Select Committee on Defence Minutes of Evidence

Examination of Witnesses (Questions 1020 - 1039)



Mr Howarth

  1020. If I can just pick up from what the Chairman has asked you, you say that you hope within six months to get the PCTs up and running on this.
  (Dr Troop) No, that is the legislation. The legal basis is that the strategic health authorities formally come into place and there is legislation going through. The intention is that they will formally come into place in October. I think there is one which is still a Primary Care Group not a Trust. As I say, they virtually all came into being on 1 April, and so there is this transitional period while people are handing over their responsibilities, but that is the legal position I was speaking about.

  1021. So to be practicable, when do you expect the PCTs to be in a state to take over this responsibility—for example, by appointing emergency planning people?
  (Dr Troop) They will be required to take over on 1 October and our responsibility between now and then is to work with them to make sure that they have the understanding and the capability to do that. Some of the support to do that will be through our health emergency planning advisers and through our consultants in communicable disease, because, as I explained, our emergencies are of a very wide nature and, therefore, we have to have a range of staff with a range of skills. Beyond that we will be moving into the new arrangements for the Agency.

Syd Rapson

  1022. I know it is unusual for me to butt-in but Portsmouth got some notoriety yesterday on health which was unfair. We have a very good PCT, which has been operating extremely well from 1 April and they are doing a wonderful job. However, they are geographically limited to Portsmouth City Council's boundaries, whereas the hospital trusts go much wider than the boundaries and the strategic authority is even bigger. I wonder if there is a complication between now and whenever things settle down over boundary disputes between the authority of the PCT, which is only within Portsmouth's boundaries, and its need to have some emergency planning control wider than that?
  (Dr Troop) There are a number of incidences around public health emergencies and other emergencies where we need to have that wider network. Therefore, for a number of these the trusts are being required to work as a network and to nominate a lead within that network. The kind of issues they will have to take on, not just the trust issue kind of emergency, is, for example, if we had a major TB outbreak, as we have had in Leicester; a number of PCTs will have to work together to provide the resources and to make sure they work in a co-ordinated way. Part of the requirement is that they have networks and all the public health people are setting up networks so that they are working in that co-ordinated way, and, also, many specialist services for which they go much wider than a number of PCTs. So that is a process which is fitting within a number of others.

Mr Howarth

  1023. Dr Troop, I mentioned there were four points and I am going to invite you, perhaps, to write to us about the impact that the new legislation may have on you, because time is short. Can I deal with two other issues, capacity and funding? First, on the issue of capacity, which was identified as one of the areas for further work, have you made any preliminary assessment of the impact on the NHS capacity of these new policy proposals?
  (Dr Troop) We have not made that kind of assessment, no. From the department we will set out the guidance of what people are required to do and at a local level it is the responsibility of local health authorities and future PCTs to ensure that resources are deployed to ensure that they can meet that requirement.[3]

  1024. We will come on to resources in a second, but we are talking about capacity here. We all know that the NHS is stretched but you are talking about quite extensive extensions of responsibility resting upon the shoulders of people who are already pretty committed.
  (Dr Troop) There are, as I say, a range of different aspects of that capacity. For example, if we look at the types of emergencies around infectious diseases, around chemicals and those kinds of incidents which are included, as you know, we have made a proposal for a new agency, which will be, we hope, up and running on 1 April 2003. It will bring together all our key resources at a national and a local level in terms of infectious diseases, chemical, radiological and, also, will have an emergency planning division. So that the specialist support for this activity we are strengthening and developing, and that will start on 1 April 2003. On that aspect of the capacity we have had a very serious review and September 11 has contributed to our thinking very significantly on that. That will start, as I say, and we are moving very actively towards that programme at the moment. Other aspects of capacity that we have looked at are, obviously, the capacity of the service to be able to respond to emergencies at an ambulance level, at an A&E level and so on, and there are certain aspects of their funding that we have addressed, for example the equipment that they have, and so on. Some of those are part of the wider NHS planning. Most of their function, for 95 per cent of the time, is running an NHS service and, therefore, within that context we have already reviewed a number of those issues.

