Memorandum by the National Audit Office
The National Audit Office welcomes the opportunity
to submit evidence to the House of Lords Science and Technology
Select Committee inquiry "Fighting Infection". The evidence
and comments provided are drawn mainly from our published work.
1.1 The National Audit Office, established
under the National Audit Act 1983 is headed by the Comptroller
and Auditor General. We carry out the external audit of Central
Government Departments, their agencies, and many other public
bodies, on behalf of Parliament. The Comptroller and Auditor General
is an officer of the House of Commons. He and the National Audit
Office are independent of Government. Our primary objective is
to provide independent information, assurance and advice to Parliament
on the way Government departments, agencies and public bodies
account for and use tax payers money. We also aim to be constructive
and realistic, and direct our work towards making practical recommendations
to help audited bodies improve the economy, efficiency and effectiveness
of their activities.
1.2 The Comptroller and Auditor General
is the statutory appointed auditor of the Department of Health
and two of the existing Non-Departmental Government Bodies that
it is proposed to amalgamate within the new Health Protection
Agency. Each year the Comptroller and Auditor General provides
Parliament with his opinion on whether the financial statements
of each of these bodies present a true and fair view of their
state of affairs and that expenditure and income have been applied
to the purposes intended by Parliament.
1.3 We also have inspection audit rights
to all NHS Trusts, Strategic Health Authorities and other NHS
organisations under section 7 of the NAO Act which we exercise
in carrying out our value for money audits and other inspection
1.4 This response/evidence from the National
Audit Office draws on our experience, status and role as:
The auditors responsible for a number
of value for money studies that have considered issues that relate
both directly, and indirectly, to your inquiry. The main study
from which we draw our evidence for our comments is The Management
and Control of Hospital Acquired Infection in Acute NHS Trusts
in England (HC 306, Session 1999-2000), together with the
subsequent Public Accounts Committee report and the emerging findings
from our current follow-up investigation. In addition we draw
to a limited extent on findings in other reports, for example
The 2001 Outbreak of Foot and
Mouth Disease (HC 939, Session 2001-02): specifically the
more general recommendations on the control of disease outbreak
Modern Policy-Making: ensuring
policies deliver value for money (HC 289, Session 2001-02
which examined how organisations making changes to services use
effective identification, assessment and management of risks.
Examples of new policy were cited and assessed against the Cabinet
Office's nine characteristics of modern policy-making set out
in Professional Policy Making for the Twenty First Century.
Our report identified key questions that departments need to consider
in managing the risks of policies not delivering what is intended
and the questions to consider to promote value for money (Appendix
Emergency Planning in England (HC
36 Session 2002-03); and
We have also drawn on our response
in October 2002 to the Consultation Document on the Creation of
a Health Protection Agency (HPA).
Copies of all NAO reports can be accessed on
our website www.nao.gov.uk.
1.5 Our aim in commenting is to provide
constructive advice and commentary on the questions posed in the
call for evidence where we feel qualified to do so. The questions
(i) What are the main problems facing the
surveillance, treatment and prevention of human infectious disease
in the United Kingdom?
(ii) Will these problems be adequately addressed
by the Government's recent infectious disease strategy, Getting
Ahead of the Curve?
(iii) Is the United Kingdom benefiting from
advances in surveillance and diagnostic technologies; if not,
what are the obstacles to its doing so?
(iv) Should the United Kingdom make greater
use of vaccines to combat infection and what problems exist for
developing new, more effective or safer vaccines?
(v) Which infectious diseases pose the biggest
threats in the foreseeable future?
(vi) What policy interventions would have
the greatest impact on preventing outbreaks of and damage caused
by infectious disease in the United Kingdom?
1.6 These questions cover a broad range
of issues, a number of which are outside our sphere of expertise
and knowledge. In replying to your questions we have therefore
focussed predominantly on the issue of surveillance, identification
and management of infection. Our report on the procurement of
vaccines which was published on 9 April may be of some relevance
to your fourth question (copy enclosed). We have not commented
on your last two questions as we feel others are more qualified
to comment. This response, therefore, provides our comments to
some of the issues raised in your first three questions.
PART 2: NAO RESPONSE
Q1. WHAT ARE
2.1 The first problem is defining what surveillance
means. The development of the Nosocomial National Surveillance
Scheme was delayed by arguments about the definition, while this
scheme developed a customised version of the American CDC definition,
Northern Ireland and Wales chose to go with the CDC definition.
