Memorandum by PHLS Primary Care Advisory
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".
UK PRIMARY CARE
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 foldto 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
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
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
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
debatablewe 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 necessaryPCTs 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
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 PCTsperhaps best achieved
through the national HPA field units at the next geographical