Select Committee on Science and Technology Minutes of Evidence


Examination of Witnesses (Questions 228-239)

TUESDAY 10 DECEMBER

MR NIGEL EMERY, DR RUTH GELLETLIE, DR JEREMY HAWKER AND DR PHILIP MONK

Chairman

228. Good morning, lady and gentlemen. First of all, thank you very much for coming along. If you would like to introduce yourselves and, following that, if there are either collective or individual comments to make before we start, now is the time to do it.

  

Mr Nigel Emery, Dr Ruth Gelletlie,

Dr Jeremy Hawker and Dr Philip Monk  

(Mr Emery) Good morning. My name is Nigel Emery, I am a Principal Environmental Health Officer currently working at Weymouth and Portland Borough Council in Dorset. I am very pleased to be asked to come before the Select Sub-Committee because I think it is important to say a few words from the local authority, environmental health officer perspective. Thank you.

(Dr Monk) I am Dr Philip Monk. I am a Consultant in Communicable Disease Control for Leicester Health Authority, as was. I will not bore you with the primary care trust we now belong to. I am a Member of the Board of Faculty for Public Health Medicine and Vice President of the Public Health Medicine Environmental Group. In my previous incarnation I was a GP and I am a Member of that college as well. I suppose my main expertise over the last year or so has been with TB outbreaks and variant CJD.

(Dr Hawker) My name is Jeremy Hawker, from the PHLS Communicable Disease Surveillance Centre in the West Midlands. Prior to that, I was Consultant in Communicable Disease Control for Birmingham. My main interests are in inequalities in infectious diseases and training and education issues.

(Dr Gelletlie) I am Dr Ruth Gelletlie, I am a Consultant in Communicable Disease Control in Bradford. I am currently President of the Public Health Medicine Environmental Group and a Member of the Board of Faculty for Public Health Medicine. Before coming into public health I was an infectious disease physician. I have an interest in tuberculosis, and also in inequalities in health, and infectious diseases in developing countries.

229. Have you any introductory comments to make? Or can we fire away with the questions? If not, can I thank you very much for your introduction. If we can go to the first question, much of the evidence we have received refers to a shortage of joined-up working and effective communication between the various agencies that we are dealing with, those involving food, water, environment and veterinary infection—the PHLS the DLA and others. What suggestions do you have to improve communication and have a joined-up working relationship between these various agencies? May I say to Mr Emery, we thank you for your paper which gives a good historical account of the situation.

(Mr Emery) Thank you for that. As I say, I come from the background of the local authority and, as environmental health officers, we are used to working, if you like, in a sort of liaison, almost an agency role, with the CCDC, who obviously works for the National Health Service. However, we have the rather strange situation that the CCDC is a proper officer—indeed the CCDC has been appointed as the proper officer—under public health legislation by the local authority. We then work back with the CCDC as sort of officers on the ground" in the community, going out to talk to people and investigate where things have gone wrong. Unfortunately, this relationship, I do not feel, is sufficiently close. It is difficult when you are working with different authorities, bearing in mind there are 400 different local authorities anyway, and the CCDC will be working with several—8, 9, 10 or whatever. I do not yet quite see how the proposed consultant health protection role is going to work because I have not seen any hard sort of schemes as to how the HPA will be set up. I do not anticipate any particular closeness from the sort of reforms which are intended. That worries me because prior to 1974 when health authorities and local authorities were split we used to work under the Medical Officer of Health (we were then called Public Health Inspectors) and that relationship was much better, much closer, direct and we could get the information we needed much more quickly to go out and investigate why someone was ill. I think one of the problems that is likely to arise is that in any new scheme unless you have some statutory requirement to work together between the PCT, or whatever form the CCDC or the consultant in health protection is working under, and the local authority then some local authorities will tend to almost, not exactly, demote the public health function as it is only one of many priorities which they have, and if the requirement or the wish is to have partnership working in that way I fear that in some local authorities it will not be a successful relationship.

