Memorandum by Mr Nigel Emery, Principal
Environmental Health Officer, Weymouth and Portland Borough Council
1. I am a Principal Environmental Health Officer
currently employed by Weymouth and Portland Borough Council. I
have been qualified as an Environmental Health Officer for 24
years and have worked for six different local authorities, five
in England and one in Scotland.
2. I am writing to the Sub-Committee following the
request for evidence. My particular concern is with the failure
of the present system with respect to the Environmental Health
role for both preventing the incidence of infectious disease and
its spread in the community. These failures stem from the present
organisational set up which places the Environmental Health profession
within local authorities.
3. With the advent of the 1972 Local Government Act
Medical Officers of Health lost control of the Environmental Health
(then Public Health) function to local authorities. This severed
the close working relationship which had previously existed between
health authorities and Environmental Health professionals. The
CCDC role became the liaison mechanism between the local authority
Environmental Health Officer and the health authority. The direct
link which GPs had with Environmental Health Officers was also
4. The CCDC and the PHLS representative became members
of the County Food Liaison Groups which were established under
the aegis of the Chief Environmental Health Officers within the
county. One purpose of these groups was to improve liaison in
the communicable disease role (usually, but not solely, relating
to food poisoning) between local authorities and their counterparts
in the health authority. Currently, I am the convenor for the
Dorset Food Liaison Group. The use of these groups for CCDC liaison
has never been very successful because CCDCs know that the main
purpose of the groups is food hygiene enforcement, with communicable
disease playing a minor role.
5. Unfortunately Chief Environmental Health Officers
have now largely been replaced in local authorities by Directors
of Technical Services as a cost reduction measure. In some instances
these directors may be ex-Chief Environmental Health Officers
but in many cases directors will have limited understanding of
what Environmental Health Officers do because they come from a
different background such as planning, engineering, etc. In many
local authorities Environmental Health may now be only at a third
tier level of authority which means that Environmental Health
Managers request for resources to properly fund the Environmental
Health function is almost certainly going to be of limited success.
6. Allied to the loss of prestige of Environmental
Health within the local authority set up is the growing national
shortage of Environmental Health graduates causing a major recruitment
problem in the profession, a problem which is set to worsen considerably
in the next few years. School leavers are no longer attracted
to the Environmental Health profession because they see the constraints
which are operating in the local authority context and they understandably
don't wish to spend six years training to reach a professional
level of competency and then face the constraints which working
within the local authority arena then poses. These restraints
are major disincentives and include lack of recognition, political
interference, lack of resources and far too much emphasis being
placed on performance monitoring and auditing at the expense of
actually being able to get on and do the job. The figures are
since 1995 an 80 per cent reduction in applications to Environmental
Health courses. In 2000 there were less than 300 applications
for degree courses. In the last three years, three Environmental
Health degree course providers have closed and the remaining providers
are struggling to remain viable. Of the 9,500 Environmental Health
Officers registered with the CIEH only 4,500 work in local authorities
and the figure is worsening (Environmental Health Journal Vol.
110/10 Oct 2002) In 2001 there were only 50 applications for Environmental
Health degree courses (EH News Vol. 17 No. 34 6 Sept 2002).
7. Environmental Health needs to be relocated into
the Health Protection Agency. After all, it is the work of Public
Health Officers over the last 150 years that have made crucial
advances in the improvement of air quality, food and water quality,
housing conditions, working conditions, ensuring effective sewerage
and removal of nuisances as well as the investigation of infectious
disease in the community.
8. The current re-organisation which is taking place
with the creation of the Health Protection Agency and PCTs has
completely ignored the role of Environmental Health. Primary Care
Trusts and local authorities are being encouraged to develop strong
working relationships" not least by the Minister for Public
Health Hazel Blears but the problem with this concept is that
local authorities don't work with that degree of flexibility.
They are still very authoritarian and bureaucratic organisations
so I don't believe that the hope for strong working relationships
is realistic. Environmental Health will remain a subdued function
under the local authority umbrella largely cut off from the mainstream
health protection role as it has been for the last 30 years.
9. One specific problem with the current set up is
the failure of the communicable disease notification loop to work
fast enough or even to work at all. The current system is that
an individual suffering from, say, food poisoning notifies their
GP who may or may not decide to take a stool sample. If no sample
is taken the loop stops there. The sample is analysed by the PHLS
who give the result to the G.P. and in the case of a positive
result to the CCDC. The CCDC then informs the Environmental Health
Officer in the local authority. It is not uncommon for the Environmental
Health Officer to be given a positive result a week after the
patient first went to the surgery with their symptoms. The Environmental
Health Officer then has to contact the patient to ascertain where
they may have picked up the infection, from food, from water,
milk or some other source in the U.K. or abroad, but often the
trail has already gone cold and the person has resumed their work.
10. A typical recent example of what can happen with
the current communication loop is as follows. A resident within
this Borough was suffering severe diarrhoea and contacted her
GP on a Friday, not being fit to make a visit to the surgery she
requested a home visit but this was refused and the patient attended
surgery on the following Monday when a stool sample was taken.
She was not questioned at this juncture about her occupation.
