How quickly have they deteriorated?'. So, if it's somebody who's ill but who's, sort of, not very well, shall we say, and they've been like that for a few days, you maybe have more time to assess and give antibiotics there and then before you've actually found what the cause of the sepsis is. It could be counterproductive because you might give the wrong sort of antibiotics. It might be a way of actually increasing the likelihood of antimicrobial resistance.

So, you are right. I totally agree that, when there is clear evidence of life-threatening sepsis, antibiotics should be given at the earliest possible opportunity. But if you think of sepsis as being a scale, there is more time with the less severe manifestations, providing—and this is a big 'if', if you like—you have arrangements to assess that patient, because if you classify somebody as having one of the—. The NICE guidance gives three categories for sepsis: severe, moderate and mild, and it talks about severe sepsis requiring immediate treatment, but if you're classifying it as one of those lower levels, if you like, it doesn't mean you can just forget about the patient, 'Yes, we've classified them; they can come back and see me next week', sort of thing. No. It means that you have to set clear boundaries, both for yourself as a clinician saying, 'How am I going to make sure that this isn't going to move up the scale?', and, 'How do I tell the patient these are the things to watch for?'. Our guidance says that it's not enough to tell patients, 'Well, if you're not improving in 24 hours, get back in touch'. You have to be specific. You have to give the patient clear guidance. And it comes back to my first statement, that the patient, the person, the citizen is the first step in this getting treatment better to empower them and educate them to know what to do at all stages, really.

09:40

We've got some specific questions about safety-netting towards the end. Angela. 

You'll probably be aware that the Royal Pharmaceutical Society was very clear. They told us that a significant contributory factor for the rise of sepsis in hospital admissions is treatment failure for urinary tract infections in the primary care setting. Would you care to comment on that, because you mentioned UTIs earlier as something that can potentially lead to sepsis?

UTIs are difficult because, often, they're not properly diagnosed, I would agree. So, good practice, we encourage clinicians to do testing, whether it's dip-stick testing or sending off to the lab, and I think most doctors, probably treat more urinary tract infections than we should because the latest guidance, particularly in older people, is that you don't actually need to treat urinary tract infections, so—. Well, sorry, you don't need to treat asymptomatic urinary tract infections. So, sometimes, we get mixed messages. On the one hand, we're saying, 'Right, you've got a positive result. Bacteria there. The patient's not ill', we're being told, 'Don't treat it', and on the other hand, we're being told that patients are being avoidably admitted to hospital with urinary tract infections because they're not getting treated.

So, it brings me back to education and guidance, really, and using the criteria for sepsis for managing suspected sepsis and treating the patient, really, rather than the results. So, I think most doctors—. All good doctors would be treating the patient irrespective of what the results are. It's one of these things in medicine where there is no—. Well, it won't be long until I'm retired, but if I wasn't retiring, I wouldn't be worried about artificial intelligence, because it's one of these things that you need an experienced clinician to make decisions about. It's very hard for AI to follow an algorithm. And, I think that making sure that our colleagues have got this experience and expertise is one of the important focuses of medical education.

09:45

Perhaps just one more question, if I may, because the other topics that you raise, I know other Members want to speak about. And I'm sorry, perhaps this is a declaration of interest that I should have made at the very beginning—I'm chair of the cross-party group on sepsis. The cross-party group sent out a questionnaire to all of the general practices in Wales—some 423, I think it is—and the feedback we got was very, very limited. And of the feedback that we had, there was a significant proportion who were—I think to say the word 'dismissive' would be too strong—but who essentially said, 'Look, it's one of the many multiples of illnesses that come through our front door. We're very busy, we're under pressure. There's nothing out there that can help us specifically diagnose sepsis per se; it's a bit of a chameleon, although there are very clear indicators—the shivering, all the rest of it', and I was quite surprised by that takeaway that we got from the GPs. And you talked earlier about an ideal world where the ambulance would turn up on time. Well, we took evidence last week that the ambulances don't turn up on time, ever, let alone to the GP practice because they feel they're in a point of safety. And you made up a comment about not dying from sepsis, but it's not just about surviving sepsis, is it? It's about surviving sepsis well, because it can have catastrophic physical and mental effects.