The existence of different definitions and the confusion and arguments
caused can be counter productive. For example the Infection Control
Doctor at University College London has undertaken a surveillance
exercise using three different definitions and found each gave
quite different surveillance results. We consider that there is
a need for the NHS to reach a consensus on a standard definition
of surveillance that has the agreement of the clinical specialties
and enables comparison of practice outcomes.
2.2 Another problem is a lack of consistency
in the approach taken to surveillanceour report in February
2000 on the management and control of hospital acquired infection
highlighted a lack of consistency across NHS trusts and a paucity
of robust comparable information on infection rates etc. We also
highlighted a lack of post-discharge surveillance. We concluded
that there was scope for surveillance to be done much more effectively
in order to improve the NHS's understanding of infection problems,
both within and between trusts and also to enable them to determine
the effectiveness of any interventions. There was also a need
for significant improvement in the dissemination of the results
of surveillance activity. We have yet to see any evidence of this
being addressed in a consistent way.
2.3 The Committee of Public Accounts in
November 2000 concluded that the Nosocomial National Surveillance
Scheme (NINNS) should be made mandatory; and that post discharge
surveillance should be monitored through the national surveillance
scheme (Figure 1 details the Committee's recommendations and the
Government's response in relation to surveillance).
|Figure 1: Comparison of the Committee of Public Accounts Report recommendations on the surveillance of hospital acquired infection and the Government's Response COMMITTEE OF PUBLIC ACCOUNTS REPORT RECOMMENDATION|
Research indicates that between 50 per cent and 70 per cent of surgical wound infections occur post-discharge, but these infections are not monitored. The NHS Executive are undertaking research into post-discharge infection, and we look forward to seeing the outcome later this year. We recommend that post-discharge infections are monitored in future through the national surveillance scheme.
GOVERNMENT'S TREASURY MINUTE RESPONSE
The Department funded report referred to by the Committee has just been received by the Department and is currently being subject to peer review. A copy of the final report will be sent to the Committee as soon as it is finalised. It is well recognised in published literature that once a patient has left the confines of a hospital it is difficult to ensure accuracy in surveillance of any post-discharge infection. However, a UK-wide meeting of consultant microbiologists and others with a key interest in this area was held in Glasgow on 16 January 2001 to review progress and make recommendations. The NHS Healthcare Associated Surveillance Group referred to below will now take this work forward.
COMMITTEE OF PUBLIC ACCOUNTS REPORT RECOMMENDATION
The NHS Executive have now taken action to improve surveillance, including researching the links between antimicrobial resistance and prescribing, measuring infections that occur after patients have been discharged from hospital, and doubling their investment in the Nosocomial Infection National Surveillance Scheme. But by December 1999, only 139 self-selecting Acute NHS Trusts in England were participating in the surveillance scheme. We recognise that the Executive are expanding the Scheme, but we believe that they should go further and make it mandatory.
GOVERNMENT'S TREASURY MINUTE RESPONSE
The Minister of State for Health announced in September that surveillance of hospital acquired infection would be made compulsory for all Acute NHS Trusts from 1 April 2001 and that data would be published from 1 April 2002. A new NHS Healthcare Associated Infection Surveillance Steering Group, chaired by an NHS Chief Executive, was set up in September 2000 to provide the Department with urgent recommendations on infection surveillance needs at local, regional and national level, building on improving on the limited coverage of the current Nosocomial Infection National Surveillance Scheme, to deliver national surveillance reporting of hospital acquired infection by all Acute Trusts from 1 April 2001. Details of the proposed arrangements will be announced shortly.
2.4 Following the Committee of Public Account's hearing,
but prior to publication of their report, John Denham MP, the
then Health Minister, announced that surveillance of hospital
acquired infection was to be made mandatory. As has now become
clear, the initial response by the Department has been to focus
on making MRSA surveillance mandatory. Information on MRSA is
collected by Centre for Disease Surveillance and Control (CDSC)formerly
in the PHLS, now part of the HPA, from all participating laboratories
and reported in their quarterly Communicable Disease Report (CDR).