  1025. We all know that in the event that there were to be a biological or chemical attack on a large urban area in this country a lot of people would be affected. In terms of capacity, are you making any plans to open emergency medical centres outside the existing NHS provision?
  (Dr Troop) We sent guidance out two years ago and after September 11 we sent out additional guidance, both on how to cope with mass casualties but, also, how to manage infectious diseases. If I take one of those, we sent out guidance, for example, on smallpox, plague and all the other threats that we were advised on. On each of those we gave a step-by-step guide as to the things that locally people had to consider, including the kind of facilities that they could open up or transform to cope with a major problem. Clearly, if we had that kind of infectious disease problem we would not have sufficient infectious disease beds on a routine basis, and you cannot build that level of redundancy into a system. Therefore, we asked them each to identify which hospitals, which sections of their health service locally might be applicable. It would be wrong for us to do this nationally because they have the local knowledge of how they could do this. They have all been required to do that. We have been going back to check that they have all integrated that planning into their emergency planning, and part of the work over the coming months is to keep double-checking and to scenario-plan whether or not they would be able to do this. Obviously we need to do more testing of those plans but locally they have all done this; they have all gone to see how they would respond against this very detailed guidance on how they should look at this.

  1026. So if there were an attack tomorrow you could, with some confidence, tell us and assure the British people through us here today, that there would be in place an adequate emergency plan, albeit it would be of necessity, to a certain extent, make-shift, to be able to deal with a large number of casualties?
  (Dr Troop) Yes, we have sent that guidance out and checked that everybody has incorporated that planning into their guidance across the country. We have also provided them with additional equipment. For example, we have now what we call "equipment pods" which are distributed right across the Ambulance Service across the whole of the UK which has got additional equipment for respirators, for breathing support, for ventilators etc. So that if there were an attack anywhere within the UK—for example, if there was a chemical attack—the ambulance people would have access very quickly to additional equipment which is out there, with standard operating procedures on how to get hold of it, with clear instructions as to how to use it, so we could support a large number of casualties. We have gone through a fairly detailed logistic exercise to make sure that all those different elements were in place both in terms of knowing how to respond and, also, this back-up material. There has been a very big logistics exercise over the last few months to make sure that that is there and available for our front-line staff.

  1027. Finally, and I am sorry this has been a long set of questions, but the fourth issue identified for further work was funding. You have told us about the new agency, you have told us about the additional responsibilities on Primary Care Trusts and upon others. Can you assure us that the funding for investment in this area of emergency planning and the capacity to respond to the new threat from chemical, biological or nuclear attack is in place? For example, are you providing the PCTs with more resources in order to enable them to take on staff to deal with the responsibilities that are being thrust upon them?
  (Dr Troop) There are some additional resources in place. I think for me to say that we always have enough resources in any of these aspects - I think most departments would say "I could always use more resources"—

  1028. I thought that all changed last week.
  (Dr Troop) As you are aware, the NHS was allocated a large volume of resources but it will be up to ministers to decide precisely how that is deployed. We have set out the framework of all the guidance and the requirement of the NHS, and we have had a number of discussions with ministers about the relevance of different resources. We have received some additional resources over the last few months and we hope that that will continue over the following months.

  1029. Can you quantify that amount of additional money?
  (Dr Troop) Some of it is tied up with our procurement policy. Therefore, I would prefer not to give the details of that in an open meeting.

  Chairman: Drop us a note, if you will, please. It will not necessarily be published.

Syd Rapson

  1030. Can we move on to the Health Protection Agency. I know the Chief Medical Officer drew up a strategy for the combatting of infectious diseases called Getting Ahead of the Curve. I was lucky enough to be reading it last night at 1 o'clock and fell asleep looking at the Tokyo Subway, so I did not get very far at all. The idea of Getting Ahead of the Curve is very good to combat infectious diseases and the driving force behind that was sometime ago, and joining together the Public Health Laboratory Service, the National Radiological Protection Board and others to form this new Health Protection Agency. We know the pressures to create this new arrangement did not arise out of 11 September because it was in place, but since it has been constructed how markedly could that new agency affect or make things better in response to a CBRN attack?
  (Dr Troop) I think, first of all, all our planning for CBRN attacks is based on the premise that we need a sound infrastructure. We have emergencies of all sorts all the time, we have a lot of chemical incidents to which we have to respond and we have infectious disease outbreaks. We have to plan for a flu pandemic which would be just as devastating. Our infrastructure has to be there for emergencies in general. All our planning is based on having a sound base on which to add on things for CBRN. That is how we have taken it. So that when we were planning modernising the infectious disease infrastructure we had a lot of feedback over the last 18 months "make it integrated into other aspects of health protection" because, on the ground, that is how we work. When we had the foot-and-mouth disease we worked in a very integrated way across infectious diseases, chemicals and radiological. Therefore, we were already planning that we ought to make it an integrated structure, and then after September 11 we brought together experts from all those fields, all working together, all sharing their knowledge and expertise. That just made it absolutely obvious to us that we had to have an integrated health protection infrastructure, which would, as I say, form the basis of all emergencies but the bedrock on which any emergency from CBRN could build. Within that, though, we have also identified some additional work that needs to be done. There will be in the Agency an emergency response division proposed, and part of that would be helping to continue to develop our knowledge and understanding of how to respond to these emergencies. We are leading a lot of the work internationally on modelling, and we would take forward that kind of work within that kind of division. It would be a major contributor both to the response and the expertise at the national, regional and local level but, also, to provide a lot of the thinking and development.