So, I just wondered if you could, perhaps—having talked about the ideal world—just give us a very quick synopsis of where you think the real reality really is on a day-to-day basis in those very busy GP practices, where receptionists are overwhelmed; they don't have the time to talk to the patients; where patients actually think, 'I feel dreadful, I ought to go to the doctor, but, actually, I'm going to have to phone up loads of times before I can get an appointment, if at all'. I mean, that's the real reality. And the second part of my question is, I wondered if you could give a view on the possible use of C-reactive protein machines in GP practices, because I understand that that's a simple blood test that can take two hours or so to develop and is quite a good way of seeing where someone's infection markers are. And were you aware that, for example, in Anglesey, that whole Anglesey cluster, they've all got CRP machines in there? And what we're looking at now is to see if their rates of sepsis, compared to anywhere else, have dropped because they can actually, very quickly, check where somebody is on that scale.

May I answer that question first?

Although, I probably will have forgotten the first question, so you might have to remind me. Yes. So, CRP is a marker in the blood that measures inflammation, and in any infection, it will be raised. It can be raised in other conditions as well. It's one of these that's coming out for near-patient testing. For example, there are some pharmacies in Wales that do near-patient testing for streptococcal sore throats to help them decide on who needs treatment. And I think it's something that will develop further as time goes on.

The issue that I have—and I'm not an expert on CRP—is knowing what to do in the presence of a positive result. It can be positive for a number of reasons, and it's the sort of thing that, I think, you've got a patient in front of you, and you're thinking, 'I'm a bit worried about this patient', say they've got a temperature, they've got rapid breathing, they're looking flushed and they're not quite 100 per cent. It gives you that extra confidence to say, 'Their CRP is sky high. Brilliant, I'm right; I can deal with this patient'. The issue is where maybe it's not raised. Does that mean, 'Well what do I do now?' The CRP isn't raised. Does that mean everything's all right?' Or the CRP's raised just a bit.

Your point about they're doing some work to find out if it influences, I think that's the key. A lot of this, until about 10 or 15 years ago, sepsis was very poorly recognised and poorly understood, and over that period, we are getting more knowledge about it. I don't know if we're going to come on to the national early warning score, these scoring systems—

—but we don't really know what NEWS scores mean in primary care, because they were developed for a hospital. And the danger is that you get a test or a scoring system or something, and if it's used inappropriately, it can make things more complicated, rather than making them simpler. So, we want to identify things that are going to make life simpler and easier, and I think that's the importance of the study.

Moving on to the first question, which is—I think you were asking me what are the bits—. I described an ideal situation—

09:50

—and where are things going wrong? Okay. Have you got an hour or so? [Laughter.]

I'll probably just start at the GP practice. We've heard about access. I think, as a college, we recognise that access is still not ideal, and we acknowledge and support the Welsh Government's proposals to improve access so that patients have a range of ways of getting in touch with the doctor, face to face, telephone, through electronic apps and suchlike. We accept that there has to be work done on that.

We accept that the front-line staff such as receptionists are often—they're people who do their best, but sometimes, they don't have the knowledge and training, and we need to train them better. I mentioned that the Royal College of GPs has got a toolkit for sepsis. One of the parts of that toolkit is a workbook for reception staff so that they can recognise, 'This does not sound right, I need to get one of the doctors or nurses to deal with this patient quickly.' So, that's what we need to do for that.

The doctors now—again, 10 or 15 years ago, sepsis was not really on my horizon as a GP. It's come up over the last five years, and I think committees such as this and work such as you've been doing is really important, because what it's doing is raising the awareness of GPs and other clinical staff, and that's ongoing. As part of our work in the college, when we first looked at this in 2015, we did a survey, and only 60 per cent of GPs felt particularly familiar with the presentations of sepsis. We audited that about a year or so later, after we'd done some educational work and that had gone up to—I think it was about 73 per cent. So, it's an ongoing—we want 100 per cent.