2.5 While this has certainly raised the profile of the
issue both within trusts and with the media, clinicians and infection
control teams have raised with us their concerns that this does
not distinguish between infections that are hospital acquired
or that are increasingly being acquired in the community setting
and therefore outside the hospitals control. As a result there
are concerns that the findings from MRSA surveillance, and the
proposed application of an improvement score based on MRSA bacteraemia
rates hospitals, may be used inappropriately. In particular that
MRSA rates do not represent a good marker of specific hospitals
infection control practices. It is also relevant to note that
the NINNS data from the results of their bacteraemia surveillance,
which examines the extent of these infections across different
specialties and also identifies devicerelated infection,
illustrates the wide variations between specialties within hospitals.
2.6 As far as your inquiry is concerned, however, the
MRSA mandatory surveillance does provide an easy to collect, overall
indication of the burden of MRSA in hospitals. The problem that
then needs to be addressed is how this surveillance information
can be used to effect improvements in patient care. From our observations,
the media and, to some extent, the Department are in danger of
using it as a blunt tool for measuring the effectiveness of NHS
trusts whereas staff and clinicians may disregard it because they
do not feel any ownership of the information. We will return to
this issue of ownership later in our response.
2.7 The second stage of the Department's new surveillance
strategy is to develop an enhanced surveillance scheme to monitor
infections following orthopaedic surgery which we understand will
also be made mandatory and will revert to using standard CDC definitions.
While this will enable comparisons to be made with Wales, Scotland
and Northern Ireland, using a different set of definitions will
prevent any direct comparison with the last six years of NINNS
data and it will therefore be several years before there is any
robust comparable information. Furthermore, we consider that the
success of this scheme will depend on ensuring that this is accompanied
by systems for effective feedback of the results and by ensuring
that clinicians accept/acknowledge ownership of the data.
2.8 A number of clinician groups carry out their own
surveillance of complications, including infections, for example
on Coronary Heart Bypass surgery, caesarean sections, orthopaedic
surgery etc. Here the clinicians clearly own the data and use
it to influence practice, but in a non public, and non threatening
way. There are also a number of national audit initiatives which
provide surveillance data. The CDSC's weekly CDR reports provide
useful surveillance information on a number of diseases such as
tuberculosis, influenza, SARs etc. Again the problem is on dissemination
of this information and how widely it is accessed and how effectively
it is used to develop strategies to fight infection.
2.9 A concern that we expect to raise in our follow-up
report is that the decision to suspend NINNS and introduce a new
surveillance system means that there is a danger of missing an
opportunity to learn from six years worth of robust comparable
data. While we will be interrogating this data ourselves to determine
whether there are discernible changes in patient outcomes due
to particular interventions, it appears to us that more could
be done to learn from this past experience. The importance of
learning from past experience in order to prevent history repeating
itself is one of the lessons emphasised in the three national
inquiries into the lessons to be learned from the past management
and control of national outbreaks of foot and mouth disease in
England and Wales (Appendix 1). There may be some parallels for
hospital acquired infection surveillance.
(b) On treatment and prevention
2.10 In a number of our value for money reports we have
identified concerns about the capacity of the NHS to treat patients
and for patients to access treatment. Demand is inherently unpredictable
and changeable and can increase disproportionately at times of
national outbreaks and international pandemics. The problem as
far as "Fighting Infection" is concerned is in identifying
the disease early enough so as to provide appropriate treatment
and prevent its spread.
2.11 Our findings on hospital acquired infection may
provide some relevant insights. They pointed to a tendency in
the past to focus on treatment rather than prevention. The Chief
Medical Officer in response to the PAC acknowledged this point
in his evidence to the Committee of Public Accounts. Some of our
other reports, for example our report on Obesity (HC 36 Session
2001-02) also emphasised the Department's tendency to treat rather
than develop prevention strategies. A main thrust of the report
was to emphasis the cost effectiveness of having improved prevention
2.12 In our original report, we indicated that infection
control teams believed that on average 15 per cent of hospital
acquired infection could be prevented by better application of
existing knowledge and good practice, with potential savings to
the NHS of £150 million a year. However we also identified
a lack of compliance by hospital staff with good practice, in
particular we cited the problem of compliance with good hand hygiene.
Given the lack of robust surveillance data on what is actually
happening in trusts in relation to the extent of infections we
are not confident in being able to develop this point in our follow-up
study but will be attempting to do so through our follow-up survey.