  1031. I know you chair the steering committee and your colleagues assist in that very worthy cause, but when do you expect the new agency to be operational? When is this new structure going to be ready to go?
  (Dr Troop) Our hope is that it will be on 1 April 2003, and that will depend on whether or not the legislation that we are working on will go through. We are going through the regulatory reform order process, and if that goes through in the timetable that we hope then we should be okay for 2003.

  1032. Because we have done away with the health authorities now, from 1 April, what contingency provision have we got in place between now and the formation of this new agency so that we are protected? Presumably you would say that the PCTs will cover that in between, but is there some interim arrangement?
  (Dr Troop) Yes there is. Although we have lost a lot of the NHS regions we have maintained having a Regional Director of Public Health and they are moving into the government offices of the region, which means they will also have a relationship with local authorities, which will be very helpful. They have been required to ensure that the health protection arrangements are in place in their region in this interim. For example, previously we had consultants in communicable disease control in every health authority, and we have asked each region to ensure that they are employed by PCTs and by a network of PCTs so they can continue to provide the support that they provided before, but to a group of PCTs as opposed to a health authority, and that their staff are in place to support them. Each of them have ensured that those staff are employed on a temporary basis through the network of PCTs until they are able to move into the agency next year.

Mr Crausby

  1033. In reply to a written question on 16 April the Minister, John Hutton, said that additional expenditure of £1,176,000 had been incurred by the Public Health Laboratory Service and the Centre for Applied Microbiology and Research on counter-terrorism and civil protection since 11 September. Can you tell us what these sums have been spent on? What additional resources will be available to the new agency over and above the aggregated budgets of the component bodies?
  (Dr Troop) First of all, on the work that has been done by the PHLS (and I will, perhaps, ask Mary to expand on this) they gave very urgent and very comprehensive support in putting together very detailed guidance on a number of infectious diseases at a very early stage. We were able to get it up on their website. We also decided that their website would be the website for clinicians on all emergencies, were it chemical, biological or whatever. So there is a range of guidance on the PHLS website available for all clinicians. They have also set up a closed website for another range of clinicians, and then they gave us a huge amount of support during the anthrax scares that we all had. They had to have a 24-hour team rotating the whole time to respond to that as well as their laboratories responding to that. They have also done a lot of work out in the field. We took in some of their staff to the department. It has been a huge programme. Mary is from the PHLS. Do you want to add to that, Mary?
  (Dr O'Mahony) It may be helpful just to explain the background to the Public Health Laboratory Service. It was set up in 1938 as the Emergency Public Health Laboratory Service before the onset on the Second World War, when there were concerns at that time about the possibility of germ warfare and, also, civil disruption. So since the very inception of the Emergency Public Health Laboratory Service, and the Public Health Laboratory Service after the War, the notion of the PHLS being an expert body to give microbiological advice and public health support in the event of any biological attack, or any other emergency around infectious disease, has been implicit in its work. In 1977 the Department of Health gave funds to the Public Health Laboratory Service to set up a epidemiological wing (CDSC) to help with the public health epidemiological expertise to the nation. Thus within the Public Health Laboratory Service it is always implicitly understood that its remit is to assist the nation and provide expert advice in peacetime and potentially in any war time or terrorist footing. It is in that context that the PHLS came in to assist the department on 11 September. This they do that all the time through assisting the NHS, local authorities, working with DEFRA and the Drinking Water Inspectorate in the investigation of any number of incidents of infectious diseases or potential incidents of infections. That background explains the constant oiling of the wheels for the use of their expertise and the availability to shift resources to whatever investigation or major activity that is in play. That is something that has been there since its beginning, and the PHLS can ratchet up and down the emergency response activity because that is how it was set up.

  1034. Will there be additional resources?
  (Dr Troop) The first additional funding will come because we anticipate that when we put these agencies together there will be some significant savings because of some of the management structures, and that first additional funding will be redeployed to front-line services. We will still have the whole of that funding but we will be able to use it in a more effective and efficient way. Beyond that, of course, we were party to discussions with spending reviews and so on about any additional resources we have in this area, and you can imagine that for the control of infectious diseases and so on we have ensured that we have made our requests known in that system.