On the Wednesday afternoon the PHLS isolated Salmonella in the
stool sample and told the surgery, the CCDC got the information
on the Thursday and the Environmental Health Unit received the
information on Friday. We had a name and address but no contact
telephone number because one is not requested on the PHLS form.
When the Environmental Health Officer visited the address on the
Friday no one was at home and a card was left. The patient actually
contacted our office on the following Monday when she was back
at work in a play group and she was still unwell. We immediately
told her to stop work until 48 hours after cessation of symptoms
which she was happy to do. She was however, annoyed that this
information had not come to her through her GP and she was annoyed
that it had taken us so long to make contact with her as she felt
guilty (rightly so) that she was exposing children in her care
to a risk of infection. Under the old pre-1974 system the Environmental
Health Officer would have been contacted directly by the GP who
would immediately have investigated the cause of the patient's
Salmonella and ensured that the person did not go to work until
it was safe for them to do so. Delays in Environmental Health
Officers receiving information about a communicable disease victim
makes it very difficult to identify the source of infection and
protect others in the community. Few food poisoning outbreak investigations
manage to positively identify cause because the Environmental
Health Officer's intervention is usually too late because of the
way the system works.
11. Another example of the difficulties with a multi-organisational
approach to infectious disease occurred in April this year in
this Borough with a cholera case. Briefly, I was notified by the
CCDC of a man with cholera living in the Borough, he had reported
it to his GP and been potted. I visited him at home and confirmed
that he had been travelling in Africa and India and had become
ill initially in Botswana. He was still unwell but not bad enough
to be in bed. The CCDC was awaiting confirmation of whether the
strain was toxigenic. She assumed that the GP had given tetracycline
to the case but checking revealed that in fact the GP hadn't.
The CCDC asked me to contact the Enteric Pathogens Lab at Colindale
to get the vibrio typing result. I did this but they refused to
give me the information. They would only deal with the PHLS lab
at Dorchester Hospital who had initially analysed the sample.
They would be sending it to Dorchester PHLS that day. I asked
how this information would be sent: e-mail? fax? I was told to
my surprise that it would be sent by posta totally unnecessary
delay with a potentially highly infectious individual at large
in the community. The next day I was able to learn from PHLS that
the cholera was non-toxigenic (fortunately). I informed the CCDC
who in the meantime had learnt from the GP that no tetracycline
had been prescribed. I telephoned the case and learnt that he
had moved to London to stay with his brother, fortunately not
a high risk contact, being self-employed working from home. I
told the case that he must find a GP to get a course of tetracycline
and to have his condition monitored as he was still unwell and
undoubtedly excreting vibrios. I had at my first meeting impressed
upon him the need for strict toilet hygiene. I rang two days later
and confirmed that he had visited the London Hospital for Tropical
Diseases who were doing all that was necessary by way of treatment.
Overall, I didn't think it was a very impressive exercise in practical
infection control within the community. As an Environmental Health
Officer I was a key player but certainly didn't feel part of the
12. Another example illustrates the need for effective
communication between various agencies involved in the investigation
of infectious disease control. It also highlights the need for
the medical teams, who treat illnesses, to have a greater understanding
of the needs of those investigating them, so that the cause and
sources of infection can be identified and controlled. There is
also a need for effective communication with the ward medical
teams if food poisoning and or viral infections are suspected.
A South Wales football team stayed at hotel accommodation
near Wimborne. The following morning they left the hotel by coach
for a training session at a local training ground. After this
they travelled by coach on the motorway towards Southampton where
the coach driver felt so ill that he stopped at the Services.
Four members of the team also felt ill and because of the severity
of their symptoms (Diarrhoea and vomiting) an ambulance was called.
They were admitted to hospital where despite their
symptoms it appears that the medical staff did not arrange to
get samples that would be useful in determining whether it was
a viral or bacterial episode. The hospital administration did
inform our consultant in health protection but by the time it
was realised that suitable samples had not been taken from all
the patients, it was too late for the laboratory to identify if
the cause was viral. No food poisoning bacteria were found.
Samples of the food remaining from the team's stay
at the hotel revealed no food poisoning bacteria and there were
no further reports of other guests displaying similar symptoms.
The football team returned to South Wales where more
team members developed similar symptoms. Despite officers from
the investigating authority advising the club's coaching staff
of the importance in getting samples quickly to hospital so that
they could be checked for viruses all the samples failed to produce
results due to various delays. One patient held onto the sample
for nearly a week before submitting it despite having said that
it had already gone. Another sample failed to produce results
because the laboratory staff were not asked to look for viruses.
This despite making it clear to the authorities.
Therefore, the investigating authority was left with
little evidence that anything untoward had happened. Naturally
the club management found this difficult to believe particularly
as the episode had resulted in disruption to their training programmes
during the build up to the start of the new football season.
It is recommended:
1. That GP's and staff in accident and emergency
units should, as a matter of routine, organise the taking of faecal
samples as soon as practical after seeing patients presenting
with symptoms involving the gastro intestinal tract.
2. That all the various NHS units and laboratories
have designated contact officers who will be responsible for co-ordinating
and liasing with the local authorities Environmental Health Officers
during such investigations.
Principal Environmental Health Officer
8 October 2002