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Public health post-2013 Contents

5Case study: Health protection

Summary

Health protection - encompassing prevention, preparedness and response to outbreaks and other health threats - is a critical public health function. Despite several sets of guidance on responsibilities, difficulty, confusion, duplication and lack of clarity persist in some local areas.

121.The system for health protection is now more complicated than it was before 2013. One local authority public health team told us that in their area, when an Outbreak Control Team was convened to respond to a local outbreak of an infectious disease, some nine different organisations needed to be represented on it.66 It was felt that this complexity and scale increased the chances of errors in communication and co-ordination occurring, and could also cause delays in the response to such outbreaks.67

CHALLENGES: Complex system Multiple players/ Uncertainty over roles and responsibilities Reduced response capacity in provider organisations Lack of clarity over funding

122.Wolverhampton public health teams raised concerns about the fragmentation of health protection, arguing that the separation of public health from the NHS “has led to numerous difficulties including the sharing of and access to data on health protection incidents, engaging with other NHS services, and understanding each organisations role and responsibility for the wide array of health protection issues within their boundary.”68

It has… led to examples where either work has been duplicated or rather alarmingly where there are gaps in work required …alarmingly there have been examples where potential significant public health issues in the community have resulted in more time being expended on ascertaining whose responsibility it is, who is to resource it, accessing key information and whether there is the relevant experience and knowledge within that organisation to respond rather than responding.

Our experience is that we are dependent on good relationships a lot in what is a fractured and very complex system; so we are dependent on goodwill. Our experience over the last three years is that there are capacity issues with all our partners in being able to respond to health protection issues. [Ian Cameron, Director of Public Health, Leeds City Council, Q139]

123.Establishing arrangements that work effectively across the complex web of different organisations now involved in delivering health protection requires good relationships. While witnesses were generally positive about the quality of these relationships in their local areas, there was a strong feeling that arrangements for health protection should not be dependent on them:

We are very clear in terms of reports to one another and there is dialogue immediately on any threats that are on the horizon or concerns that might get into the public eye and cause some real anxieties.…However, if we had not had those local relationships and networks, that would be an area of real concern. A system should not rely on personalities and individuals to make it work. It should work whoever is in post and whoever has been, historically, working in that field. [Ros Jervis, Director of Public Health, Wolverhampton City Council, Q139]

124.There was also evidence of variation between local areas. While some areas were clear about the challenges posed for health protection by the new system, others, including London and Manchester, reported no difficulty at all.

In Greater Manchester, we started work on setting out roles and responsibilities as part of the transition process from the NHS into local government. We were able to build on some very excellent assets that local authorities had already put together around joining together their emergency planning function [Professor Kate Ardern, Director of Public Health, Wigan Council, Q223]

125.PHE regional centres were universally seen to be providing good support to local areas on health protection.69

126.Reassuringly, the response to Ebola at both a national and a local level was seen to have worked well.70 However, when asked how the new system would cope under the strain of a pandemic, witnesses felt that it would be more difficult than during the last pandemic in 2009.

[In 2009] directors of public health were situated within primary care trusts at the time embedded in the NHS …. to some degree directors of public health were able to influence more and call upon NHS resources at a local system level slightly more easily as part of the flu planning [Abdul Razzaq, Chair of Association of Directors of Public Health North West, Q192]

We have done a number of exercises….There are differences. Certainly our experience was that there was an issue about capacity of the various elements that were needed. Everything … seemed to speed up in the sense of organisations suddenly struggling with being able to take various actions. The message with which I have come away from both our exercises is that the capacity that is available now has reduced and so is a concern for us. Also, quite clearly, people have come and gone and there are new people. It was clear that those who had experience of 2009 were far more knowledgeable about what happened there, and so, for some, that had gone. [Dr Ian Cameron, Director of Public Health, Leeds City Council, Q193]

Things have changed since 2009 …This links to the capacity issue … We no longer have primary care trusts. I am not saying that is some kind of Utopian past that we should want to hark back to, but it provided a single unifying organisation through the executive power of the director of public health in order to mobilise NHS resource at very quick notice. We do not have that any more, so we have to find a way around it. [Paul Davison, Deputy Director Health Protection, North East Public Health England Centre, Q236]

Community services … were absolutely vital in 2009 … health protection work carried on, and at the same time in the north-east we had a significant outbreak of measles in the Hartlepool area. We were managing two very significant incidents. As we continued the containment phase, in terms of trying to get antivirus treatment and all the rest of it, there was a lot of work to be done. We drew on NHS colleagues to come and train them, and they came into our response centre and did that. I believe that we still could do that, but how we do that has become much more difficult because people are in different organisations and in different parts of the system. [Paul Davison, Deputy Director Health Protection, North East Public Health England Centre, Q236]

I also think probably—although this is anecdotal and I have no evidence for it other than talking to colleagues who work in that field—that the pressure on them, the reduction in resource in those teams and the increased numbers of targets that they have to meet have caused them to concentrate much more on their core business. When you have an environment where resources are shrinking, people concentrate on their core business, and sometimes you lose those residual skills that are needed in that response situation. [Paul Davison, Deputy Director Health Protection, North East Public Health England Centre, Q236]

127.In particular, lack of clarity around CCGs’ role was an issue raised by several witnesses.

128.As well as the difficulty associated with forging relationships across more complex systems, specific problems with capacity and funding were also highlighted.