You mentioned about practices not seeing this a priority. I think they do see it as a priority, it's just that there are so many other priorities that we feel that we have to deal with. Again, it's like so many messages—I mentioned, say with child protection, you have to keep on and on and on about it. With your children, you keep on and on and on about looking both ways before they cross the road. You don't say, 'Oh, we've told them how to cross the road, they'll be fine.' I'm not suggesting that GPs and other clinicians are like children—well, sometimes they are, but—[Laughter.] But, again, it's something you have to—and that's the role of the college, it's the role of Health Education and Improvement Wales, it's the role of universities and that to keep on with that.

Over the last two years, you've seen a number of tools come out. We've seen the NICE guidance, we've got guidance from the RCGP, we've got the RCGP toolkit, and we've run some workshops on acutely ill patients. It's work in progress. Have I—? I've agreed with you, I've highlighted some areas—

No, that's fine. It's just I think that, having talked to so many GPs that I have to put on the record that quite a lot of them are not—. Certainly, when I say to them, 'What tools do you have to help you?', there are only a very few who ever mention the toolkit. Most of them have never mentioned the toolkit, which makes me think that perhaps they don't know they've got a toolkit.

Of course, the toolkit is open to non-members, so it's unrestricted. So, if any of you are interested, there's stuff on it for the general public as well. But, of course, many doctors who perhaps aren't engaged with the college, maybe because they're not members, might not think that it's there.

I have to declare an interest here in that I'm employed by Health Education and Improvement Wales. But having said that, I'm actually—I'm not really going to criticise them, because they've only been established for a year. But HEE, Health Education England, have actually done a lot more work on this, and it's probably a little bit of a gap that, maybe through some either direct working with HEIW or Welsh Government/HEIW or Welsh Government/the Royal College of General Practitioners/HEIW in Wales could do some stuff for Wales on sepsis. Obviously, we could be doing it bilingually as well, both for patients and for healthcare workers. Also, I keep coming back to reception staff. They're really important, because they're the link, often, between the patient and the clinician. If that link doesn't have the educational support—. So, maybe some materials for them—as I said, the college has got some—some little cards and that sort of thing, may be helpful.

09:55

Rhun, some of your questions have been sort of answered, but carry on. 

Yes. Certainly, when we talk about awareness raising and training, they intertwine with each other, and you've addressed a number of the questions that I wanted to ask. Is there a need to formalise a bit more the kind of training options available to everyone within the general practice setting, including the receptionists that you mentioned, who can play such a key role?

I'd hesitate to make a recommendation for mandatory training every so often, because where do you draw the line, so to speak? We have mandatory training for safeguarding and for life support. I think that it would be helpful to say that every health board should ensure that there are opportunities for staff to train. That could be linked with asking practices to report what training has taken place, because, if you're asked, 'We think this is important. We're not actually saying how or when you should do it, but you have to report what you have done towards supporting training in this area'—

With the expectation that it happens, but it's not quite mandatory. 

Yes. I'm sure you're very familiar as politicians that just asking the question makes people do things or stimulates them to move. So, that might be one way to go forward. 

So, ensuring that there is provision for training, not just of clinicians but of non-clinical staff, and having some reporting mechanism to ask practices, 'Well, there is training; what have you engaged in?' And then if it was found that there was poor engagement, then the next question is: how do we actually increase engagement? But certainly as a college we would support that sort of approach. 

And you'd engage with a debate on mandatory training, perhaps, because some organisations, including the Royal College of Nursing and, I think, the Royal Pharmaceutical Society are suggesting that we go down the mandatory route. There's perhaps a discussion to be had about it. 

Yes, absolutely. I've been careful to talk about clinicians because, often, pharmacists are clinicians and they would need to be included, because people might turn up at the local pharmacy and say, 'Do you think I need to go and see the doctor, because I've got these symptoms?'

Yes, and we want people to do that, in effect. 

You mentioned NEWS, the national early warning score system, and you say in your letter to us as evidence prior to this meeting that it's not established as a screening tool in primary care currently. Public Health Wales, though, and Improvement Cymru say they've been rolling out NEWS and sepsis screening in community settings—that that is happening. Are you seeing evidence of that?

