Examination of Witnesses (Questions 1020
- 1039)
WEDNESDAY 24 APRIL 2002
DR PAT
TROOP, DR
DAVID HARPER
AND DR
MARY O'MAHONY
Mr Howarth
1020. If I can just pick up from what the Chairman
has asked you, you say that you hope within six months to get
the PCTs up and running on this.
(Dr Troop) No, that is the legislation. The legal
basis is that the strategic health authorities formally come into
place and there is legislation going through. The intention is
that they will formally come into place in October. I think there
is one which is still a Primary Care Group not a Trust. As I say,
they virtually all came into being on 1 April, and so there is
this transitional period while people are handing over their responsibilities,
but that is the legal position I was speaking about.
1021. So to be practicable, when do you expect
the PCTs to be in a state to take over this responsibility—for
example, by appointing emergency planning people?
(Dr Troop) They will be required to take over on 1
October and our responsibility between now and then is to work
with them to make sure that they have the understanding and the
capability to do that. Some of the support to do that will be
through our health emergency planning advisers and through our
consultants in communicable disease, because, as I explained,
our emergencies are of a very wide nature and, therefore, we have
to have a range of staff with a range of skills. Beyond that we
will be moving into the new arrangements for the Agency.
Syd Rapson
1022. I know it is unusual for me to butt-in
but Portsmouth got some notoriety yesterday on health which was
unfair. We have a very good PCT, which has been operating extremely
well from 1 April and they are doing a wonderful job. However,
they are geographically limited to Portsmouth City Council's boundaries,
whereas the hospital trusts go much wider than the boundaries
and the strategic authority is even bigger. I wonder if there
is a complication between now and whenever things settle down
over boundary disputes between the authority of the PCT, which
is only within Portsmouth's boundaries, and its need to have some
emergency planning control wider than that?
(Dr Troop) There are a number of incidences around
public health emergencies and other emergencies where we need
to have that wider network. Therefore, for a number of these the
trusts are being required to work as a network and to nominate
a lead within that network. The kind of issues they will have
to take on, not just the trust issue kind of emergency, is, for
example, if we had a major TB outbreak, as we have had in Leicester;
a number of PCTs will have to work together to provide the resources
and to make sure they work in a co-ordinated way. Part of the
requirement is that they have networks and all the public health
people are setting up networks so that they are working in that
co-ordinated way, and, also, many specialist services for which
they go much wider than a number of PCTs. So that is a process
which is fitting within a number of others.
Mr Howarth
1023. Dr Troop, I mentioned there were four
points and I am going to invite you, perhaps, to write to us about
the impact that the new legislation may have on you, because time
is short. Can I deal with two other issues, capacity and funding?
First, on the issue of capacity, which was identified as one of
the areas for further work, have you made any preliminary assessment
of the impact on the NHS capacity of these new policy proposals?
(Dr Troop) We have not made that kind of assessment,
no. From the department we will set out the guidance of what people
are required to do and at a local level it is the responsibility
of local health authorities and future PCTs to ensure that resources
are deployed to ensure that they can meet that requirement.[3]
1024. We will come on to resources in a second,
but we are talking about capacity here. We all know that the NHS
is stretched but you are talking about quite extensive extensions
of responsibility resting upon the shoulders of people who are
already pretty committed.
(Dr Troop) There are, as I say, a range of different
aspects of that capacity. For example, if we look at the types
of emergencies around infectious diseases, around chemicals and
those kinds of incidents which are included, as you know, we have
made a proposal for a new agency, which will be, we hope, up and
running on 1 April 2003. It will bring together all our key resources
at a national and a local level in terms of infectious diseases,
chemical, radiological and, also, will have an emergency planning
division. So that the specialist support for this activity we
are strengthening and developing, and that will start on 1 April
2003. On that aspect of the capacity we have had a very serious
review and September 11 has contributed to our thinking very significantly
on that. That will start, as I say, and we are moving very actively
towards that programme at the moment. Other aspects of capacity
that we have looked at are, obviously, the capacity of the service
to be able to respond to emergencies at an ambulance level, at
an A&E level and so on, and there are certain aspects of their
funding that we have addressed, for example the equipment that
they have, and so on. Some of those are part of the wider NHS
planning. Most of their function, for 95 per cent of the time,
is running an NHS service and, therefore, within that context
we have already reviewed a number of those issues.
