Select Committee on Science and Technology Fourth Report


Chapter summary

Improving infectious disease services requires flexible multi-disciplinary teams. This involves developing better collaboration at all levels. This will be complex because of the breadth of expertise needed. The Minister for Public Health should take a lead in improving collaboration across all relevant departments. The HPA, as a new organisation, also has opportunities to set standards and clarify lines of accountability in the services and to develop a strategy for collaborative work with those outside of the HPA.

On a local level there is need to develop both breadth and depth of expertise. We recommend that the Government establishes a number of infection centres to provide a critical mass of expertise and to improve collaboration by including professionals from universities, hospitals and community settings.

International collaboration provides opportunities to help tackle some infection at its source before it spreads across the world. Involvement in international events benefits national services by developing expertise. We recommend providing formal means to allow health professionals to be seconded overseas.

Inter-departmental and inter-organisational collaboration

9.1 The responsibilities for different aspects of protection against infectious disease are divided amongst a number of Government departments and organisations [see Box 14]. Because of the number of organisations which have broader responsibilities than just infection we heard that there is a danger that infection will not always be a high priority. We heard that lines of communication and accountability are often unclear and collaboration inadequate [Emery, II p112, Emery, Gelletlie, Hawker, Monk Q229-231].

9.2 Infectious agents do not respect boundaries between community and hospital settings. Yet we heard that there is very little collaboration between hospital and community infection disease services, with microbiologists providing the only formal link. We note that there are some recently established initiatives to encourage rotation of infection control nurses between hospital and community settings in order to broaden experience and develop collaborative relationships [Naylor, Q672].
Box 15

Main organisations in England with some responsibility for human infectious disease services

Government Departments (Health, DEFRA, Home Office, DfID)

Health Protection Agency

Veterinary Laboratory Agency

Strategic Health Authorities

Primary Care Trusts

NHS Hospital Trusts

Local Authorities (environmental health)

Food Standards Agency

Health and Safety Executive

Prison Medical Service


9.3 In addition to those Departments listed in Box 14 we note that the Department for Trade and Industry and the Office of Science and Technology are responsible for technology development and the research councils respectively. In addition the Office of the Deputy Prime Minister oversees local government issues, and thus is ultimately responsible for environmental health.

9.4 We note that the role of Minister for Public Health was in part developed to ensure cross-departmental working and whilst we heard some positive reports about improvements in relation to surveillance it is clear that departmental collaboration is still insufficient and must be significantly strengthened [see chapter 5].

9.5 We recommend that the Minister for Public Health should publish an annual account of all progress in cross-departmental working in relation to infectious disease.


9.6 Lines of communication and accountability between organisations are complex and unclear [see Boxes 2 and 3]. Witnesses suggest that this should be addressed, particularly in relation to the role of Primary Care Trusts [Beeching, II p50; Bradford MDC, I p34-5; Brit Inf Soc, I p37; Emery, II p112, Q229; Faculty Pub Health Med, I p52-6; Gelletlie, Q229; Hawker, II p118, Q258; National Audit Office, II p 372; Roberts, I p139]. We are concerned that this lack of clarity inhibits full, effective and formal collaboration. All of those organisations that are involved in infection control should be clear about their roles and responsibilities and how they fit into the service as a whole. Whilst the HPA clearly has a key role in ensuring effective overall infection control services are in place, it can only achieve this through commitment and cooperation of others.

9.7 We recommend that the Minister for Public Health should publish as a matter of urgency a document outlining roles and responsibilities of all organisations involved in infectious disease services and should disseminate this to those concerned in order to facilitate effective communication and collaboration.

Health Protection agency

9.8 The Health Protection Agency should be able to provide opportunities to develop closer working relationships between different areas of the services: indeed many witnesses welcomed it for that reason. The Health Protection Agency is still establishing itself and it has a huge task ahead in order to live up to its promise. We have some concern about the speed in which it was established with perhaps insufficient consultation but believe that it is now important to focus on developing the most effective agency possible.

9.9 We note that there was some concern expressed about environmental health remaining divorced from public health following the creation of the HPA [Bradford MDC, I p34; Emery, II p111; Q232]. The suggestion was made that there perhaps could have been bolder moves to develop formal links between organisations responsible for food-borne infection [Humphrey, II p366; Inst Food Res, I p95].

9.10 Structural changes to organisations may bring benefits but they can also lead to confusion over lines of responsibility and thus can disrupt long established collaborative relationships [Hawker Q231]. The National Audit Office was extremely concerned that the HPA had been established without clarifying lines of responsibility between that body, other organisations and individual professionals [II p372]. Our recommendation above should rectify this.

9.11 We heard that exchange of information and collaboration between England, Northern Ireland, Scotland and Wales has historically been satisfactory, owing to good relations between relevant organisations [Donaghy, Q701; Salmon, Q700]. However, we note that the House of Lords Constitution Committee recommended in its report on Devolution[18] that there should be formal mechanisms for intergovernmental working in case more informal mechanisms broke down. We support this view in relation to infection and believe that the HPA has a role to develop formal collaborative relationships with relevant organisations in devolved administrations [Soc Gen Microb, I p157].