Yes. I had one of my colleagues two weeks ago who said, 'I've had a really frustrating discussion with the ambulance service. They wouldn't dispatch an ambulance until I'd given them the NEWS score on this patient. I hadn't got all the stuff to work it out, and I was concerned about this patient being unwell.' The English approach is that NEWS scores are almost voluntary in primary care. If you've got the expertise and the equipment to do a NEWS score, then that's fine. It doesn't really form—. You don't admit somebody because of a NEWS score; you admit somebody because of a range of parameters, some of which are in the NEWS score, and because of your clinical judgment. What the NEWS score does is it can provide a baseline for further assessments. So, they get into hospital and there's a clinician in the hospital who can see, 'They had a NEWS score of such and such, and now it's gone down to so and so. This is important.' So, it's useful in that respect, but it's not been proven to be useful in deciding whether I admit this patient or that patient.

10:00

Is it considered useful enough by enough people for GPs to actually start using it? Are you hearing that it is being used by GPs? 

We're still—. Our guidance has different markers, many of which are in the NEWS score, but our sepsis guidance lists some key features that are markers of sepsis, some of which, as I say, compromise the NEWS score, but we would expect the evidence that supports these—. There is a lack of evidence for NEWS scores being helpful in admission, but a lack of evidence doesn't mean—. I'm not saying they're not useful, I'm just saying there isn't evidence to show that it makes a difference. 

So, in attempting to achieve a standardised identification system, would you say that the best model is to use, say, NEWS and your guidance alongside each other and that that's the way to make sure that we operate in a standard way across Wales? 

So, the evidence is that respiratory rate, capillary refill, pulse oximetry, temperature and the general demeanour of the patient are all predictive of the patient being unwell, together with the doctors' or the clinicians' clinical judgment. We advise clinicians to use these. We say, 'If you can do a NEWS score, that's great, but it's these key points, together with your clinical judgment, that are the important ones.' So, if I was designing a card to give out to clinicians, it would have: 'Think about sepsis if any of these are present, combine it with your clinical judgment, and if these are present then consider seeking further admission, depending on the clinical state of the patient.' I wouldn't give them: 'Here is how to do a NEWS score', if you see what I mean. I might on the back say, 'By the way, here's the NEWS score, here's the NEWS scoring system, and if you can do one of these it may help the future management of the patient.' But at the moment, I think that NEWS scoring in primary care is still unproven as to how it helps acute management. 

That's very useful and very graphic. I was going to ask you, if you had a little bit of room at the bottom of card, would you mention NEWS, but you flipped it over so you were a step ahead of me. 

I did—. This doctor who I was speaking to—I said, 'Gosh, yes. It's a bit like if you take off from, in my part of the world, Manchester Airport, because I'm in north-east Wales, and the captain comes on the radio and says, "One of our engines, I'm getting a bit of vibration here. All the numbers are looking okay, but I think we're going to turn back", and then you took a vote and you said, "Okay, who wants to carry on?" ' It's a bit like that. Clinical judgment must trump everything else, and we don't want to see—. All these scoring systems are to help clinical judgment, and I think, if you get—. I'll just say that.

10:05

That's useful for the next conversation I have with a pilot. [Laughter.] David.

That's important, because we appreciate that the clinical judgment, and the expertise, and the experience of an individual is what counts at the end of the day, and that's what people rely on when they go and visit a GP.

That's not to say that I'm saying that, 'Oh, doctors—I'm a doctor, I know everything', because the older you get as a doctor—I'm looking to my Chair, again—the more you realise you don't know. And there's always room—. Clinical judgment is not innate; it is something that you have to follow, but it's only useful if you can back it up with knowledge and experience, which is what we need to further develop.

Okay. Just a couple of points from me, because you've answered some of the points already as far as the questions are concerned. You've identified that sepsis is one of the priorities, because you've mentioned many priorities, but in England, they've identified a sepsis lead in practices. Do you think that's a direction we should be going down in Wales as well, so that a practice would be able to identify a sepsis lead?

I really don't know the answer to that question. I think in large practices it can be useful.

It has to be large; you can't do it for one-person practices, because they'd lead everything.

Yes. In my practice, we've got four GPs. I lead on safeguarding—I can't remember who leads on other things. I'm sorry, I can't really answer that question. I think it's all part of raising awareness. Like I was saying, for example, getting practices to report on training in certain areas may be useful. Having a practice lead is also for raising awareness and helping lead education in the practice.

