Select Committee on Science and Technology Written Evidence

Memorandum by PHLS Primary Care Advisory Group

  This submission is made by Professor David Mant, Head of the Department of Primary Health Care, University of Oxford, in his role as chairman of the PHLS Primary Care Advisory Group. It is based on extracts from the Advisory Group's response to the CMO's report "Getting Ahead of the Curve".


1.   General Points

  1.1  The public health potential of the UK primary care structure (with registered lists, geographically defined populations and expert staff) has not been fully exploited by previous public health arrangements. Other European countries, particularly in Scandinavia, achieve better integration between public health and primary care.

  1.2  In making improvements, it is important to recognise the uneven quality and coverage of current provision but also to recognise and preserve the expertise in the system. This expertise includes a number of very able and committed CsCDC (Consultants in Communicable Disease Control), community based infection control nurses, and local NHS and PHLS microbiologists (including the PHLS staff leading the current Primary Care Initiative) who provide essential leadership and support in primary care.

  1.3  Latent public health expertise also exists in many UK primary care staff. A significant number of general practitioners in the UK have undertaken formal public health training and the majority will have some experience of disease control. Most primary care teams include health visitors, and some include school nurses, who also have public health skills.

2.   Disease Surveillance

  2.1  The surveillance task in primary care is two fold—to give early warning of new public health hazards and to monitor the incidence of known hazards. The Advisory Group acknowledges and welcomes the specific surveillance tasks cited in the recent CMO report, including the need to establish reliable denominators and links between databases (eg antibiotic prescribing and resistance).

  2.2  A specific UK primary care strength is the population based RCGP sentinel surveillance service. This is based on morbidity recording from practices across the UK. We recommend that the RCGP sentinel service is expanded and enhanced so that it receives data from at least one practice in every PCT. This will provide a strong framework to allow more precise sampling for specific enhanced surveillance objectives (guided by issues such as socio-demographic representativeness, seasonal variation, required precision and cost). There must be scope for spreading the workload of enhanced surveillance between practices, with some sentinel practices recording certain diseases with additional data, and other practices studying other conditions.

  2.3  There is strong potential for the existing mechanisms for surveillance to be strengthened and enhanced. This requires detailed specification but four key issues stand out:

    —  The potential for systematic sampling to provide denominator based microbiological data (eg in the context of antibiotic resistance).

    —  The future potential to use new PCR and near patient testing techniques to increase the microbiological specificity of surveillance.

    —  The potential to survey more efficiently by integrating different methods of surveillance with common outcomes and by more careful consideration of issues of geography, population structure, disease variation over time, and required precision of estimates.

    —  The potential to integrate surveillance data on both communicable and non-communicable hazards, so that the role/interaction of both in ill health can be more completely investigated.

  2.4  The use of NHS Direct data for surveillance also has potential, both because of its consumer base and its "real time" attributes. As it lacks the firm denominator of practice based surveillance data, it augments rather than replaces the need for practice based surveillance.

3.   Disease control

  3.1  All PCTs must accept responsibility for disease control in their geographical area and in the premises and staff groups that they control. To discharge this responsibility each PCT must invest in the services of an Infection Control/Health Protection Support Team with appropriate expert leadership. Creating such teams will involve identifying primary care staff with existing skills as well as recruiting new staff. Team membership should include one or more infection control nurses, a PCT Public Health Specialist, the PCT Immunisation Co-ordinator and the input of a Consultant Microbiologist. Provision of specific training for the new teams will be essential.

  3.2  The appropriate population to be served by a local Infection Control /Health Protection Support Team is debatable—we would suggest about one team for every 250,000 people. Small PCTs may share the services of one team, with one PCT taking the lead.

  3.3  The PCT Infection Control /Health Protection support team should take responsibility, within the Clinical Governance/management framework of the PCT, for all aspects of infection control and input into decontamination, waste disposal and infection control aspects of new developments across the PCT(s) it serves. In addition it will play a key link role between the PCT and the local "node" of the National Health Protection Agency.

  3.4  One key advantage of the size of most larger PCTs is that they are geographically related to local government environmental health arrangements, and are likely to evolve closer relationships. The PCT Infection Control/Health Protection Support Team could therefore form an important point of local liaison with local government environmental health staff. Such links with primary care already exist in some areas (eg through health promotion initiatives such as Health City projects, Health Improvement and Modernisation Programmes, accident prevention schemes, and undergraduate medicine teaching arrangements). In addition, some PCT Directors of Public Health are joint PCT/LA appointments.