2.13 In our original report we noted the lack of evidence
based guidelines on measures to reduce hospital acquired infection,
and recommended the need to develop them and improve dissemination
of good practice. Subsequently, national "Guidelines for
Preventing Healthcare Associated Infections" (EPIC) commissioned
by the Department were published as a supplement to the Journal
of Hospital Acquired Infection in January 2001. They include the
general principles of good infection control practice that cover
the hospital environment and hand hygiene, the use of personal
protective equipment and the safe use and disposal of sharps,
and in addition, guidelines for preventing infections associated
with the use of short-term indwelling urethral catheters, and
for the insertion and maintenance of central venous catheters.
2.14 While the Department of Health funded EPIC guidelines
are a welcome development, it is not clear whether the guidelines
are widely known about at Trust level or if they are being implemented
in many Trusts. Our findings from the workshops suggest that,
other than the Infection Control Teams, staff are mostly unaware
of their existence. Again this is something we will be seeking
to answer through our follow-up survey.
2.15 As part of improving prevention, the Department
allocated a total of £61 million between 2001-02 and 2002-03
to clean-up hospitals and NHS Estates issued new National Standards
of Cleanliness for the NHS in March 2002. The Department also
allocated a further £200 million to improve sterilisation
and decontamination arrangements for medical and surgical equipment
by 2003 (an increasingly sensitive issue due to concerns over
the spread of variant Creutzfeldt-Jacob Disease).
2.16 Since autumn 2000, the Department's Patient Environment
Action teams have inspected hospital premises at six monthly intervals
and over the last two and a half years "traffic light"
ratings awarded to NHS Trusts show demonstrable improvements in
the hospital environment. However of the 19 categories covered
by the inspections only one pertains to hygiene. There are therefore
risks in linking positive assessments of hospital cleanliness
(the traffic light system) with good infection control. Indeed,
some of the Trust awarded a "green light" have some
of the highest rates of MRSA.
2.17 The availability of adequate isolation facilities
is also crucial in preventing and treating infection. We identified
significant concerns across NHS trusts about the lack of isolation
facilities and recommended that trusts should undertake a risk
assessment and review the extent to which availability of isolation
facilities met with Health and Safety legislation. The Committee
of Public Accounts hearing also raised concerns about this issue
among wider concerns about the impact of bed management policies
on infection control. However bed occupancy rates remain high
(latest estimate is 90 per cent compared with the target of 82
per cent told to the Committee of Public Accounts. There is also
little evidence of any progress in relation to improving the availability
of isolation facilities.
2.18 A further prevention strategy is the use of antibiotic
prophylaxis. At our Conference in June 2000, the Government set
out its three year strategy for tackling antimicrobial resistance.
Our workshops identified a need for some rationalisation of antibiotic
prescribing policies, and for a national policy on antibiotic
prophylaxis together with evidence based guidelines. There also
remains a need to develop enhanced national and local surveillance
of antibiotic resistance, something that was promised in response
to the Public Accounts Committee recommendations ( Figure 2).
|Figure 2: Comparison of the Committee of Public Accounts Report recommendations on the prevention of hospital acquired infection and the Government's Repsonse (v) Complacency, poor prescribing practice and misuse of antibiotics has led to the emergence of drug resistant infections. As the Chief Medical Officer told us, there are no simple solutions any more. The NHS Executive have now launched initiatives to look at the more prudent use of antibiotics, and to monitor and control prescribing including the new Government stategy to tackle antibiotic resistant infections announced in June 2000. We expect this work to lead to evidence-based guidance on effective prescribing strategies.|
GOVERNMENT'S TREASURY MINUTE RESPONSE
The UK Antimicrobial Resistance Strategy and Action Plan published in June 2000, to which the Committee refers, outlined the areas where work is underway to promote optimal antimicrobial prescribing in clinical practice. An Interdepartmental Steering Group (IDSG) is overseeing and co-ordinating work on the Strategy. Twelve months ago the IDSG set up a Clinical Prescribing Group which is looking at ways of optimising and monitoring prescribing of antimicrobials in clinical practice through professional education, promotion of evidence-based guidelines, prescribing and organisational support and surveillance. As part of this, the Public Health Laboratory Service (PHLS) has developed and distributed a template intended to be used as a basis for the development of local evidence-based antimicrobial prescribing policies in primary care. It is available on the PHLS website and will be reviewed in the light of comments received and updated as the evidence-base evolves. PHLS has also organised a series of workshops with local healthcare professionals on the use of antibiotics in primary care.