I'm sorry, I really don't know the answer, because you don't want to just have too many leads, but, on the other hand, it can be useful, I agree.

Okay. Obviously, raising awareness—you've mentioned that it's an important aspect, not just awareness amongst the clinicians, but also awareness amongst the public, as you mentioned earlier. Is enough being done about raising the awareness of the public? Because I remember when there were meningitis outbreaks happening, all of a sudden, we had huge awareness, across the piste, on meningitis, and what the symptoms were, and everything else. And at the moment, I'm not seeing that in sepsis. Should we have a more focused campaign on raising awareness for the public, on the symptoms, and what issues to be looking out for, and if you feel that there's a need to go and see the GP or out-of-hours?

Yes, I think you're right. Why isn't there? I think because it tends to be more adults affected by sepsis than children—not that you can't get sepsis from children, particularly meningococcal sepsis. One of the biggest awareness-raising ways is actually stories in the media, because people take notice of that—they can relate to individuals and families that have been touched by sepsis, or indeed other conditions. So having a—. There is a—I'm sorry, I should be more familiar with this. But in terms of, there's a sepsis—I think there's a sepsis organisation, to support—

Yes. So, finding people—survivors—who can tell their stories I think is very powerful. And I think short messages, little cards—there are meningitis cards that we've got in the practice. There could be sepsis cards.

Do you think GPs are doing enough to do that advertising? I'll be honest, I haven't been to my GP practice—touch wood—for a while. But when I last went, I didn't notice any notifications or awareness things of sepsis at all on the notice boards.

I'm thinking about my practice—whether we've got anything; there probably isn't. Partly, it's dependent on what resources we have available to put out—posters and leaflets, and things like that.

But Public Health Wales could be doing something. Public Health Wales could be producing the posters—[Inaudible.]—for example.

10:10

The other problem we have is the overload of information in that most GP practices, I'm thinking about my own here—we're not very good at putting stuff on notice boards. Stuff gets put on the notice board and I'm standing outside my room waiting for a patient to come from the other side of the surgery, because they've gone to the wrong place, and I'm looking at the notice board and I'm thinking, 'Oh goodness me, that happened two years ago; maybe we ought to remove that'. We don't refresh things very well. So, almost less information, more often, is better—so, helping GPs have a better information policy in their practices is good. And also, things like awareness weeks. There probably is a sepsis awareness week, but I'm not aware of it.

Yes, so correlate that with some stories and some stuff out to GP practices rather than say, 'Well, here's a leaflet, put it up all year around', because it'll be put up and then something to do with hearts will come along and then 'Where can we put that? Oh, we'll just put it partly over that one', and it just—. I think most of you will agree that GP notice boards are usually not very good.

The only other point is, clearly, it has been identified that 80 per cent of cases tend to originate in community settings rather than in hospital or alternative settings. So, is there more that can be done to look at early detection and awareness in those types of settings? Because it's the same message in a sense.

Yes, it's about patient, people, education, access and getting them to a suitable clinician at the right time and not sitting at home thinking, 'Oh he's getting worse. Give him some more aspirin', or whatever.

But is that—? To the older generation, and I do relate this to the older generation, many of them think, 'I don't want to bother the doctor', sometimes. So, is it a message that we need to get out to people: if you are unwell, you need to contact your doctor?

Good. The next couple of questions—. We need some agility now, team, because time is going on. Lynne is very expert in the field of agility.

Well, we've kind of covered some of it with public awareness. Is there anything you wanted to add in terms of—. Because the Government, I think, is looking to say that a public awareness campaign is not going to be helpful. I know that you've talked a bit about notices and things like that, but do you think it would help if we had a similar public awareness campaign to the one that seems to work very well on stroke?

Yes. It has to have clear messages. Stroke does have clear messages. And the same with the meningitis one—we've had good public awareness about that. So, short messages, different ways of getting through to the public, backed up with a better education programme for health professionals and support staff.

So, you think as long as it is done right, it would be beneficial.

Okay. My second question is around care homes. Are there any messages for the committee on how you feel sepsis is being managed in care homes—anything that could be improved in that regard?