1025. We all know that in the event that there
were to be a biological or chemical attack on a large urban area
in this country a lot of people would be affected. In terms of
capacity, are you making any plans to open emergency medical centres
outside the existing NHS provision?
(Dr Troop) We sent guidance out two years ago and
after September 11 we sent out additional guidance, both on how
to cope with mass casualties but, also, how to manage infectious
diseases. If I take one of those, we sent out guidance, for example,
on smallpox, plague and all the other threats that we were advised
on. On each of those we gave a step-by-step guide as to the things
that locally people had to consider, including the kind of facilities
that they could open up or transform to cope with a major problem.
Clearly, if we had that kind of infectious disease problem we
would not have sufficient infectious disease beds on a routine
basis, and you cannot build that level of redundancy into a system.
Therefore, we asked them each to identify which hospitals, which
sections of their health service locally might be applicable.
It would be wrong for us to do this nationally because they have
the local knowledge of how they could do this. They have all been
required to do that. We have been going back to check that they
have all integrated that planning into their emergency planning,
and part of the work over the coming months is to keep double-checking
and to scenario-plan whether or not they would be able to do this.
Obviously we need to do more testing of those plans but locally
they have all done this; they have all gone to see how they would
respond against this very detailed guidance on how they should
look at this.
1026. So if there were an attack tomorrow you
could, with some confidence, tell us and assure the British people
through us here today, that there would be in place an adequate
emergency plan, albeit it would be of necessity, to a certain
extent, make-shift, to be able to deal with a large number of
casualties?
(Dr Troop) Yes, we have sent that guidance out and
checked that everybody has incorporated that planning into their
guidance across the country. We have also provided them with additional
equipment. For example, we have now what we call "equipment
pods" which are distributed right across the Ambulance Service
across the whole of the UK which has got additional equipment
for respirators, for breathing support, for ventilators etc. So
that if there were an attack anywhere within the UK—for
example, if there was a chemical attack—the ambulance people
would have access very quickly to additional equipment which is
out there, with standard operating procedures on how to get hold
of it, with clear instructions as to how to use it, so we could
support a large number of casualties. We have gone through a fairly
detailed logistic exercise to make sure that all those different
elements were in place both in terms of knowing how to respond
and, also, this back-up material. There has been a very big logistics
exercise over the last few months to make sure that that is there
and available for our front-line staff.
1027. Finally, and I am sorry this has been
a long set of questions, but the fourth issue identified for further
work was funding. You have told us about the new agency, you have
told us about the additional responsibilities on Primary Care
Trusts and upon others. Can you assure us that the funding for
investment in this area of emergency planning and the capacity
to respond to the new threat from chemical, biological or nuclear
attack is in place? For example, are you providing the PCTs with
more resources in order to enable them to take on staff to deal
with the responsibilities that are being thrust upon them?
(Dr Troop) There are some additional resources in
place. I think for me to say that we always have enough resources
in any of these aspects - I think most departments would say "I
could always use more resources"—
1028. I thought that all changed last week.
(Dr Troop) As you are aware, the NHS was allocated
a large volume of resources but it will be up to ministers to
decide precisely how that is deployed. We have set out the framework
of all the guidance and the requirement of the NHS, and we have
had a number of discussions with ministers about the relevance
of different resources. We have received some additional resources
over the last few months and we hope that that will continue over
the following months.
1029. Can you quantify that amount of additional
money?
