Select Committee on Science and Technology Written Evidence

Memorandum by Professor Jennifer A Roberts, London School of Hygiene and Tropical Medicine

"The strategy outlined in "Getting Ahead of the Curve"1 represents a great stride forward. It poses formidable challenges. The critical issues of governance, resources and training must be resolved now before health authorities are dissolved at the end of March". (Roberts and Haworth, 2002).

  The above quotation is from a paper that I wrote with a colleague in March 2002 as a response to the proposed structure for health protection, outlined in the Strategy Document "Getting Ahead of the Curve", (GAC) (DOH, 2002). The strategic approach outlined in GAC is an attempt to orchestrate a system that integrates the protection of the public from threats of infectious disease, chemical and radiological disasters and bio-terrorism. The overall strategy includes improved surveillance and the development of strategies for many disease groups. Our reservations were not directed at the grand design but at the practicalities of its implementation. This memorandum of evidence concentrates on these organisational issues that are very important if the policy is to be effective.

  The pathways of infection control prior to the proposed changes were well designed and were supported by a network of key medical and laboratory professionals. It provided a rapid and largely effective response to outbreaks of infection and a framework that limited secondary spread of infection and an effective mechanism for caring for those affected.

  With the demise of Health Authorities and before the Health Protection Agency is set up in 2003, residual Health Authorities and Primary Care Trusts (PCTs) are operating the system. Adequate handover arrangements were lacking and the system has been held together by the professionalism of the infection control specialists, many of whom have been located in inappropriate facilities, often with inadequate telephone and computer lines of communication, and who are uncertain about the system in which they will be expected to operate in future.

  The Department of Health has been organising workshops and consultation groups with an aim of achieving good strategic plans for the various infections and has achieved some progress in producing such strategy documents, eg the recent Hepatitis C strategy. However, for any of these strategies to operate effectively proper accountability and financial support must be in place. A hard-pressed PCT is unlikely to place infection control high up on its list of priorities unless it is contracted to provide it and funded for it. There is already evidence of some PCTs being unwilling to provide adequate support for hospital acquired infection. Hospital infectious disease doctors and microbiologists, very busy and increasingly difficult to recruit professionals, are spending time trying to persuade PCTs to provide meagre resources for them to operate effective control teams in hospitals. Yet hospital infection control is of paramount importance in containing the spread of antimicrobial resistance such as MRSA. It is unclear whether the response to community outbreaks will be as rapid or as effective operating via a number of PCTs that are not clearly mandated to provide resources. Delays may be encountered. The reporting of suspicious cases by health professionals could be sidetracked by internal mechanisms in PCTs before being communicated to Consultants in Communicable Disease Control (CsCDC). Policies for control of hospital acquired infection and antibiotic prescribing need close collaboration between CsCDC, Infection Control Doctors (ICDs) and the rest of the infection control team. New clinical governance and quality assurance systems and the specific responsibility of chief executives for infection control should improve the overall management of infection control in hospitals (Taylor et al, 2001), but the links with the Health Protection Agency and CsCDC are not clear. Over the past 10 years contracts or service agreements, reorganisations, amalgamations and public/private partnerships have weakened relationships. Fracturing of relationships following the introduction of managed care and the privatisation of public health laboratories was identified as a problem in public health systems in the USA (Davis J R, Lederman J 2000). We must endeavour not to fracture relationships and to foster new links.

  In addition to weakening relationships and networks the changes have weakened the epidemiological basis for the surveillance systems and made estimates of coverage for vaccination programmes difficult to establish as a consistent time series for a defined population.

  The use of generic staff at PCTs to provide surge capacity and handle health protection, whilst being useful if there is an outbreak, may not be appropriate for the day-to-day management of infection control. Such a policy runs counter to the general trend in the NHS that recommends the use of specialists with an adequate case load to ensure their technical competence. To add to the infectious disease burden other complex fields of chemical, radiological and bioterrorism compounds these problems and seems to stretch the abilities of front line workers.

  The resources to staff the new service seem to be "neutral" (no more than in the previous system); no extra funding seems to be forthcoming. However, the staffing levels in the previous organisation were not adequate. "In 2001, 54 per cent of CsCDC were responsible for populations of more than 500,000. CsCDC support teams are small, usually a secretary and perhaps a public health nurse5. In hospitals 30 per cent of ICDs were responsible for more than one acute hospital and 55 per cent were also responsible for community trusts. They were supported by only one or two infection control nurses (ICN)" (Roberts and Haworth, 2002).

  It is considered that at least 1,000 environmental officers are needed to staff this important complementary service. Both new staff and existing staff who are expected to play a role in health protection require training. This means more than the short courses that are taking place.

  The provision of health protection is to be ensured via contracts between the Health Protection Agency and the Regional Health Authority and the PCTs. Contracts in this problematic area do not always ensure adequate performance but contracts not informed by those with expert knowledge in the field are less likely to be effective. Yet the expertise of CsCDC, ICDs and ICNs was rarely used to inform contracts in the previous system. It is unclear how specialist advice and input into contracts will be obtained. In addition hospital Infection Control Teams found it difficult to obtain funds from the various budget holders within the hospital sector. Infection control affects everyone in the organisation and increasingly those outside the hospital in nursing homes etc, yet funding was dependent on separate budget holders who were reluctant to accept the common responsibility for infection control. In the past Health Authorities used contingency funding to support outbreak investigation and control. Will PCTs be willing to underwrite these activities? These budgetary constraints must be dealt with in both hospitals and PCTs.

  Governance within PCTs for infection control is not clear. It is important that someone has authority and can take control and mobilise resources if an outbreak occurs. At present even information is cascading down to staff in what appears to be a haphazard manner sometimes, to CEO, DrPHs and sometimes to CsSDC. Apart from the contract between Regions and PCTs governance is unclear either within PCTs or between PCTs and HPA professionals. It is essential that someone has the authority to take control if an incident occurs. But who will have such authority has not been specified. CsCDC might be expected to have executive responsibility for health protection at PCT level with access to the PCT board and supported by the Director of Public Health (DrPH). But they have no executive authority and may relate to many PCTs. This issue must be resolved.

  Thus if the benefits of GAC are to be recouped attention must be paid to implementation: governance and accountability, resources and training.


  Alford K Plowman R M, Roberts J A. The Way Ahead, Progress towards the control of Hospital Acquired Infection, National Audit Office, London, 2001. ISBN 0-11-702858-4.

  Davis JR, Lederman J Public Health systems and emerging Infections Assessing The Capabilities of the Public and Private Sectors. Workshop Summary, Institute of Medicine, National Academy Press Washington DC 2000.

  Department of Health "Getting Ahead of the Curve". A strategy for combating infectious diseases (including other aspects of health protection) A report by the Chief Medical Officer

  Roberts J A Haworth "Getting ahead of the Curve"—Lancet Infectious Disease Vol 2 (4) p 205-6.

October 2002

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