I think the message with care homes is that they are very cautious—most care homes—and I think that they are very aware. I've not come across, or heard of that many patients who've been, if you like, neglected in care homes, it tends to be the opposite; they'll seek advice. And, of course, the staff in care homes are very familiar with pathways to getting clinical support. They know how to contact the doctor, when to contact the doctor, and they've got district nurses going in frequently, so I don't actually see care homes as a major problem. I see the first example, perhaps—the older person at home not wanting to bother the doctor—as being more of an issue.

Thank you, Chair. I think you've covered the points around safety-netting very well previously. So, we've heard about lack of communication between hospitals and GPs, particularly for discharged patients—that sepsis is not recorded and the GP isn't always aware of it. Is this something that you'd recognise and, if so, how could that be improved?  

10:15

I think that, again, this is one of these things that's ongoing, and you have to keep on and on and on about it, just because it's human nature. But, the timeliness of discharge summaries coming out needs to be better. Of course, discharge summaries are often written by the most junior person in the team—one of the F1 doctors; not always, but often. The ones in Wrexham are, for example. And they may not have the insight that a more senior clinician would have in terms of emphasising what's going on. Also, the presentation of information—. If sepsis has been a problem, then it should be right at the head of the letter with the other clinical diagnoses. Sometimes, it's buried within the text. This is down to the experience of the clinician who is writing the letter.

Okay. Your evidence says that GPs are actively engaged in support for patients through their pre- and post-sepsis event. Can you tell us a little bit more about this and describe the support that you think is available to sepsis survivors?

Yes. Typically, we'll see people who have been discharged from hospital with sepsis, and we'll be looking at a range of things to see what impact it has had on them. One of the important issues, I think, will be the psychological effects that it will have had, and trying to address what their questions are, you know, 'Why did it happen? What can I do to stop this happening again?' The fear that it might be coming back. Perhaps, how they are dealing with some of the residual impacts of the illness.

So, the role of the GP is to try and address some of these, to help talk the patient through these, and also to signpost and resource any additional support that they might need. They might need some talking therapies with some of the mental health services that are practice-based. It may be putting them in touch with self-help organisations and that.

We've also heard overwhelmingly from a number of people, including sepsis survivors, that there's little or no support available for survivors who have not had amputations. But, often, they are the ones who are struggling with, as you mentioned, the psychological effects and sometimes, the physical effects. How do you think that that could be improved? 

I think that, again, it returns to a theme that I mentioned earlier, and that is clinician education, as part of our sepsis educational programme, to help make clinicians aware of some of the long-term effects—the perhaps hidden long-term effects of sepsis. GPs are often dealing with people in 10-minute appointments. So, more time—accepting that people may need more time and accepting that we need to improve, as a part of general psychological support, mental health support services within primary care. These would be part of that group of people who would benefit from this.

The other thing is probably helping the patients deal with their employers. So, we're often certifying sepsis survivors, and helping them to get back to work is quite important, and helping employers to see that they may need a bit of support in getting back to work. Getting back to a normal lifestyle is probably one of the most important things that you can do to help somebody through some of the psychological issues.  

Yes, it's just on this. Listening to your evidence, I think that in good practices, or where practices have time and they've taken on board this challenge, it kind of does work. My real concern is that, actually, in an awful lot of practices, this isn't happening and there isn't this recognition. ITV Wales did a programme on sepsis a couple of weekends ago. As a result of that, I received, as chair of the cross-party group on sepsis, a huge amount of mail from sepsis survivors throughout Wales talking about their experiences, and I just wanted to read this one little paragraph: 'Dear Angela. Thank you for responding. I've now been to my GP, who had not heard of post-sepsis syndrome, neither had the physio, nor the nurse practitioner. The doctor was very supportive, but thinks it's one of "these" syndromes.' You know, 'Let’s put a label on everybody' and what have you. She said that she was quite negative, but kind—not unkind at all—and the physio was completely dismissive of the physical outcomes.