(Dr Troop) Some of it is tied up with our procurement
policy. Therefore, I would prefer not to give the details of that
in an open meeting.
Chairman: Drop us a note, if you will,
please. It will not necessarily be published.
Syd Rapson
1030. Can we move on to the Health Protection
Agency. I know the Chief Medical Officer drew up a strategy for
the combatting of infectious diseases called Getting Ahead
of the Curve. I was lucky enough to be reading it last night
at 1 o'clock and fell asleep looking at the Tokyo Subway, so I
did not get very far at all. The idea of Getting Ahead of the
Curve is very good to combat infectious diseases and the driving
force behind that was sometime ago, and joining together the Public
Health Laboratory Service, the National Radiological Protection
Board and others to form this new Health Protection Agency. We
know the pressures to create this new arrangement did not arise
out of 11 September because it was in place, but since it has
been constructed how markedly could that new agency affect or
make things better in response to a CBRN attack?
(Dr Troop) I think, first of all, all our planning
for CBRN attacks is based on the premise that we need a sound
infrastructure. We have emergencies of all sorts all the time,
we have a lot of chemical incidents to which we have to respond
and we have infectious disease outbreaks. We have to plan for
a flu pandemic which would be just as devastating. Our infrastructure
has to be there for emergencies in general. All our planning is
based on having a sound base on which to add on things for CBRN.
That is how we have taken it. So that when we were planning modernising
the infectious disease infrastructure we had a lot of feedback
over the last 18 months "make it integrated into other aspects
of health protection" because, on the ground, that is how
we work. When we had the foot-and-mouth disease we worked in a
very integrated way across infectious diseases, chemicals and
radiological. Therefore, we were already planning that we ought
to make it an integrated structure, and then after September 11
we brought together experts from all those fields, all working
together, all sharing their knowledge and expertise. That just
made it absolutely obvious to us that we had to have an integrated
health protection infrastructure, which would, as I say, form
the basis of all emergencies but the bedrock on which any emergency
from CBRN could build. Within that, though, we have also identified
some additional work that needs to be done. There will be in the
Agency an emergency response division proposed, and part of that
would be helping to continue to develop our knowledge and understanding
of how to respond to these emergencies. We are leading a lot of
the work internationally on modelling, and we would take forward
that kind of work within that kind of division. It would be a
major contributor both to the response and the expertise at the
national, regional and local level but, also, to provide a lot
of the thinking and development.
1031. I know you chair the steering committee
and your colleagues assist in that very worthy cause, but when
do you expect the new agency to be operational? When is this new
structure going to be ready to go?
(Dr Troop) Our hope is that it will be on 1 April
2003, and that will depend on whether or not the legislation that
we are working on will go through. We are going through the regulatory
reform order process, and if that goes through in the timetable
that we hope then we should be okay for 2003.
1032. Because we have done away with the health
authorities now, from 1 April, what contingency provision have
we got in place between now and the formation of this new agency
so that we are protected? Presumably you would say that the PCTs
will cover that in between, but is there some interim arrangement?
(Dr Troop) Yes there is. Although we have lost a lot
of the NHS regions we have maintained having a Regional Director
of Public Health and they are moving into the government offices
of the region, which means they will also have a relationship
with local authorities, which will be very helpful. They have
been required to ensure that the health protection arrangements
are in place in their region in this interim. For example, previously
we had consultants in communicable disease control in every health
authority, and we have asked each region to ensure that they are
employed by PCTs and by a network of PCTs so they can continue
to provide the support that they provided before, but to a group
of PCTs as opposed to a health authority, and that their staff
are in place to support them. Each of them have ensured that those
staff are employed on a temporary basis through the network of
PCTs until they are able to move into the agency next year.
Mr Crausby
1033. In reply to a written question on 16 April
the Minister, John Hutton, said that additional expenditure of
£1,176,000 had been incurred by the Public Health Laboratory
Service and the Centre for Applied Microbiology and Research on
counter-terrorism and civil protection since 11 September. Can
you tell us what these sums have been spent on? What additional
resources will be available to the new agency over and above the
aggregated budgets of the component bodies?