The National Prescribing Centre (NPC) has developed a tool kit providing clinical audit guidance on antimicrobial prescribing and monitoring. This has been disseminated to all Health Authorities (Has), Primary Care Groups/Trusts (PCGs/Ts) and hospital trusts. A change management resource pack has also been developed by the NPC, in which the prudent prescribing of antimicrobial agents is used as an illustrative example. The NPC has run four full-day therapeutics seminars for HA and senior PCG/T prescribing advisors this year on the proper use of antimicrobials. Nineteen senior prescribing advisors have been recruited by the NPC and given two days intensive training plus materials; they will each present at and lead a minimum of two half-day seminars for PCG prescribing advisors and practice-based pharmacists on the appropriate use of antimicrobials and use of the audit materials.
2.19 Antibiotics provide a necessary treatment for infection
but over or misuse, as your previous inquiry identified, creates
problems for future treatment (the MRSA problem being a classic
example). We emphasised in our original report the recommendation
from your previous inquiry on the need for more prudent use of
antibiotics and while there is some evidence of progress with
antimicrobial prescribing in primary care falling by 23 per cent
there does not appear to have been the same progress in terms
of hospital prescribing.
Q. Will these problems be adequately addressed by the
Government's recent infectious disease strategy, Getting Ahead
of the Curve?
2.20 One of the key initiatives introduced in Getting
Ahead of the Curve, as far as "Fighting Infection" is
concerned was the proposal to create the Health Protection Agency
(HPA) and the restructuring across the NHS of the epidemiology,
microbiology and public health services previously provided by
the PHLS. In October 2002 we provided a formal response to the
Department's consultation document Creating a Health Protection
Agency. In responding to the above question I have therefore
drawn on our comments made in our response to the consultation
2.21 The agency's central purpose, as noted in the consultation
document is the provision of information, expertise, advice and
training on infectious diseases, chemical and radiation hazards,
and health emergency planning; and commissioning and carrying
our research to inform all of these activities. The functions
proposed are the management of surveillance activity for infectious
disease, chemical and radiological hazards; support for the provision
of services at local level; the provision of advice and support
at national level; and to provide and commission certain services
at national or regional level.
2.22 We consider that the success of this proposal to
manage surveillance activity and to provide a one-stop agency
for the provision of advice on health protection will depend on
the provision of effective links and networks
between the HPA, NHS and Local Authorities;
the specification of Service Level Agreements
for HPA activity within the NHS; and
designation of clear responsibilities and lines
of accountability for HPA staff giving advice within the NHS and
2.23 We suggested that the benefits of the change would
be maximised if attention was given to the recommendations in
our report on Modern policy-making: ensuring value for money and
the ten key questions the Department needed to consider (Appendix
2). The principle issues that we identified were:
clear accountability arrangements for the public
surge capacity for dealing with national outbreaks
and emergencies including bioterrorism;
the feasibility of the proposed changes and implications
of the risk assessment; and
need for a value for money review to study the
effect of cost neutrality on the future delivery of services.
2.24 While there are clear benefits in the proposal which
should strengthen the health protection function of the NHS there
is nevertheless a need for the Department to identify and manage
the risks inherent in a re-organisation and amalgamation of such
magnitude. In responding to the consultation document we:
emphasised the need to balance the process of
reform with risk assessment and risk management to ensure that
the current and future service provision in health protection
is enhanced; emphasising yet again the need to ensure that effective
audit and accountability arrangements would be in place;
mentioned that we were aware that the Public Health
Laboratory Service Board had expressed concerns over the logistics
and timetable for the transfer of specific functions to NHS Trusts
and that we hoped that these concerns would be addressed and any
risks that were identified, would be properly mitigated;
commented that the timetable appeared very tight,
especially if effective regional arrangements were to be established
and drew attention to the danger of operational risks to the ongoing
noted that some of the processes we would expect
to see included effective corporate governance arrangements including
clarification as to the roles, responsibilities and accountability
structures; documented change management procedures, including
a realistic timetable; clarification of what improvements in services
they would expect as a result of the changes; and controls to
ensure that there was no diminution of the services provided.