Jim Knight

  1035. In the event of a major incident, clearly, time is essential and making the best use of it. You are bringing together all these various agencies and you have talked about the need for infrastructure and sorting that out as a starting point. Can you comment on how well developed the communications infrastructure is between the various agencies and then national, regional and local links, both on IT and other forms of communication, so that in the event of that major incident we can make best use of that and buy time?
  (Dr Troop) What we have at the department is a set of standing operating procedures whereby we can have emergency contacts for all of those organisations nationally, and they can contact each other. This is carried by a number of senior people in the department—all the directors and ourselves here and some of our staff. We have an on-call rota for emergencies which at a senior level we staff. That is there an available for the CCS and for the service but, also, internationally as well, I am the first point of contact and David Harper is my back-up on that. So that we have set up those standing operating procedures with this detailed contact list, and all of these organisations have made sure that they have their own emergency contact. Out of hours I can always get hold of the Public Health Laboratory Service, I can always get hold of CAMR and I can always get hold of the other bodies.

  1036. You have tried all of this?
  (Dr Troop) Yes, and we, obviously, test it to make sure that it works. We all carry this and we all carry it all the time. So that is at the national level. Within that, we also have an emergency contact list for people at the regional level, so that the Regional Directors of Public Health are also part of that network. There are times when we have tested it and there are times we have had to test it, and if it is not working we can always go back and say "Why did that not work?" They also have systems on how to get out to the wider NHS. We have a cascade electronic system out to the medical profession which, because of the change to PCTs, we are obviously having to review because it is a different list. At the moment, if I want to get a message out, in every health authority somebody carries a pager and we can send this off on a national pager message and they then know that they have got an e-mail message. It may be withdrawal of a vaccine, it may be something that they need to tell the GPs. We have that network. So we have a number of networks which we have reviewed significantly since September 11. Some of it needs constantly reviewing, constantly checking and constantly strengthening but I think our communications system now is much better than it was.

  1037. Two tiny supplementaries to that: the first is whether that system is secure? Clearly if you have got a terrorist attack they could decide to try and take out that system in order to disrupt the response.
  (Dr Troop) We have had another section of our department particularly working on our IT looking at the resilience of the system and looking at the alternative means of communication and have identified alternatives. For the medical cascade system we are trying to set up a new back-up system because the old technology is pretty inadequate.

  1038. In the event of a bio-terrorist attack, using communications to just pick up that attack is, obviously, important. Do you have a process of communication with the primary care level, with NHS Direct and with the other aspects of the service in order to be able to pick up the signs that there is a concentration of an attack that has occurred?
  (Dr Troop) There are two ways of communication. As well as our emergency network the PHLS also has a network out to A&E consultants and consultants in community disease control, infectious diseases. They have an emergency e-mail system out to them. This is part of our normal surveillance system. We constantly, and particularly through the PHLS, receive information on a daily basis from NHS Direct, from GPS reporting, from clinics reporting and from laboratories reporting. They collect this information on a daily basis and every week they publish trends of particular infectious diseases, so that should there be a problem they should pick it up that way. If I can give an example, about a month ago the PHLS was informed by three different clinicians in three parts of the UK that they had found a case of botulism. Now, that is a pretty rare diagnosis. They were in three cities and all three were picked up within 48 hours through them reporting in that here was an unusual disease. We then, within 24 hours, had alerted the whole service to ask if there were any more cases out there. It turned out not to be anything sinister, fortunately, and in fact we did not hear of any more new cases but we got quite a few which could have been, which we checked out and they were not. So I think our challenge—and we recognise the challenge and we are certainly not complacent about it—is how do you keep that thinking in people's heads all the time? Will they do it for a year? Will they do it in two years' time? Whilst I have a lot of confidence in our service we do not under-estimate the challenge we have to keep that up-to-date, refreshed and people aware of what is going on—the communication going on and the training going on. It is a major programme that we have to keep maintaining. So when I say I have confidence, it is against a background of recognising that actually we have got a major programme. So I would not under-estimate it. We have looked very seriously at all those systems.


  1039. When you use the words "we have confidence" and you talk with people who know exactly what that means, that is why we are a little anxious, because we use it incessantly and we know the qualifications to the issuing of those words.
  (Dr Troop) I hope I have given you the kind of qualification, that it is not because we have not worked on the system, it is because the NHS is a huge and complex organisation with a million employees. Health is a devolved activity, and we cannot direct what the other three countries do; we have to work in partnership with them. To keep the whole of the system primed, up-to-date, trained and communicated with is not straightforward and I would never say that things do not sometimes fall down, or whatever, but it is not because we have not recognised that.

3   Note from Witness: The role and funding of PCT's is discussed in the document Shifting the Balance of Power: The Next Steps (not printed). Back

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