(Dr Monk) If I may make a number of comments, my Lord Chairman, I think one of the difficulties in linking this up is that you have got to say at what level will this linking take place? In the way that government is being structured in England and Wales at the moment, my interpretation of the view of government is that it is going to be at the regional level. I think there are lots of opportunities there. The first comment then to make, if that is a correct interpretation, is that the Food Standards Agency (if I can address it as the FSA in future) needs to have a regional presence. It is a national body at the moment, centred in London, effectively working through its effector mechanisms, which are environmental health officers, but I think in order to join things up my own view is that the FSA needs to have a regional structure which maps on to that of regional government. I think then there are models that you can use. For example, if you look at what happens in southern Ireland, they have a lot of joined-up committee working between the equivalent of the Food Standards Agency in Ireland and between the water companies in the region, because they have a significant and substantial number of private water companies there. But they join together at the regional tier, and I think you could envisage a model that would do that. So if I just reflect on those comments, the first thing is that the weakness currently is that there is not a regional presence of the Food Standards Agency. The veterinary side does have a regional presence in its investigation centres, and in our region we have regular meetings that join that up, but the Food Standards Agency is missing. The other comment I would suggest to you which could be built into the legislation, as that affects other organisations within the health service and social service sector, is a duty of partnership. If that is built into the legislation then it would make the arrangements that Mr Emery has described a statutory duty and, I think, would ensure that if you have got the fundamental structures in place then that joined-up-ness would take place.

(Dr Hawker) Firstly, I agree with everything that has been said so far. One comment I would make particularly about local authorities (and I think Mr Emery alluded to this to some extent) is the tremendous variation between them. Getting Ahead of the Curve had little to say on local authorities and before that the previous Acheson Inquiry had virtually nothing to say on local authorities—I think, primarily, because the health service side of things was seen to be so much worse that they just felt the need to tackle that. However, if we compare, firstly, the resources available to local authorities, you will be aware that communicable disease control is done at the district level, so at the smaller of the two-tiers of local authorities. Some of these districts are extremely small, which firstly means they do not have that much resource, so they do not have much access to surge capacity, and secondly because they do not have that many staff it is actually very difficult for them to specialise. So if we compare somewhere like the City of Birmingham which covers one million people, firstly when we have a problem—for example when we had our Legionella outbreak in the 1990s—they can lend us 50 people to go out walking the streets and try and find unregistered cooling towers; for routine control of food-borne pathogens they have a team of six or eight people who specialise solely in food and water. When you compare that to some of the smaller authorities—I will pick East Staffordshire not because it is bad but because it is tiny—there is no way it can reproduce that level of service, whether they wanted to or not. So my first comment would be I wonder whether environmental health is actually done at the right level.

(Dr Gelletlie) I would like to agree with what my colleagues have said. One other point that has not been made, I think, yet, is the need to clarify roles and responsibilities and to be sure that we all understand each other's roles and responsibilities. That will help us to work better together. One of the ways we can do that is—for example, if we take the Food Standards Agency or some of the national bodies—we could review some incidents where things have worked well and where things have not worked so well and draw out some of those lessons and use them to build better practice. We also need, when we clarify roles and responsibilities, to be absolutely certain that all roles are assigned to a particular body. A current problem that occurs sometimes is when we have possible outbreaks of Legionnaires Disease it is very difficult to decide who precisely is responsible for taking samples from certain premises. So those are the sorts of areas where we need to be sure roles and responsibilities are clear and all roles are assigned to one or other body.

230. Dr Hawker, maybe I cut you off before you had finished. I am sorry about that.

(Dr Hawker) You saved me some time, my Lord Chairman, because Dr Gelletlie made one of the points I was going to make, which relates to the issues around joint planning, which I think needs to be done at a local level, a regional level and a national level. At local level planning is, to some extent, done between the old health authorities (now the Primary Care Trusts) and the local authorities, although its extent and how well it is done varies. However, it does not much include the other agencies that they have to liaise with. One good example is in Legionnaires' Disease outbreaks with the Health and Safety Executive. In almost every outbreak that I hear about, when we get to the stage of identifying where we think the source is, there is a dispute as to whose responsibility it is to go and sample the cooling towers, how quickly it needs to be done and what sort of powers we have to enforce changes. It seems that most of the agencies appear to think it is another agency's job to do it. I do not think that can be a particularly robust system and I think these things need to be sorted out in advance. Quite often, these sorts of priorities ought to be sorted out at the higher level than the local level. With HSE, for example, they have national policies but the partner agencies need the chance to actually negotiate with them as to what those national policies should be.