2.25 In relation to your question about whether these
new arrangements will improve the problems affecting surveillance,
treatment and prevention it is too early to tell. We consider
that the consequences of regionalisation of surveillance services
may be to create different approaches which will make developing
a national picture even more difficult than at present. There
are also likely to be issues about the current level and speed
of response in the service provided by the Communicable Disease
Surveillance Centre, but these are as yet untested. Our workshops
identified concerns about the potential for diminution in service
and control functions due to the lack of clarity of the roles,
responsibilities and relationships of key players such as Consultants
in Communicable Disease Control and Directors of Public Health.
2.26 Some other issues that may be relevant to your inquiry:
Our report, Facing the Challenge: NHS Emergency
Planning in England, (HC 36, 2002-03) examined how ready NHS bodies
including acute and ambulance trusts are to deal with major incidents.
The findings are relevant to NHS handling of major incidents in
general and by extension to NHS handling of risks such as incidents
that might arise from pandemics and bio-terrorism. The findings
and recommendations are also relevant to the achievement of the
objective of the Health Protection Agency to enhance and improve
the co-ordination of current expertise both between and within
the existing agencies.
Our report on The Outbreak of Foot and Mouth
Disease (HC 939, 2001-02), recommended that contingency plans
for outbreaks of foot and mouth disease need to be substantially
revised. The report cited nine key points on contingency plans,
which have wider relevance for all departments. Several of these
points are applicable to the management and control of national
emergencies whether due to biological, chemical or radiological
agents. Specifically; the need for contingency plans to be risk
based; for clear lines of responsibility, reporting and accountability;
a general awareness of these reporting lines; the requirement
for appropriate and tested information and communication systems;
and the need for surge capacity and access to additional resources.
We consider that there could be a parallel drawn from the earlier
report by the Drummond Committee on the possible consequences
of downsizing the veterinary investigation service and the changes
to the diagnostic services available for public health microbiology
2.27 Overall, we consider that our reply to the HPA consultation
document gave a clear steer to the Department as to the risks
involved and other matters that we would expect to be addressed.
We have stressed the importance of ensuring good risk and project
management processes are in place to ensure that service delivery
will not, as a minimum, be diminished. However, we do not feel
that it would be appropriate for us to intervene any further during
this process of change nor would we wish to go outside our remit
and argue against what is clearly government policy. Nevertheless
we are keeping a close eye on the situation by monitoring developments
and will need to return to some of the issues we have raised in
assembling the evidence for our follow-up report.
Q. Is the United Kingdom benefiting from advances in surveillance
and diagnostic technologies; if not, what are the obstacles to
its doing so?
2.28 This is not an area where we have much expertise
or evidence from our work. Nevertheless, from the evidence cited
in our reports we believe that the following points may be obstacles
to the UK being able to benefit effectively from advances in surveillance
and diagnostic technology, in summary these obstacles include:
regionalisation of surveillance with the potential
dilution of expertise, and also the potential for re-invention
of the wheelhowever there is also the potential that this
could encourage innovation and, with effective dissemination of
good practice, improve techniques/technologies etc;
delays, lack of technology and expertise at Trust
level to implement the new surveillance strategy and interpret
the results appropriately;
continuing delays in implementation of NHS national
IT initiatives and networks;
an apparent lack of communication and transparency
within the HPA as to the nature and extent of existing risk assessments
and the sharing of programmes for risk management.
2.29 It remains unclear as to how the proposed new national
and regional surveillance systems will provide local, regional
and national users the evidence that is needed to improve patient
outcomes in the hospital setting. It is also unclear as to the
extent that comparisons will be possible either between the devolved
administrations within the UK, within and between EU countries
or with the surveillance undertaken in North America and the Antipodes.
2.30 Finally, there does not appear to have been any
cost benefit analyses or business case assessment to support the
concept that the changes in creating the HPA should be cost neutralcovering
both implementation and integration of HPA functions and the transfer
of all diagnostic microbiology and some public health microbiology
services to the NHS. We are concerned that the intention to achieve
cost neutrality could result in some reduction in end point services
in order to fund the costs of multiple and in some cases temporary
changes in the management arrangements. This may in itself prevent
trusts benefiting from advances in surveillance and diagnostic
technology. Again it is perhaps too early for us to make any judgements
on this issue.