(Dr Troop) First of all, on the work that has been
done by the PHLS (and I will, perhaps, ask Mary to expand on this)
they gave very urgent and very comprehensive support in putting
together very detailed guidance on a number of infectious diseases
at a very early stage. We were able to get it up on their website.
We also decided that their website would be the website for clinicians
on all emergencies, were it chemical, biological or whatever.
So there is a range of guidance on the PHLS website available
for all clinicians. They have also set up a closed website for
another range of clinicians, and then they gave us a huge amount
of support during the anthrax scares that we all had. They had
to have a 24-hour team rotating the whole time to respond to that
as well as their laboratories responding to that. They have also
done a lot of work out in the field. We took in some of their
staff to the department. It has been a huge programme. Mary is
from the PHLS. Do you want to add to that, Mary?
(Dr O'Mahony) It may be helpful just to explain the
background to the Public Health Laboratory Service. It was set
up in 1938 as the Emergency Public Health Laboratory Service before
the onset on the Second World War, when there were concerns at
that time about the possibility of germ warfare and, also, civil
disruption. So since the very inception of the Emergency Public
Health Laboratory Service, and the Public Health Laboratory Service
after the War, the notion of the PHLS being an expert body to
give microbiological advice and public health support in the event
of any biological attack, or any other emergency around infectious
disease, has been implicit in its work. In 1977 the Department
of Health gave funds to the Public Health Laboratory Service to
set up a epidemiological wing (CDSC) to help with the public health
epidemiological expertise to the nation. Thus within the Public
Health Laboratory Service it is always implicitly understood that
its remit is to assist the nation and provide expert advice in
peacetime and potentially in any war time or terrorist footing.
It is in that context that the PHLS came in to assist the department
on 11 September. This they do that all the time through assisting
the NHS, local authorities, working with DEFRA and the Drinking
Water Inspectorate in the investigation of any number of incidents
of infectious diseases or potential incidents of infections. That
background explains the constant oiling of the wheels for the
use of their expertise and the availability to shift resources
to whatever investigation or major activity that is in play. That
is something that has been there since its beginning, and the
PHLS can ratchet up and down the emergency response activity because
that is how it was set up.
1034. Will there be additional resources?
(Dr Troop) The first additional funding will come
because we anticipate that when we put these agencies together
there will be some significant savings because of some of the
management structures, and that first additional funding will
be redeployed to front-line services. We will still have the whole
of that funding but we will be able to use it in a more effective
and efficient way. Beyond that, of course, we were party to discussions
with spending reviews and so on about any additional resources
we have in this area, and you can imagine that for the control
of infectious diseases and so on we have ensured that we have
made our requests known in that system.
Jim Knight
1035. In the event of a major incident, clearly,
time is essential and making the best use of it. You are bringing
together all these various agencies and you have talked about
the need for infrastructure and sorting that out as a starting
point. Can you comment on how well developed the communications
infrastructure is between the various agencies and then national,
regional and local links, both on IT and other forms of communication,
so that in the event of that major incident we can make best use
of that and buy time?
(Dr Troop) What we have at the department is a set
of standing operating procedures whereby we can have emergency
contacts for all of those organisations nationally, and they can
contact each other. This is carried by a number of senior people
in the department—all the directors and ourselves here and
some of our staff. We have an on-call rota for emergencies which
at a senior level we staff. That is there an available for the
CCS and for the service but, also, internationally as well, I
am the first point of contact and David Harper is my back-up on
that. So that we have set up those standing operating procedures
with this detailed contact list, and all of these organisations
have made sure that they have their own emergency contact. Out
of hours I can always get hold of the Public Health Laboratory
Service, I can always get hold of CAMR and I can always get hold
of the other bodies.