(Dr Monk) I think Jeremy has made a point I wanted to make. If you look at the HSE in Legionnaires, there is a document that tells you how to manage incidents of legionnella, and it describes the roles and responsibilities very clearly. The problem is that it has not been agreed with any of the partner agencies. So that is why the disputes arise as to what the responsibilities are, because the HSE has produced an excellent document which specifies precisely who does what, and not only who does what but how to do it—almost turn the tap on and let this volume of water flow out". But, that has not been agreed with partner agencies, and we somehow need to get that joined-up-ness at the very top level.

Lord Lewis of Newnham

231. I admit, my Lord Chairman, I find this somewhat terrifying. Who, at the end of the day, does carry the buck? You are implying, if I understand it correctly, that when you are dealing with a problem, say, of a particular outbreak, it is difficult to decide who eventually will go in and do what they have to. Who makes the decision about who will do what?

(Dr Hawker) The decisions are relatively informal, in the sense that most outbreaks are controlled by an outbreak control team, and they have a chairman. Usually it is the chairman's job to persuade somebody to do it and see who cracks first. That can sometimes mean we go and do it ourselves. Although we usually get it done, it just seems foolish not to try and sort these problems out in advance. If I can give you another example, and this is not one which has proven to be a problem for me but, again, it just flags up the lack of robustness of the system, we had an incident fairly recently where an individual had developed psittacosis a potentially fatal pneumonia, which you contract from animals, particularly from birds such as parrots. This person had a parrot, he had recently bought it from a dealer, the dealer had sold it to him at a big show with lots of other parrots and we were quite keen to know whether he caught it from his own parrot and whether anyone else was infected. It did not seem to be anyone's job to sample the parrot: DEFRA were very helpful and they said that if we sent the sample they would get it through somehow or other and the local authority were finally persuaded that they would go and take some droppings from the cage but it was not really their job to do it. Episodes like this strike me as not particularly robust. When we are talking about responsibilities, I think not only do we need to identify initially what the responsibilities of organisations are but I would press for somebody to have some reserve powers so when something like this comes up we would still have to make a case that what we wanted to do was reasonable and worthwhile but, if we did, somebody would go out and make sure it got done.

(Mr Emery) Just by way of possible clarification, when it comes to something like Legionnaires Disease at a works premises, then the responsibility lies with the business proprietor, the undertaker, of the business, but the actual enforcement responsibility either devolves to the Health and Safety Executive or to the local authority environmental health department, depending on the main activity of the premises. So, for example, if the main activity was an office block then the environmental health department could use its enforcement powers to get work done, which I think includes sampling—I do not see why not—and if it was something like a hospital then it would be the Health and Safety Executive who would have the powers to do this. They could use Section 3 of the Health and Safety At Work Act, which is a section intended to protect the public at large from health or safety hazards from a work activity. I just want to make the point that environmental health officers have to deal with a lot of different agencies: the Environment Agency, the Food Standards Agency; we deal with DEFRA, we deal with lots of different government departments, we deal with lots of local authorities and talk to vets and doctors and so forth. We have a very wide brief because we deal with legislation to do with food, health and safety at work, air pollution, communicable disease, various public health nuisances, housing standards and so on and so on. Generically we have evolved from the very beginning when bad conditions obtained in the mid-19th Century and the first public health acts arose. We have grown from there and various things have been added on. In fact, one might almost say we have reached the point at which somebody ought to review the whole function of environmental health and decide, in relation to the different things we do, are they best placed? Or maybe some of our work should go to other agencies. I should not, possibly, professionally, be suggesting that—and I am not necessarily suggesting it—but the point I am making is that EHOs cover a very wide remit of work, we have a lot of different priorities, we are working with local authorities whose budgets are very restrained in many ways and it is sometimes very difficult for us to have sufficient staff to put them where we regard the priority is highest. All these things have to be considered. I should just also say that there is a national environmental health officer recruitment crisis. I alluded to that in the background papers which I submitted to the Committee. This is not going to get any better; it is likely to get worse and so it really is a difficult problem for a lot of local authorities to actually respond to anything but very high priority work. We will always endeavour to respond to any crisis—indeed, we seem historically to be the profession that does not say no; where somebody else will not deal with it or cannot deal with it or they do not know whose liable, usually the environmental health officer will find some way round the problem and some way of achieving a solution. However, that is not a satisfactory state of affairs in this day and age. I am looking, really, to get the point across that we would like this opportunity to find a firm working relationship with another agency, whichever part it may be of the NHS reforms, where we can have a definite locked-in responsibility with access to sufficient resources to get the job done.

