Supplementary memorandum by Ms Hazel Blears
MP, Minister for Public Heath
An example illustrating how the Integrated Care
Record Service could contribute to Improved Surveillance for Micro-organisms.
New Disease Alert
The Health Protection Agency (HPA) is notified
through WHO of a new type of pneumonia of unknown cause, probably
viral. First identified in Southern China and Hong Kong. WHO asks
to be kept informed of any occurrences within the UK.
The HPA sends what details there are on the
new condition to all microbiologists and to front line clinical
staff via the Health Protection alerting system, asking that any
possible cases be reported to local HPA staff and to its Communicable
Disease Surveillance Centre (CDSC). An identical alert is sent
via the CMO's Public Health Link.
Local microbiologists inform their Infection
Control Staff of this new condition and ask them to survey the
wards to identify possible cases. At this stage all that is known
is that there is a severe form of pneumonia, most likely caused
by a virus but no organism has been identified.
In three different localities the Infection
Control Staff use the national patient record analysis service
to interrogate the local ICRS spine and identify small clusters
of three to five cases. The microbiologists are able to get clinical
details from the ICRS Spine including treatments given. These
details are sent to the HPA electronically in accordance with
current data protection legislation and the Health Service (Control
of Patient Information) Regulations 2002.
The microbiologist also notifies the local Health
Protection Unit, who investigate the situation and discover for
each cluster there was a common contact of someone returning from
conference in Hong Kong. They update each patient's record with
this information from terminals in their offices.
The microbiologist gets together all the requested
clinical and laboratory data by accessing the ICRS spine and through
this the local electronic record of each patient (again, in accordance
with the Health Service (Control of Patient Information) Regulations
The HPA collates all the information by combining
information from different elements of the local electronic records
linked through the ICRS spine to get a more accurate picture of
the disease in terms of symptoms, helpful treatments and likely
outcomes. This information is published electronically on the
HPA web site and this is drawn to the attention of all GPs and
appropriate hospital consultants, including microbiologists, via
Some time later a virus is identified as the
cause. All the microbiologists who submitted cases are asked to
test for that virus in any specimens they have from the original
cases and to take convalescent serum for central testing.
In this scenario, the ICRS could contribute
to the networking and e-mail facilities for the HPA and the microbiologists
to communicate with each other.
The ICRS "Spine" provides basic clinical
details, which both the microbiologist and the local Public Health
teams could access and update.
Through the ICRS "Spine" the local
microbiologist could access the full electronic records of the
patients in his hospital(s) and abstract relevant data for transmission
to the HPA in an anonymised format.
1. The ICRS (integrated care record service)
is one component of the "National Programme for IT"
launched in June 2002. The ICRS is the electronic medical record
component. The programme to develop it is managed by Richard Granger,
Director General for IT in the NHS with a National Programme team,
which includes a Design Authority responsible for the details
of the ICRS.
2. The ICRS will consist of two parts a
national component which consists of a Common Patient Data, known
as the "Spine" and local systems already in existence
covering the day to day activities of general practice, community
3. The national component or "Spine"
will hold some data for all NHS patients in England. The data
will include demographics, summary of health events provided by
local systems, and significant clinical data such as current drugs,
allergies and alerts, see below. Through the Spine access to local
systems will be possible.
4. Local systems, which either exist or
will be acquired, will provide support for day to day care. These
are still called EPRs they will communicate with the Spine to
send data to it and to access the data that is there. They will
also communicate with each other to provide some integration of
all patient's health details.
5. The ICRS replaces the previous programme
for the introduction of EPRs (electronic patient records) and
EHRs (electronic health records). However, existing EPRs will
continue to be used and upgraded to reach a level where they provide
a basic set of functionality and can communicate with each other
and the Spine.
6. The ICRS Spine will be developed and
delivered in a number of phases. The first phase will provide
largely data for viewing, the second phase data from users interacting
with systems such as prescribing and order communications.
7. Phase 1:
Some clinical correspondence
Support for NSF data collection
8. Phase 2
Hospital discharge summaries
Some clinical correspondence
9. The timescales for introduction are
Phase 1 available across England
by end of 2004
Phase 2 available across England
by end of 2006
Phase "other" available
across England by end of 2008
10. At the moment the ICRS does not encompass
data extraction for administrative purposes.
11. At this time, no provisions have been
made to link the ICRS with HPA systems.
We have heard disquiet about the integration of
virology into the HPA and that the proposed arrangements will
not make the best use of the available expertise in virology.