2.31 We thought we might take the opportunity provided
in responding to your call for evidence to share with you a risk
model that highlights the complexity of the changes affecting
the management of communicable disease and the factors that may
influence the detection and control of outbreaks. This crude risk
analysis identifies the potential for there to be a reduction
in ability and capacity to rapidly diagnose infection at a time
of Government attempts to introduce multiple changes and working
practices in the NHS. And that this is exacerbated by a period
of heightened risk of deliberate release and international terrorism
and the existence of social change and unrest in some local populations
of the United Kingdom. The latter includes the effect of European
Directives on asylum seekers and other causes of population immigration
and movement of people which may result in the importation of
communicable diseases normally more prevalent in developing countries.
2.32 The model has been developed principally by Dr Andrew
Pearson, who has been on a 12 month secondment to the National
Audit Office from the then PHLS. Following an analysis of the
NAO reports referred to in our response he developed the risk
model to illustrate the different risks that need to be taken
account in developing a strategy for "Fighting Infection".
The strategic overview and risk model together highlight the unintended
consequences that may arise from the change management arrangements
in the NHS and PHLS, and the possible impacts from national and
international events that may influence infection risks. On their
own, these risks may well be being managed effectively but if
the risks should line up in time and place then they could well
result in a real threat to Public Health. Figure 3 uses A SWISS
CHEESE RISK MODEL to depict a crude risk model that illustrates
the multiplicity of factors that could reduce the UK's ability
to fight infection.
SUMMARY OF LESSONS TO BE LEARNED FROM THE 2001 OUTBREAK
OF FOOT AND MOUTH DISEASE
The lessons to be learned from the 2001 Outbreak of Foot
and Mouth were identified by both the Anderson Inquiry and the
National Audit Office report. These cover three aspects of outbreak
the need for early reporting and rapid control
measures for initial local outbreaks;
that satisfactory disease control depends on a
strong Veterinary Service with sufficient numbers of appropriately
trained staff; and
the need for more detailed outbreak planning to
prevent history repeating itself.
The NAO study of the 2001 outbreak emphasised the value of
learning from past experience and cited the Drummond report which
identified that for national disease control there needed to be
adequate surge capacity in the veterinary service. Both reports
summarised the actions noted in the past and identified how professionals
were aware of the impact of changes on the capability to prevent
national outbreaks but that these risks had not been adequately
drawn to the attention of Ministers. Our NAO report also summarised
recommendations that could be more widely applied to assessing
and managing both the risks of an outbreak occurring and facilitating
early and successful intervention (see table 2)
NAO REPORT ON THE
2001 OUTBREAK OF
In the light of our examination and the findings set out
above we make the following recommendations. Although these recommendations
are addressed specifically at controlling foot and mouth disease,
they are also applicable in large measure to the control of other
animal diseases. The Department already has in hand or has planned
actions in response to many of these issues we have identified.
1. Contingency plans should be based on an analysis of
the risks associated with an outbreak of foot and mouth disease.
They should incorporate a range of different assumptions about
the nature, size and spread of an outbreak. Plans should have
regard to the economic, financial and environmental impacts of
different methods of disease control.
2. A clear chain of command is required for handling
any future crisis. Responsibilities, reporting lines and accountabilities
need to be clearly defined in contingency plans, both at headquarters
3. The plans should include arrangements for the deployment
of staff and the emergency purchasing of supplies and services.
The Department should have access to key supplies and services
and approved firms of contractors. Where possible, pre-agreed
rates should be negotiated.
4. The Department should consult widely with central
and local government, farmers and other major stakeholders about
its contingency plans. The plans should identify the roles and
responsibilities that each of these would have in the event of
an emergency and how and at what point each would become involved.
5. Contingency plans should be tested on a regular basis
at national and local level. Simulation exercises should involve
appropriate stakeholders including local authorities, environmental
agencies and farmers' representatives. The plans should be regularly
reviewed and updated to ensure that they remain relevant in the
light of any significant changes in the farming industry or elsewhere.
6. Communications and information systems need to be
reviewed to ensure that they would be able to cope in an emergency.
There are also wider lessons for future contingency planning
for all departments from the 2001 foot and mouth crisis. Departments
need to be aware of the major threats in their areas of business
and to manage those threats by having contingency plans in place
which conform with best practice on risk management.