  3.5  The most appropriate base for the local Infection Control/Health Protection Support Team is probably in PCT offices, to have daily contact with other public health specialists, and to be at the focal point of primary care communications.

  3.6  The creation of a "network" of PCT level Infection Control/Health Protection Support Teams would provide the specific advantage of "surge control"—a relatively large pool of trained staff from neighbouring PCTs who can be called upon in emergencies that exceed the capacity of a single PCT.

  3.7  The new National Health Protection Agency staff must play a part in creating and maintaining this PCT network, and would provide expert advice, but additional resources and leadership only as necessary—PCTs themselves must be able to mobilise primary and community care staff, with local knowledge, to play effective roles in emergencies.

4.   Clinical diagnosis

  4.1  Both the surveillance and disease control functions are dependent on clinical diagnoses being made in primary care at the required level of precision. In infectious diseases, these functions will continue to depend on good microbiological support (which in the past has been provided by both PHLS and NHS laboratories). Technical and laboratory support will also be required for diagnosis in a number of important non-infectious conditions highlighted in the CMO's report. Good and effective liaison between laboratories, Health Protection Agency field teams and primary care organisations will be essential.

  4.2  Variation in primary care access and use of diagnostic facilities is endemic in the UK. This is particularly marked in relation to infectious disease, where use of laboratory diagnostic services varies substantially between clinicians. The emergence of reliable near patient tests (NPTs) for microbiological pathogens, many of which tests are minimally invasive, is an important development which may impact on the attainable precision of surveillance and disease control in primary care. However, quality control and quality assurance issues need to be fully addressed before widespread use of NPTs in primary care. Unfortunately, the evidence base to guide appropriate and cost-effective use of both old and new diagnostic technologies in primary care is still lacking, so the operating characteristics of the technologies in a field setting and the conditions which need to be met to ensure testing reliability remain ill defined. Importantly, this evidence must address the issue of sample taking as well as sample testing. Where evidence exists, the PCT Infection Control/Health Protection Support team should play an important role in ensuring its implementation in primary care practice.

5.   Research and development

  5.1  The comments made above in relation to surveillance, disease control and clinical diagnosis indicate a substantial "R&D Gap" where both service development and basic research are urgently needed. Three key issues are: (1) how best to use the laboratory for diagnostic support and surveillance; (2) how to achieve better diagnostic precision; and (3) who (among the many patients present in the community with minor infections) should be treated with antibiotics to prevent adverse outcomes.

  5.2  The PHLS Primary Care Initiative has led to (directly funded) PHLS development work and has stimulated new research in some areas with PHLS collaboration. It is important that this important research and development agenda is not lost under the new arrangements.

  5.3  In order to ensure that the primary care research agenda is met, DH should consider a specific policy research initiative in support of the CMO's agenda. It should also consider carefully how to commission such research, given the difficulties experienced with the antibiotic resistance initiative and the limited research capacity in primary care within the UK.

6.   Proposed structure

  6.1  Responsibility for local health protection must be given to Primary Care Trusts. This responsibility should be met by the creation of Infection Control/Health Protection Support teams as described above. These teams need to be supported by, and independently responsible to, field units of the National Health Protection Agency, working at an appropriate geographical level for the wider population, to provide support and leadership.

  6.2  To minimise loss of expertise in the transition to the new structure, current epidemiological and communicable disease control specialists that provide expert support and guidance to primary care should be given a remit to support the Primary Care Trusts within their defined geographical area in developing and supporting Infection Control/Health Protection Support Teams.

  6.3  Although most primary care in the UK is organised through primary care teams, educational and social care facilities (eg nursing homes, schools, nurseries) present public health challenges which may cut across practice boundaries and registered practice lists. These challenges involve premises and staff for which the PCT has no managerial or legal responsibility. It is therefore important that any new organisational arrangements preserve the ability to respond across practice boundaries. Furthermore, infections do not stop at administrative boundaries, so there must be co-ordination between PCTs—perhaps best achieved through the national HPA field units at the next geographical level.

October 2002

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