9.12 We recommend that the HPA publishes by April 2004 a proposal for developing collaborative relationships with organisations concerned with tackling infection, including the devolved administrations, environmental health departments and the Food Standards Agency.

Broadening and deepening expertise

9.13 We note that one of the difficulties with fighting infection is that it is difficult to predict when and where infection will arise. The first sign of a major epidemic may present to a GP, an epidemiologist, an outpatients' clinic, an ID physician or a veterinarian. Therefore breadth of expertise in infection is required. It is also fundamental to have collaborative structures in place. If, for example, a GP sees something unusual, they should know how to access the appropriate expert.

9.14 One of the properties of infectious disease is its potential for sudden unexpected increases in cases, outbreaks and epidemics. If significant numbers of people are exposed to an infectious agent they are potentially infected and may require investigation, preventative treatment and reassurance. This means that services need surge capacity. Surge capacity should exist at all levels: in clinical, laboratory and epidemiological services, and in the production and delivery of interventions such as vaccines [AcMedSci, II p353-4].

9.15 Surge capacity can be provided if all staff are well trained. There is also a need for improved collaboration, so that areas of the country under increased pressure can receive assistance from other areas.

9.16 We recommend that the Government recognises and addresses the fact that, although England has not experienced major epidemics of infection in recent years, this owes as much to good fortune as to good management. Without improvements we fear that this country will suffer from major epidemics and will continue to see infectious disease take its toll in economic terms, in suffering and in lives.


9.17 Throughout this inquiry we heard that the infection team should not be confined to medical nursing infection specialists. In part broadening expertise can be tackled by improving education and training in infectious disease of all health professionals medical and nursing specialists and we have discussed this in chapter six. Relevant expertise is however wider than doctors, nurses and basic scientists. Many different people have played key roles in identifying and helping to control infections including mothers and anthropologists.

9.18 In Connecticut, USA, mothers helped to identify Lyme disease when they spoke to the local epidemiologist about the unusual number of children in a small area diagnosed with juvenile rheumatoid arthritis—a rare condition. The epidemiologist investigated further and found that all these children had been exposed to ticks and suffered from an unusual rash. This led to identifying Lyme Disease. Anthropologists working amongst women in New Guinea highlighted the way that Kuru disease, a rare degenerative, and fatal brain disorder is transmitted, when they described the practice of eating and smearing on their bodies the brains of dead relatives.

9.19 There are concerns about shortages of specialists who could provide help to infection services. For example, we heard in the US that entomologists are necessary to help understand and control insect-borne diseases such as West Nile virus, yet there is a nationwide shortage [USA, II p386]. The situation in the United Kingdom is much the same, as we outlined in our reports Systematic Biology Research[19] and What on Earth?[20]. The need for such expertise was recently highlighted in the Chief Medical Officer's Annual Report 2002, Health Check: On the State of the Public Health.

Infection centres: improving communication, developing teams and expertise

9.20 Whilst broadening understanding may be necessary, we heard that national expertise in infectious disease should also be improved and access to that expertise made easier [Bri Infect Soc, I p37-8]. The Academy of Medical Sciences and others raised the idea of developing "infection centres" [Cohen, Q55; Lachmann, Q54, Birmingham, II p394]. These would be similar to the model used to develop cancer services and should be placed within a geographical area such as that served by a Strategic Health Authority.

9.21 We support the establishment of infection centres as they would provide an excellent opportunity to

(a)  develop expertise in clinical services and research

(b)  improve collaboration between hospital, community and university settings

(c)  provide training of infection specialists and others

9.22 We envisage that infection centres should be associated with an academic institution and should provide a clinical infection service for adults and children to the local district. In addition they should provide high quality training in order to ensure a supply of sufficient well trained health professionals to meet current and future requirements. Research should be actively encouraged and should span clinical infection (adult and paediatric), microbiology (including infection control), virology, and public health medicine.

9.23 Centres should be closely allied to the HPA in order to improve the interface between clinical, laboratory and public health based infectious disease services. Ideally there should be close collaboration with other relevant specialists such as in hepatitis, HIV, tuberculosis and paediatrics. These centres should also seek to facilitate relationships between specialists in human and animal infection and others who could help with outbreaks, such as entomologists.

9.24 We recommend that the Department of Health encourages and facilitates the development of infection centres which integrate scientists (virologists, microbiologists), clinicians and epidemiologists. These should be associated with academic and tertiary referral centres and the regional HPA laboratories. Each Strategic Health Authority should have access to services of one of these.

