Select Committee on Science and Technology Written Evidence

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 audit work.


  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 on:

    —  The 2001 Outbreak of Foot and Mouth Disease (HC 939, Session 2001-02): specifically the more general recommendations on the control of disease outbreak (Appendix 1);

    —  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 2);

    —  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

  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 asked are:

    (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.



 (a)   Surveillance

  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 surveillance—our 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.


  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.


  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.


  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 device—related 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 strategies.

  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.


  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 document.

  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 three factors:

    —  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 Local Authorities.

  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 health function;

    —  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 service provision;

    —  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 (Appendix 1).

  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 wheel—however 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 neutral—covering 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.



  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 management:

    —  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)


Table 2

  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 and locally.

  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)



  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 implemented.

    —  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 and creative).

  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 evidence).

  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 be forecast.

    —  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 ways—via the telephone, internet or in person at a local office—so 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 joined up).

  For example, practical expert advice should be commissioned to assess whether other parties involved in implementation—whether in the private or public sector—have 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 programmes.


May 2003

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