Our experience is that we are dependent on good relationships a lot in what is a fractured and very complex system; so we are dependent on goodwill. Our experience over the last three years is that there are capacity issues with all our partners in being able to respond to health protection issues”. [Dr Ian Cameron, Director of Public Health, Leeds, Q167]

Using the hep A outbreak as an example, the capacity that providers had to respond very quickly became an issue, and we are talking about a small outbreak there. With the question referring to a flu outbreak, it would be multiplied. So, as a very practical example, the capacity at the moment for providers to respond is an issue. [Dawn Bailey, Health Improvement Principal - Health Protection, Leeds City Council, Q199]

129.Clarity over funding responsibilities was also raised as an issue by witnesses:

Despite the fact that we do have good working relationships, we found there was an issue of who funds what. While across West Yorkshire we had a memorandum of understanding that said that agency x and y should be responsible for this, when it came down to the nitty gritty of who funds the vaccines, who funds practice nurses to do x and y, who is going to pay for the security, the admin and the bus driver, that is where it undoubtedly got trickier for us… [Dr Ian Cameron, Director of Public Health, Leeds, Q170]

In my area, I underwrote the cost … just to make sure that the funding issues did not delay all the action … and we want to get to a state where the number of grey areas is reduced in the future. [Dr Ian Cameron, Director of Public Health, Leeds, Q183]

Where there is an outbreak of vaccine-preventable disease, whose responsibility is it to lead and to write the cheque for a group of immunisers to be provided to immunise rapidly a population of university students, as we had when we had two linked cases of meningitis W? The system is not clear about that but … the relationships that we have and the commitment to serve the populations that we are there to serve meant that we mobilised and did that. In that circumstance, it was NHS England that underwrote it … We are having different people underwriting; so there are gaps in there… [Dr Dan Seddon, Public Health Consultant, Screening & Immunisation Lead for Cheshire and Merseyside, Q229]

130.Responding to these concerns, PHE told us that some of the problems raised by witnesses around health protection responsibilities pre-dated the 2013 transfer to local authorities.71 They also described their ongoing efforts since then to clarify the situation:

We are aware that it is an ongoing problem. We were aware at the time. In 2013, we worked with the Department of Health to produce clear guidance, we felt, for local government, the NHS and Public Health England as to who does what in the circumstances of any outbreak. In principle, Public Health England runs the outbreak response. The NHS delivers the clinical aspects of that outbreak response, and local government has to absolutely assure itself, through the director of public health, that that is being done properly. [Professor Paul Cosford CB, Director of Health Protection and Medical Officer, PHE, Q301]

As we went through into 2014, we were aware that some places felt that was less clear than it needed to be. So we did a piece of work with all local health resilience partnerships and asked them to assure themselves that they had arrangements in place, and we produced some further guidance in 2014. It is still the case that, sometimes, in the complexity of dealing with outbreaks, it is difficult to be exactly sure who is going to respond in what way, and that gets dealt with at the time. [Professor Paul Cosford CB, Director of Health Protection and Medical Officer, PHE, Q301]

131.Concluding, Professor Cosford, PHE’s Director for Health Protection, said “I do not see a reduction in the quality of the response to outbreaks as a result of the 2013 changes. I do see that there is still a need for us to work on clarifying some of the roles and responsibilities so that it can be made smoother in certain circumstances.”72 Professor Cosford argued that the response to health protection will always be prioritised by Public Health England, but it may be at the expense of other areas of work particularly if the incident is large or prolonged.73 We also heard that for the first time, health protection is now going to be included in NHS England’s national ‘Who Pays’ guidance, in an attempt to clarify the funding situation.74

132.Dr Ian Cameron, Director of Public Health for Leeds City Council, articulated the need for clearer, more coherent national guidance and support as follows

There have been enough incidents of different types and nature across the country for there to be, by now, a common set of issues. From my viewpoint, it is about collating those incidents and saying what the key issues are and who is responsible for what. Whether that is done at a local level, which could be done under the health and wellbeing board, or for the local health resilience partnership to get agreement, or whether there should be something done on a wider level that comes down and says “No, this is who should be responsible for what,” is a judgement call. But, to me, when I am having conversations with people out with our area, it is clear there are issues, whether it is TB, hepatitis, or whatever, that are not fully resolved. Personally, that seems ludicrous in health protection incidents, where the funding has in the main been sorted out and we can get on with responding. I think there is more work to be done, and, as I say, there is a big enough experience now of different types of issues to try to get a collective view.” [Dr Ian Cameron, Director of Public Health, Leeds, Q215]

133.However, differences remained amongst our witnesses from different areas about which were the most appropriate local forums for health protection to be led from. Local health resilience partnerships were mentioned as one option, and another recommended structure was for health and wellbeing boards to assume responsibility through establishing a Health Protection Committee reporting directly to the main board. One witness pointed out that in his locality, that would not be a good use of resource, as it could lead to PHE local health protection consultants having to attend some 48 meetings per year.75

Conclusions and recommendations

134.The system within which the health protection function is now delivered is complex. Despite PHE’s efforts to provide guidance, in some areas there is still uncertainty over roles and responsibilities, and lack of clarity over funding arrangements. A further concern raised by several witnesses is the shrinking capacity in provider trusts to provide additional, timely support during outbreaks.

135.Health protection is a critical public health function, and more work needs to be done at a national level to support local areas to deliver a seamless and effective response to outbreaks and other health protection incidents. This work should begin with an audit of local arrangements, including a review of capacity in provider trusts, and the development of a national system to collate and disseminate lessons learned from incidents. We will review PHE’s progress on this work in six months’ time.

66 Local Authority written evidence, (PHP0102) para 3

67 Local Authority written evidence, (PHP0102) Executive Summary

68 Public Health Wolverhampton (PHP0098) para 3.2

69 Q270

70 Q185, Q190

71 Q301

72 Q304

73 Q310

74 Q309

75 Q257



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30 August 2016