Now, I raise this particular e-mail because, absolutely, in this one e-mail are all the threads of so many of the other e-mails that we've received, come together. So, I suppose my last question to you is: what else do you think the royal college can do to really do this training of clinicians, and get clinicians to up their game on this particular area? Because as I said at a previous point in this inquiry, it's not just surviving sepsis, but it's actually surviving it well. There are so many benefits to the state, there are so many benefits, obviously, to the individual if they survive well. And the Government can't possibly train every single healthcare professional and every single receptionist, so what do you think your organisation might be able to add to this? Or do you think that there could be a renewed drive to get your sepsis toolkit out there and really used in a useful way? Because I fear that, whilst many doctors, or most clinicians will recognise sepsis, this whole after-effect of sepsis is in an entirely different ballpark.

10:20

Yes, you're right about getting our toolkit better centre stage. We have a chair's blog at the college, and one of the things I'll be doing after this meeting will be making sure that we highlight it in the next blog. But going back to the—. You were talking about patient survivors, healthcare professionals don't take enough notice of patients' stories or patents' narratives, and we need to be better at this. We are trying. Last week, for example, we had a training session on health for asylum seekers here in Cardiff, and we actually got some asylum seekers to talk about their experiences. So, one of the things we're trying to do as a college—and it depends on who's available and the format of what we're doing—is to actually get patients to come along, because that's really powerful, when you can actually get somebody to tell their story. So, we need to get better at listening to patients' stories, because they will tell the story. The stories will tell us what's important, and you've highlighted that being aware of some of the after-effects of sepsis is very important to survivors. So, listening to patients, we need to get better at; we will try and get better at listening to patients.

Okay. Right. 

Diolch yn fawr. Dyna ddiwedd y cwestiynu, a dyna ddiwedd y sesiwn. Felly, diolch yn fawr iawn i chi, Peter, am eich presenoldeb, a hefyd am y papur y gwnaethoch chi ei gyflwyno ymlaen llaw. Mi fyddwch chi yn derbyn trawsgrifiad o'r trafodaethau yma hefyd, er mwyn i chi gallu eu gwirio eu bod nhw'n ffeithiol gywir. Ond gyda chymaint â hynny o ragymadrodd, diolch yn fawr iawn i chi. Dyna ddiwedd yr eitem.

Thank you very much. That is the end of the questions, and the end of the session. So, thank you very much, Peter, for attending, and also for the paper that you presented in advance. You will receive a transcript of these proceedings also so that you can check them for factual accuracy. But with those few words, thank you very much. That's the end of the item.

Croeso.

You're welcome.

3. Papurau i’w nodi
3. Paper(s) to note

I'm cyd-Aelodau, rydym ni'n symud ymlaen i eitem 3 nawr, a phapurau i'w nodi. Mi fyddwch chi wedi darllen y llythyr gan Fwrdd Iechyd Prifysgol Cwm Taf gyda gwybodaeth ychwanegol yn dilyn eu sesiwn dystiolaeth o'r blaen.

To my fellow Members, we will move on to item 3, and papers to note. You will have read the letter from Cwm Taf University Health Board with additional information following their evidence session.

4. Cynnig o dan Reol Sefydlog 17.42 (vi) i benderfynu gwahardd y cyhoedd o weddill y cyfarfod hwn
4. Motion under Standing Order 17.42 (vi) to resolve to exclude the public from the remainder of this meeting

Cynnig:

bod y pwyllgor yn penderfynu gwahardd y cyhoedd o weddill y cyfarfod yn unol â Rheol Sefydlog 17.42(vi).

Motion:

that the committee resolves to exclude the public from the remainder of the meeting in accordance with Standing Order 17.42(vi).

Cynigiwyd y cynnig.

Motion moved.

Eitem 4, cynnig o dan Reol Sefydlog 17.42 (vi) i benderfynu gwahardd y cyhoedd o weddill y cyfarfod hwn. Pawb yn gytûn?

Item 4 is a motion under Standing Order 17.42 (vi) to resolve to exclude the public from the remainder of this meeting. All agreed?

Pawb yn gytûn. Awn ni i mewn i sesiwn breifat, felly.

All agreed. We'll go into private session.

Derbyniwyd y cynnig.

Daeth rhan gyhoeddus y cyfarfod i ben am 10:24.

Motion agreed.

The public part of the meeting ended at 10:24.

Dysgu am Senedd Cymru