Chairman

232. I think, Mr Emery, we have got the message that you have concerns about the new schemes that have been recommended, but they are still recommended rather than being in place. Since the Health Protection Agency has yet to be formally set up there is the question of negotiation and getting it right, bearing in mind the points you have made. Would you agree with that? Or do you think they have gone too far?

(Mr Emery) I would be quite happy if environmental health officers stayed working in local authorities, provided that our function is adequately resourced. But in fact, I think I made the point in my written submissions that in a way, possibly, the Committee ought to be looking at environmental health officers—who are, if you like, health workers in the community—moving back into a closer relationship with the health authority—in whichever bit of it one may suggest is most appropriate. This present situation, where we are talking about partnerships between the health service, whether it is PCT or Health Protection Agency, and local authorities is, to my mind, not a sufficiently strong relationship; it is one that some local authorities will be able to respond to but a lot of others will not be able to respond to, for resource reasons and political (with a small p") reasons. I do not think that we can, in this day and age, leave communicable disease control to that kind of informal arrangement, which has not worked terribly well, from our point of view, in the past.


Chairman: I think we must move on to our second question.

Lord Lewis of Newnham

233. I think, in part, you have discussed this, but could I just ask you specifically to describe how you believe the HPA would interface with local authorities and environmental health officers under the proposed arrangements? I recognise that these arrangements are, at the moment, not finalised but, nevertheless, they are there.

(Mr Emery) I have to confess that I have not seen anything about the new arrangements and, again, I think this is probably part of the problem, which is that local authorities and environmental health officers have not been privy to the sort of changes which are being proposed. We know, as far as I am concerned in Dorset, there is going to be a Dorset Health Protection Unit. I am not exactly sure what the status of that is—a specialist health authority (I do not know exactly what the term is). That does not seem to me, from my perspective, to be very different from working with a CCDC who works for a health authority. I am afraid I have not seen any lay-out or any schemes of co-operation, and I am not alone in that.

Chairman

234. Are there any other comments?

(Dr Gelletlie) In my function as President of the Public Health Medicine Environmental Group, I have been sitting on the Deputy Chief Medical Officer's steering group for the setting up of the Health Protection Agency. I have seen drafts of proposals as to how the Field Services Division of the Health Protection Agency will work with partners at local level and at regional level as well but, particularly in this context, at a local level. The suggestion is that a lot of public health is achieved through partnership working. It may not be terribly satisfactory but because the public's health is affected by a whole raft of things like poverty, housing and the environment you have to do it in a multi-agency partnership manner. That is essential. No one body can have sole responsibility. That, therefore, requires good joint working at local level and good partnership working. As far as possible, that should be set in a framework which can then be monitored, clearly, and enforced, if possible. The point that local authorities are autonomous bodies is well taken. The current suggestion is that local units of the Health Protection Agency, which will include the CCDC and the staff who work with them—nurses and information people—will continue to work closely with the local authority. The CCDC will continue to be the proper officer of one or more local authorities, there will be partnerships between all the relevant local players, and that will include Primary Care Trusts who now hold the budget for the health services, which are an important element in communicable disease and infection control. So at local level you will have Primary Care Trusts, one or more local authorities, you will have the local Health Protection Unit and, I would suggest also, you will have the local NHS trusts, who are also key partners in this. These four partners will come together and agree local plans which will include programmes to be delivered and resources to be committed. That is the general suggestion as to how this will work at the local level. It will depend on partnerships, it will depend on the HPA staff being senior, authoritative figures on the local scene and not being removed too far from their local partners, because joint working depends on good relationships. I would echomy colleague, Mr Emery's, comments that environmental health departments are starved of resources and have been, and that is one of the weakest links, I think, currently, in our ability to control infection.

