Select Committee on Science and Technology Minutes of Evidence


Memorandum by Mr Nigel Emery, Principal Environmental Health Officer, Weymouth and Portland Borough Council

THE ROLE OF THE ENVIRONMENTAL HEALTH OFFICER IN FIGHTING HUMAN INFECTIOUS DISEASE  

1. I am a Principal Environmental Health Officer currently employed by Weymouth and Portland Borough Council. I have been qualified as an Environmental Health Officer for 24 years and have worked for six different local authorities, five in England and one in Scotland.

2. I am writing to the Sub-Committee following the request for evidence. My particular concern is with the failure of the present system with respect to the Environmental Health role for both preventing the incidence of infectious disease and its spread in the community. These failures stem from the present organisational set up which places the Environmental Health profession within local authorities.

3. With the advent of the 1972 Local Government Act Medical Officers of Health lost control of the Environmental Health (then Public Health) function to local authorities. This severed the close working relationship which had previously existed between health authorities and Environmental Health professionals. The CCDC role became the liaison mechanism between the local authority Environmental Health Officer and the health authority. The direct link which GPs had with Environmental Health Officers was also lost.

4. The CCDC and the PHLS representative became members of the County Food Liaison Groups which were established under the aegis of the Chief Environmental Health Officers within the county. One purpose of these groups was to improve liaison in the communicable disease role (usually, but not solely, relating to food poisoning) between local authorities and their counterparts in the health authority. Currently, I am the convenor for the Dorset Food Liaison Group. The use of these groups for CCDC liaison has never been very successful because CCDCs know that the main purpose of the groups is food hygiene enforcement, with communicable disease playing a minor role.

5. Unfortunately Chief Environmental Health Officers have now largely been replaced in local authorities by Directors of Technical Services as a cost reduction measure. In some instances these directors may be ex-Chief Environmental Health Officers but in many cases directors will have limited understanding of what Environmental Health Officers do because they come from a different background such as planning, engineering, etc. In many local authorities Environmental Health may now be only at a third tier level of authority which means that Environmental Health Managers request for resources to properly fund the Environmental Health function is almost certainly going to be of limited success.

6. Allied to the loss of prestige of Environmental Health within the local authority set up is the growing national shortage of Environmental Health graduates causing a major recruitment problem in the profession, a problem which is set to worsen considerably in the next few years. School leavers are no longer attracted to the Environmental Health profession because they see the constraints which are operating in the local authority context and they understandably don't wish to spend six years training to reach a professional level of competency and then face the constraints which working within the local authority arena then poses. These restraints are major disincentives and include lack of recognition, political interference, lack of resources and far too much emphasis being placed on performance monitoring and auditing at the expense of actually being able to get on and do the job. The figures are since 1995 an 80 per cent reduction in applications to Environmental Health courses. In 2000 there were less than 300 applications for degree courses. In the last three years, three Environmental Health degree course providers have closed and the remaining providers are struggling to remain viable. Of the 9,500 Environmental Health Officers registered with the CIEH only 4,500 work in local authorities and the figure is worsening (Environmental Health Journal Vol. 110/10 Oct 2002) In 2001 there were only 50 applications for Environmental Health degree courses (EH News Vol. 17 No. 34 6 Sept 2002).

7. Environmental Health needs to be relocated into the Health Protection Agency. After all, it is the work of Public Health Officers over the last 150 years that have made crucial advances in the improvement of air quality, food and water quality, housing conditions, working conditions, ensuring effective sewerage and removal of nuisances as well as the investigation of infectious disease in the community.

8. The current re-organisation which is taking place with the creation of the Health Protection Agency and PCTs has completely ignored the role of Environmental Health. Primary Care Trusts and local authorities are being encouraged to develop strong working relationships" not least by the Minister for Public Health Hazel Blears but the problem with this concept is that local authorities don't work with that degree of flexibility. They are still very authoritarian and bureaucratic organisations so I don't believe that the hope for strong working relationships is realistic. Environmental Health will remain a subdued function under the local authority umbrella largely cut off from the mainstream health protection role as it has been for the last 30 years.

9. One specific problem with the current set up is the failure of the communicable disease notification loop to work fast enough or even to work at all. The current system is that an individual suffering from, say, food poisoning notifies their GP who may or may not decide to take a stool sample. If no sample is taken the loop stops there. The sample is analysed by the PHLS who give the result to the G.P. and in the case of a positive result to the CCDC. The CCDC then informs the Environmental Health Officer in the local authority. It is not uncommon for the Environmental Health Officer to be given a positive result a week after the patient first went to the surgery with their symptoms. The Environmental Health Officer then has to contact the patient to ascertain where they may have picked up the infection, from food, from water, milk or some other source in the U.K. or abroad, but often the trail has already gone cold and the person has resumed their work.

