Memorandum by Dr D A B Dance, Plymouth
Hospitals NHS Trust
I support the formation of the Health Protection
Agency, and would endorse the recommendation in "Getting
Ahead of the Curve" that the public health activities and
outputs of all diagnostic microbiology laboratories should be
enhanced. However, I have serious reservations about the wisdom
of dismantling the national and regional networks of PHLS laboratories
in England, which is proceeding as part of the implementation
of the CMO's strategy. Whilst the PHLS is not perfect, and functions
with differing levels of effectiveness in different regions, the
integration of microbiology and epidemiology that encapsulates
the PHLS model has long been regarded as one of the strengths
of the system in England and Wales. This arrangement has been
the subject of numerous reviews, each of which has concluded that
it should continue largely unchanged. For example, the Strategic
Review of the Public Health Laboratory Service in 1994 concluded
". . . the management of a network of laboratories
carrying out clinical diagnostic and public health microbiology,
and providing microbiological and epidemiological support and
advice to all appropriate agencies in their localities, should
remain a core responsibility (of the PHLS Board)"
The report went on to say that, if many PHLS
withdrawals from laboratories were necessitated by financial pressures,
this would happen . . . "without the same degree of confidence
that the public health function could be safeguarded".
On this occasion, no formal review has been
conducted and yet sweeping recommendations have been made and
are about to be implemented.
There are also many experts outside England
and Wales who have long regarded the network of PHLS laboratories
as an extremely effective system. In a letter to Lord Turnberg,
Chairman of the PHLS Board, sent on 29 January 2002 after "Getting
Ahead of the Curve" was published, Dr James Hughes, Director
of the National Center for Infectious Diseases, CDC, Atlanta,
"In summary, reducing the number and capacity
of existing public health laboratories under the proposed reorganisation
may be counterproductive. The flow of information between the
public health and the clinical sectors will likely be reduced,
as will the ability of public health agencies to leverage new
information into changes in laboratory practice and policy on
a broad scale
. . . I suggest that you carefully assess the
potential ramifications of the changes in laboratory services
recommended by this excellent report."
The value of this integration has clearly been
recognised by the Welsh Assembly in deciding on the arrangements
for Wales, and the proposed National Public Health Service for
Wales is a structure which we believe is more likely to deliver
the required enhancements to surveillance and other public health
functions of microbiology laboratories envisaged in "Getting
Ahead of the Curve".
Some of the risks inherent in the approach for
Dislocation of microbiology from
epidemiology, which have previously been incorporated within the
Financial pressures on current PHLS
laboratories resulting from the process of transfer to the NHS.
Diversion of resources from national
and regional public health activities to Trust priorities in those
laboratories transferring from the PHLS to the NHS.
A failure to achieve the required
enhancements to public health functions and outputs, including
surveillance, in current NHS laboratories without additional resources.
Loss of synergies (functional and
financial) achieved by PHLS groups when these are fragmented.
Separation of clinical microbiology
from Food, Water and Environmental microbiology resulting in impaired
surveillance and outbreak investigation.
Difficulty in conducting enhanced
surveillance (eg current examples such as Campylobacter infection
and West Nile virus), for which the PHLS network has been an invaluable
and unique resource.
Loss of key individuals committed
to the health protection function from PHLS laboratories that
transfer to the NHS.
I know that these concerns are shared by many
of my colleagues in PHLS South West and elsewhere within the Service.