Do you consider that virology was considered fully during the
consultation exercise and as virological expertise is in short
supply how can it best be accessed to the benefit of the Public
We consider that the arrangements for integrating
virology into the HPA are at least as good as those by which it
was integrated into the PHLS and the NHS previously, except thatas
for bacteriologythe general clinical diagnostic service
is now located in the NHS where it is more accessible to the clinician
and therefore to the patient. The specialist virology laboratories
in the central public health laboratory at Colindale are unchanged,
except that they are now part of the Health Protection Agency.
The consultation exercise comprehensively consulted
all the clinical and professional bodies and we are confident
that it reached all the key playersincluding virologists.
It was certainly clear from responses we received that it had
been disseminated very widely.
The discussion exercise on the laboratories
was about the broad spread of microbiology services and how they
could best be positioned to support public health. It did not
specifically consider virology or virological services as a discrete
entity, since the exercise was not about the role of individual
disciplines or specialities.
The Health Protection Agency will clearly have
an ongoing interest in applying virological services and expertise
to best effect and integrating it into its structure if that is,
indeed, the best way to go. Exactly how it does so will have to
be a matter for its Board and its executive management to determine
and to take forward, as appropriate, in their corporate and business
Regarding the supply of virological expertise,
it may help to refer to some of the information we supplied in
response to the question about the training and recruitment of
infectious disease consultants. At 30 September 2001 there were
58 registrars (ie doctors in the registrar group) for infectious
diseases and 143 registrars in medical microbiology and virology
in the NHS in England. The output from these existing registrar
training places, when combined with other increases through improved
recruitment and retention, international recruitment and promotion
of flexible retirement and offset by expected retirements, is
expected to result in around 127 trained specialists being available
in infectious diseases by 2004 and 447 trained specialists being
available in medical microbiology and virology by 2004.
The NHS Plan made a commitment to 1,000 additional
specialists registrars (SpRs), across all specialties, by March
2004. Central funding to support 300 additional training opportunities
was distributed in 2001-02, a further 300 in 2002-03 and the final
400 for 2003-04 will be distributed shortly.
In addition, in 2002-03 we introduced a new
approach, which allows Trusts to increase the pace of SpR expansion.
We have created opportunities for Trusts to fund additional SpR
posts, up to a limit in each specialty.
We are building on this in 2003-04, allowing
Trusts to fund substantially more SpR posts. This allows Trusts
to create the workforce they need to deliver services, and provides
the opportunity to create up to 1,500 additional SpR opportunities.
In 2003-04 central funding will be available to support the implementation
of eight additional SpR posts in microbiology and virology and
two additional SpR posts in infectious disease. In addition, Trusts
will be given the opportunity to fund up to ten additional posts
in microbiology and virology locally and ten additional posts
in infectious diseases.
We have received evidence which expresses concern
about the suitability of the current Public Health Acts for enabling
effective communicable disease control. To what extent is the
Department of Health concerned about this and what, if any, plans
do you have to update these Acts?
We are committed to a review of public health
law, as made clear in Getting Ahead of the Curve. This
review will take account of the new emergency powers, which it
is planned to provide through the Civil Contingencies Bill. We
envisage that the review will look at the responsibilities of
the NHS and local authorities in relation to infectious disease.
It will consider whether changes in legislation or practice are
needed to enable them to work more effectively together and whether
any existing legislative provisions need repeal or replacement.
We would be interested to see details, if possible,
of the evidence expressing concern about the current legislation
so that we can take this into account in the planned review.
UK SUPPORT FOR
Our discussions with senior WHO officials since
8 April indicate that there may be some misunderstanding about
WHO's view of the level of support provided by the UK. Both WHO
and senior Department of Health officials responsible for international
health policy were surprised at the Committee's comments on this
question. I attach, for ease of reference, a copy of a letter
from Dr Heyman, the WHO executive director, Communicable Diseases
to you on 19 April, which describes a different view of UK support
for WHO than that reported to us at the hearing.
In addition to our earlier evidence, the UK
has played a key part in supporting WHO's development of the Global
Outbreak and Response Network (GOARN), which is an international
network of associates who collaborate in alerts to possible outbreaks
and in responding to those outbreaks. The Health Protection Agency's
Communicable Disease Surveillance Centre is a member of GOARN.
The UK has particularly supported WHO in its
response to the current SARS outbreak and there are at least 11
UK experts seconded to the WHO to assist in this and other activities.
WHO are generally appreciative of the support
they receive from this country although we both recognise, of
course, that there is always more that could be doneDr
Heyman's letter illustrates one such example. We will continue
to work with WHO, both directly and via the Department for International
Development, to ensure that we contribute effectively to international
communicable disease control.