10. A typical recent example of what can happen with the current communication loop is as follows. A resident within this Borough was suffering severe diarrhoea and contacted her GP on a Friday, not being fit to make a visit to the surgery she requested a home visit but this was refused and the patient attended surgery on the following Monday when a stool sample was taken. She was not questioned at this juncture about her occupation. On the Wednesday afternoon the PHLS isolated Salmonella in the stool sample and told the surgery, the CCDC got the information on the Thursday and the Environmental Health Unit received the information on Friday. We had a name and address but no contact telephone number because one is not requested on the PHLS form. When the Environmental Health Officer visited the address on the Friday no one was at home and a card was left. The patient actually contacted our office on the following Monday when she was back at work in a play group and she was still unwell. We immediately told her to stop work until 48 hours after cessation of symptoms which she was happy to do. She was however, annoyed that this information had not come to her through her GP and she was annoyed that it had taken us so long to make contact with her as she felt guilty (rightly so) that she was exposing children in her care to a risk of infection. Under the old pre-1974 system the Environmental Health Officer would have been contacted directly by the GP who would immediately have investigated the cause of the patient's Salmonella and ensured that the person did not go to work until it was safe for them to do so. Delays in Environmental Health Officers receiving information about a communicable disease victim makes it very difficult to identify the source of infection and protect others in the community. Few food poisoning outbreak investigations manage to positively identify cause because the Environmental Health Officer's intervention is usually too late because of the way the system works.

11. Another example of the difficulties with a multi-organisational approach to infectious disease occurred in April this year in this Borough with a cholera case. Briefly, I was notified by the CCDC of a man with cholera living in the Borough, he had reported it to his GP and been potted. I visited him at home and confirmed that he had been travelling in Africa and India and had become ill initially in Botswana. He was still unwell but not bad enough to be in bed. The CCDC was awaiting confirmation of whether the strain was toxigenic. She assumed that the GP had given tetracycline to the case but checking revealed that in fact the GP hadn't. The CCDC asked me to contact the Enteric Pathogens Lab at Colindale to get the vibrio typing result. I did this but they refused to give me the information. They would only deal with the PHLS lab at Dorchester Hospital who had initially analysed the sample. They would be sending it to Dorchester PHLS that day. I asked how this information would be sent: e-mail? fax? I was told to my surprise that it would be sent by post—a totally unnecessary delay with a potentially highly infectious individual at large in the community. The next day I was able to learn from PHLS that the cholera was non-toxigenic (fortunately). I informed the CCDC who in the meantime had learnt from the GP that no tetracycline had been prescribed. I telephoned the case and learnt that he had moved to London to stay with his brother, fortunately not a high risk contact, being self-employed working from home. I told the case that he must find a GP to get a course of tetracycline and to have his condition monitored as he was still unwell and undoubtedly excreting vibrios. I had at my first meeting impressed upon him the need for strict toilet hygiene. I rang two days later and confirmed that he had visited the London Hospital for Tropical Diseases who were doing all that was necessary by way of treatment. Overall, I didn't think it was a very impressive exercise in practical infection control within the community. As an Environmental Health Officer I was a key player but certainly didn't feel part of the team.

12. Another example illustrates the need for effective communication between various agencies involved in the investigation of infectious disease control. It also highlights the need for the medical teams, who treat illnesses, to have a greater understanding of the needs of those investigating them, so that the cause and sources of infection can be identified and controlled. There is also a need for effective communication with the ward medical teams if food poisoning and or viral infections are suspected.

A South Wales football team stayed at hotel accommodation near Wimborne. The following morning they left the hotel by coach for a training session at a local training ground. After this they travelled by coach on the motorway towards Southampton where the coach driver felt so ill that he stopped at the Services. Four members of the team also felt ill and because of the severity of their symptoms (Diarrhoea and vomiting) an ambulance was called.

They were admitted to hospital where despite their symptoms it appears that the medical staff did not arrange to get samples that would be useful in determining whether it was a viral or bacterial episode. The hospital administration did inform our consultant in health protection but by the time it was realised that suitable samples had not been taken from all the patients, it was too late for the laboratory to identify if the cause was viral. No food poisoning bacteria were found.

Samples of the food remaining from the team's stay at the hotel revealed no food poisoning bacteria and there were no further reports of other guests displaying similar symptoms.

The football team returned to South Wales where more team members developed similar symptoms. Despite officers from the investigating authority advising the club's coaching staff of the importance in getting samples quickly to hospital so that they could be checked for viruses all the samples failed to produce results due to various delays. One patient held onto the sample for nearly a week before submitting it despite having said that it had already gone. Another sample failed to produce results because the laboratory staff were not asked to look for viruses. This despite making it clear to the authorities.

Therefore, the investigating authority was left with little evidence that anything untoward had happened. Naturally the club management found this difficult to believe particularly as the episode had resulted in disruption to their training programmes during the build up to the start of the new football season.

It is recommended:

1. That GP's and staff in accident and emergency units should, as a matter of routine, organise the taking of faecal samples as soon as practical after seeing patients presenting with symptoms involving the gastro intestinal tract.

2. That all the various NHS units and laboratories have designated contact officers who will be responsible for co-ordinating and liasing with the local authorities Environmental Health Officers during such investigations.

Nigel Emery

Principal Environmental Health Officer

8 October 2002


 
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