Lord Lewis of Newnham

235. Could I just ask, through you, my Lord Chairman, about this argument over resources and, also, about recruitment? What is the problem with recruitment? Is it just that it is no longer an attractive job? What is happening?

(Mr Emery) One of the problems, as far as environmental health is concerned, is that a young person who wants to go into environmental health will face a four-year degree course, one year of which will be to obtain a practical placement with a local authority. Local authorities have, largely, ceased to offer student places because of cutbacks in resources. For example, in my current local authority, we froze our student place seven or eight years ago. That is one problem. The degree, obviously, as with most degrees, is quite demanding. The person will then face two years after the degree of reaching a sufficient state of professional competency. Again, they have got to complete a log book and accreditation. They rely on that for experience with different local authorities. The jobs are available but the pay is not very good, and if somebody contemplating a career thinks Okay, I am going to do all that, but what is the pay going to be at the end of it", then they are going to consider the career structure, and because environmental health is at district council level, small local authorities have limited prospects for promotion so you have to keep leaving one local authority to move to another. So the attraction, from a young person's perspective, for working in environmental health is limited by the local authority connection. A lot of people graduate now and go to work for private companies, so we are not retaining people in the field. My personal view is that environmental health should be pitched at regional level, (that is my view and that has been my view for 20 years), something like the Environment Agency or the Health and Safety Executive, because then you have scientific back-up and support, you have reasonable career prospects and better pay, etc. The other thing which is important, I should say, is that if you work for a local authority you are in a very political (with a small p") environment and you are at the whim of whatever a council member may wish the priority to be, and that could be something extremely low, from dog fouling to whether a new bus shelter is going to be erected. So officers feel very exposed and they are increasingly exposed to pressure from all sorts of areas. They are talking now about e-government and the fact that you have got to be responding to e-mails coming in at all hours of the day and night. We have to be incredibly accountable but we are constrained by the Data Protection Act and by the Regulatory Investigation Powers Act and by the Human Rights Acts. We are working in a very difficult environment, highly accountable but trying to be professional across a wide range of specialisms and trying to keep up-to-date with the increasing flow of new legislation. If you are working in a small local authority you have to absorb that all yourself, or for your team; you cannot have specialisms whereby new legislation is brought in and paraphrased and fed down to other people. It is quite a difficult thing. I am sorry to go on about that!

Chairman236. I would like some of your colleagues to be brought in on this.

(Dr Hawker) I think, my Lord Chairman, it is a philosophical decision that needs to be made about environmental health, which is: is environmental health a function which is left to local politicians to decide how well it is done against other competing priorities locally, or are there fundamental standards that need to be achieved by all local authorities, in which case they need to be set and somebody needs to monitor them and, perhaps, like education standards, enforce them? You will not be surprised to find out that I believe the latter should be the case, because infectious diseases do not stay within local authority boundaries.

Baroness Walmsley

237. I was just interested in this idea of organising it at a regional level. You mentioned that a young environmental health officer needs to have a log book and get various kinds of experience. Would it be easier to co-ordinate that and to be able to provide that sort of variety of experience if it was organised at regional level?

(Mr Emery) Yes, it would.

238. So it would help to feed through the professions that need—

(Mr Emery) Yes, it would, because one local authority can only provide a certain amount of experience, because there are only certain types of businesses or factories. If you want, for example, port health experience, which you have to have, then you have to go to port health authorities to get that. If you want to do fish inspection or meat inspection your authority may not have the facilities. So there is a lot of work involved in doing that. So a regional set up, I feel and have always felt, is the right sort of place for environmental health to be.

Chairman

239. Dr Monk, do you have any comment on this question?

(Dr Monk) Just a very brief comment, my Lord Chairman, and that is that I think there are two issues; there is the here and now and there is the question which relates to how do we work? I think it has got to be a duty of partnership. If we look at it with the thinking that is emerging on local government restructuring and regionalisation and with the thinking around the tiers of councils (and currently environmental health services are in district councils) I think there is a great opportunity to look at it being put into an agency which could be an all-encompassing agency with, as Dr Hawker has suggested, standards being set by politicians and monitoring of standards. I think then you would truly join the service. However, the here and now is about how we join something, and I believe that has to be through a duty of partnership, but there are great, great opportunities in the future as parts of England regionalise.


 
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