1036. You have tried all of this?
(Dr Troop) Yes, and we, obviously, test it to make
sure that it works. We all carry this and we all carry it all
the time. So that is at the national level. Within that, we also
have an emergency contact list for people at the regional level,
so that the Regional Directors of Public Health are also part
of that network. There are times when we have tested it and there
are times we have had to test it, and if it is not working we
can always go back and say "Why did that not work?"
They also have systems on how to get out to the wider NHS. We
have a cascade electronic system out to the medical profession
which, because of the change to PCTs, we are obviously having
to review because it is a different list. At the moment, if I
want to get a message out, in every health authority somebody
carries a pager and we can send this off on a national pager message
and they then know that they have got an e-mail message. It may
be withdrawal of a vaccine, it may be something that they need
to tell the GPs. We have that network. So we have a number of
networks which we have reviewed significantly since September
11. Some of it needs constantly reviewing, constantly checking
and constantly strengthening but I think our communications system
now is much better than it was.
1037. Two tiny supplementaries to that: the
first is whether that system is secure? Clearly if you have got
a terrorist attack they could decide to try and take out that
system in order to disrupt the response.
(Dr Troop) We have had another section of our department
particularly working on our IT looking at the resilience of the
system and looking at the alternative means of communication and
have identified alternatives. For the medical cascade system we
are trying to set up a new back-up system because the old technology
is pretty inadequate.
1038. In the event of a bio-terrorist attack,
using communications to just pick up that attack is, obviously,
important. Do you have a process of communication with the primary
care level, with NHS Direct and with the other aspects of the
service in order to be able to pick up the signs that there is
a concentration of an attack that has occurred?
(Dr Troop) There are two ways of communication. As
well as our emergency network the PHLS also has a network out
to A&E consultants and consultants in community disease control,
infectious diseases. They have an emergency e-mail system out
to them. This is part of our normal surveillance system. We constantly,
and particularly through the PHLS, receive information on a daily
basis from NHS Direct, from GPS reporting, from clinics reporting
and from laboratories reporting. They collect this information
on a daily basis and every week they publish trends of particular
infectious diseases, so that should there be a problem they should
pick it up that way. If I can give an example, about a month ago
the PHLS was informed by three different clinicians in three parts
of the UK that they had found a case of botulism. Now, that is
a pretty rare diagnosis. They were in three cities and all three
were picked up within 48 hours through them reporting in that
here was an unusual disease. We then, within 24 hours, had alerted
the whole service to ask if there were any more cases out there.
It turned out not to be anything sinister, fortunately, and in
fact we did not hear of any more new cases but we got quite a
few which could have been, which we checked out and they were
not. So I think our challenge—and we recognise the challenge
and we are certainly not complacent about it—is how do you
keep that thinking in people's heads all the time? Will they do
it for a year? Will they do it in two years' time? Whilst I have
a lot of confidence in our service we do not under-estimate the
challenge we have to keep that up-to-date, refreshed and people
aware of what is going on—the communication going on and
the training going on. It is a major programme that we have to
keep maintaining. So when I say I have confidence, it is against
a background of recognising that actually we have got a major
programme. So I would not under-estimate it. We have looked very
seriously at all those systems.
Chairman
1039. When you use the words "we have confidence"
and you talk with people who know exactly what that means, that
is why we are a little anxious, because we use it incessantly
and we know the qualifications to the issuing of those words.
(Dr Troop) I hope I have given you the kind of qualification,
that it is not because we have not worked on the system, it is
because the NHS is a huge and complex organisation with a million
employees. Health is a devolved activity, and we cannot direct
what the other three countries do; we have to work in partnership
with them. To keep the whole of the system primed, up-to-date,
trained and communicated with is not straightforward and I would
never say that things do not sometimes fall down, or whatever,
but it is not because we have not recognised that.
3 Note from Witness: The role and funding of PCT's
is discussed in the document Shifting the Balance of Power:
The Next Steps (not printed). Back
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