From NAO report The 2001 Outbreak of Foot and Mouth Disease
(HC 939 21 June 2002)
TEN KEY QUESTIONS DEPARTMENTS NEED TO CONSIDER TO PROMOTE
VALUE FOR MONEY IN IMPLEMENTING NEW POLICIES
To secure value for money during the policy-making process
and to uphold the nine characteristics of modern policy-making
set out in Professional Policy Making for the Twenty First Century,
departments may wish to consider how they are best able to:
Increase Productivity. Does the design of the
policy provide scope to harness developments that may have an
impact on costs and benefits? (characteristic: policies should
be forward looking).
For example, the assessment of costs and benefits over the
life of the policy should include analysis of the likely evolution
in available technology which may offer opportunities to deliver
services in new ways, and factors which may have an impact on
implementation costs, such as the need for staff training.
Be realistic. Has the balance between the cost,
quality and timeliness of the policy been assessed from previous
experience and is this balance reasonable and realistic in terms
of the expectations for service delivery? (characteristic: departments
should learn lessons).
For example, targets for the number of working days to process
applications for a service should be tested with implementers
to identify potential barriers to achieving and improving performance
and whether more practical solutions can be more cost effectively
Plan for delivery in an organised way. Have resources,
such as staff, skills and information technology been allocated
to deliver the policy, and has the responsibility to manage these
resources been clearly identified for the life of the policy as
it is implemented? (characteristic: policies should be innovative
For example, this should include an assessment of the department's
ability to manage and maintain policy delivery in the event of
departure of key staff, through succession planning arrangements.
Estimate the overall costs of the policy over
time. Have the factors that might impact on overall costs over
time been identified and assessed by breaking down the policy
into its cost components? (characteristic: policies should use
For example input costs such as human resources, training
costs, information technology development and maintenance should
be assessed, the costs to business and others affected by possible
regulations, and costs which may be influenced by the demand for
a service, such as the number of citizens claiming benefits, should
Measure the activities and outcomes of the policy.
Is there a framework for measuring the progress of the policy,
including its costs and benefits, and for reviewing and evaluating
its effectiveness? (characteristic: policies should review performance).
For example, performance measures should be selected which
are underpinned by a clear understanding of how programmes and
activities impact on desired outcomes and client groups.
Assess where and on whom costs fall and who benefits.
Has an assessment been made of the relative costs of the implementation
of the policy and which organisations and individuals will incur
costs and derive benefits as a result? (characteristic: policies
should use evidence).
For example, in seeking to achieve their performance targets,
the department may raise the costs of another department providing
a different service to the same client group, or one group may
benefit from a policy at the expense of another.
Determine whether the benefits of a policy can
be clearly identified. Are the benefits being delivered to the
client group liable to be counted several times over or can they
be clearly attributed to the policy? (characteristic: policies
should be evaluated).
For example, the effect of individual policies should be
identified and evaluated, so that their cost effectiveness can
be more accurately determined.
Secure equitable policy impacts. Are certain groups
at whom the policy is directed excluded from its benefits because
of the way that a policy has been designed or delivered? (characteristic:
policies should be inclusive).
For example, the impact and benefits of a policy should fall
equally on those at whom it is directed and assumptions about
how the policy will work in practice should be subject to a challenge
process by involving the client group or by testing assumptions
in policy design.
Enhance choice. What decisions will need to be
made about delivery routes and what impact will this have on the
way that client groups can access services? (characteristic: policies
should be outward looking).
For example, a "one size fits all" approach is
unlikely to suit all individuals in the client group, as people
may want to access services in different waysvia the telephone,
internet or in person at a local officeso departments should
assess the extent to which different delivery routes are based
on an awareness of the client groups' needs.
Assess capability to deliver. Has the department
determined the robustness of delivery mechanisms, resources and
infrastructure of those responsible for implementing the policy
and delivering its outputs? (characteristic: policies should be
For example, practical expert advice should be commissioned
to assess whether other parties involved in implementationwhether
in the private or public sectorhave the technical and business
know-how and sufficient flexibility in their infrastructure to
implement the policy, or the proposed activities involved in implementation
should be benchmarked through the Public Sector Benchmarking Service
or against organisations who have delivered similar projects and