International collaboration

9.25 It is a truism that infectious diseases do not respect borders. Whilst the focus of our inquiry and of this report is infectious disease as it affects England, it is not possible to ignore the global dimension [AcMedSci, II p33-4; Stewart, II p316]. Every year sixty-four million passengers pass through Heathrow Airport alone. Significant amounts of food and other goods arrive in the UK daily from all parts of the world. This global movement of people and goods also provides opportunities for global movement of infections, whether through spread of infections such as influenza viruses or through global travellers and immigrants importing unusual "exotic" infections [Int Org Migration, II p392, see Box 16].
Box 16

Global spread of infection

West Nile Virus is a virus causing a range of mild to severe symptoms spread by a particular type of mosquito which emerged in the US in 1999. It first arose in New York but there have now been disease in humans in forty-two of the fifty states.

SARS, a virus causing serious respiratory problems, was recognised in 2003, and has now spread to twenty-eight countries.

Congo Crimean Haemorrhagic Fever, a rare "exotic" disease causing severe internal bleeding with a thirty percent mortality rate and spread both by ticks and blood, was diagnosed in a patient in a hospital in Dorset in 1998 .

9.26 International collaboration and aid brings significant benefits to the donors as well and improves chances of a country being able to adequately fight infection. A successful infection disease service needs to accept that disease can, and will, be imported and thus health care professionals need to be able to identify, advise and protect individuals from exotic diseases [Blears, Q863-9; PHLS, Q322; Troop, Q818-9]. The US Congress acknowledged the importance of such international collaboration and formally established a budget to allow the Centers for Disease Control to engage in international work [USA, II p387].

9.27 As was recently exemplified by SARS, contributing to international work helps to provide early warning of emergence of possible epidemics, thus allowing implementation of control measures.

9.28 England currently collaborates significantly on the international stage, in particular through support to the World Health Organization (WHO) which DfID and the Department of Health support [DfID, II p360; WHO, II p391]. England also houses one of WHO's collaborating centres on influenza, based in the World Influenza Centre (WIC) at Mill Hill. There is, at present, some discussion as to whether the WIC should be moved. We suggest that when making this decision, consideration should be given to ensuring that expertise is maintained in order to continue such high-profile collaboration.

9.29 In response to the threat from infectious disease, WHO has developed an international network of experts who alert others to possible outbreaks and provide response services to those outbreaks. The Communicable Disease Surveillance Centre, HPA is a member of this Global Outbreak and Response Network (GOARN) [WHO, II p391].

9.30 WHO told us that it was imperative that GOARN could access short term aid from partners, such as through providing laboratory analysis support and experts on secondment. The UK has helped to facilitate this and has provided "excellent support" to GOARN in relation to the recent SARS outbreak [WHO, II p377, 391].

9.31 We also heard that much collaboration with WHO is through individual HPA staff who have formed ad hoc relationships [Duerden, Q322, Troop, Q818-9]. It has, in the past, often been difficult to release PHLS staff to enable further international collaboration. Dr Troop, Chief Executive of the HPA, told us that in order to increase international activity "we either need to create some internal capacity or we need to increase funding in order to free up more people to be able to do it in a more systematic way" [Q766].

9.32 We were pleased to hear that Dr Troop was committed to improving formal means by which the HPA could both benefit from and assist in international collaboration [Troop, Q766] and that the Minister was committed to the infection community making a "proper contribution" to international collaboration in this sphere [Blears, Q863-9]. We note that there is also expertise outside the HPA, such as at the Schools of Hygiene and Tropical Medicine, which could be drawn upon.

9.33 We recommend that the Government enables the HPA to second health professionals to international bodies such as WHO and provides the resources to make this possible.


9.34 Infection is spread not only by movement of people but also by food and animal trade. This has recently been highlighted by an outbreak of monkeypox in the US (see Box 11).

9.35 When we visited the WHO we heard that many trade agreements do not adequately consider public health implications [WHO, II p391]. Defra take the lead in relevant World Trade Organization meetings, with the Food Standards Agency providing public health aspect [Defra, II p355]. We are concerned that the views of the Department of Health are not sought as standard and suggest that this should be addressed.


9.36 At present there is a significant amount of discussion about the nature of EU wide collaboration [Brussels, II p381]. Closer relationships between EU countries have led to increased ease of movement of people and goods and means that the risks of infectious diseases within Europe are increasing. This risk may increase following the entrance of new countries where there are higher rates of various infectious disease and lower levels of disease control than other EU countries [Nicoll, II p160-2]].

9.37 The EU is considering developing a European centre for infectious disease to enable closer collaboration relating to surveillance and control measures. This is an important component of fighting infection but we note that a large, heavily staffed, CDC-type venture could contribute to loss of experts in infectious disease from nation states. As of present experts in England are in short supply. Furthermore the response to SARS demonstrated to us that much could be achieved through facilitating collaboration between laboratories. Duplicating facilities by creating European level laboratories may not produce further significant benefit to effective collaboration.

18   House of Lords Select Committee on the Constitution, Devolution: Inter-Institutional Relations in the United Kingdom, Second Report 2002-03, HL Paper 28 Back

19   House of Lords Select Committee on Science and Technology, Systematic Biology Research, First Report 1991-92,
HL 22-I 

20   House of Lords Select Committee on Science and Technology, What on Earth: The threat to the science underpinning conservation, Third Report 2001-02, HL 118 Back

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