Select Committee on Science and Technology Written Evidence


Memorandum by the Faculty of Public Health Medicine

  The Faculty of Public Health Medicine is the professional specialist body in public health. It is responsible for setting and maintaining professional standards through education and continuing professional development. It has members in the key health protection organisations, including CCDC, PHLS, NRPB and other specialists colleges. Faculty members contribute to chemical incidence and emergency planning.

INTRODUCTION

  The Faculty welcomes the inquiry which is timely for three reasons. Firstly, because of the creation of new health service structures and opportunities in England following the initiatives outlined in the publications Shifting the Balance of Power (April 2001)[44] and Getting Ahead of the Curve (January 2002)[45]. Secondly, as these reforms are confined to England it will be essential to consider carefully their impact for changes that may be made later in the Devolved Administrations (the Faculty has a UK-wide remit). Thirdly, these are the first reforms of local health protection services since the investment that followed the Acheson Report of 1988, and are the most major reforms of the English health services since 1974.

  The reforms of 1974 are widely recognised as having left communicable disease control in a vulnerable state, and although the post-Acheson report reforms went some way to strengthening health protection services, it is still important to consider how health protection in general, and communicable disease control in particular, will be left following the 2001-02 reforms.

  The evidence from the Faculty will be organised under the six questions posed by the Sub-Committee.

1.   What are the main problems facing surveillance, treatment and prevention of human infectious diseases?

  A major problem apparent to public health authorities and the Faculty is the inadequate and highly uneven allocation of local resource for public health aspects of communicable disease control and, as yet, a lack of integrated local organisation for the prevention and control of infection in England.

  Key Point 1. The basic building block of communicable disease control is strong, competent and integrated local health protection services. Getting Ahead of the Curve envisaged that there should be health protection partnerships for defined populations between the three key local institutions. These should now be formed from Public Health Networks (groups of PCTs and acute trusts including microbiologists and clinicians), Health Protection Units and Local Authorities.

  Getting Ahead of the Curve envisaged "Health protection agreements (between HPA units) made with primary care trusts and local authorities" (page 135). However, one difficulty is that since April 2001 local health economies and public health structures have been in the midst of the largest structural changes since 1974, whilst changes to the health protection services only began to be considered in January 2002. The local health protection agreements require a blue-print and this is only now beginning to emerge from those planning the Health Protection Agency (HPA). This is an area under active discussion. Experience across the country is variable and a high level of support is needed to maintain on-call commitments (not withstanding the Chief Medical Officer's clear direction otherwise of Getting Ahead of the Curve, page 135).

  Given the uncertainty that follows the prospect of change the Faculty welcomes the speed with which the Department of Health in England is now moving on this issue. The reforms in general public health are moving rapidly ahead and there is concern that the development of general public health and that of health protection and microbiology services are becoming out of step. The accelerated development will remove uncertainty for the cadres of workers concerned with health protection and will make it more likely that health protection partnerships will be formed.

  Key Point 2. Greater government effort should be made to achieve co-terminosity of NHS, Health Protection and Local Authority Boundaries.

  Probably the biggest threat to the successful formation of health protection partnerships is the lack of co-terminosity of NHS, Health Protection and Local Authority Boundaries. While in some areas there are logical arrangements, for example in London, in other areas there are complicated overlays which mean that Health Protection Units will have to develop and sustain complex relations with multiple PCT and local authority teams. The Faculty strongly recommends that co-terminosity be accepted as a principle. It also wishes to see resources made available for joint working between the NHS and local government.

  Key Point 3. Local investments in public health services for prevention and control of infection are uneven, not standardised and do not necessarily relate to local need. If new monies become available for communicable disease control they should be used to strengthen local services.

  The 2002 Control of Infection Survey[46] found major inequalities in the provision of communicable disease control services across England in terms of the man-power available for responding to need. The Faculty hopes that the government and the Department of Health will be successful in identifying new monies to strengthen local services.

  Key Point 4. Concerns about confidentiality and restrictions on data flows could potentially lead to situations where the health of individuals will be put at risk. Those responsible for professional conduct must balance the responsibility of doctors, nurses and scientists to protect individual confidentiality with that of their responsibility to protecting individuals through contributing to public health.

  Key Point 5. The Department of Health (DoH) should take the lead in explaining to the public how gathering and using data from them for "information for action" can contribute to their health protection.

  The Faculty has welcomed the greater emphasis on confidentiality in general in the health services and has supported its practical embodiment through the Caldicott procedures. It notes the moves of bodies such as the Public Health Laboratory Service (PHLS) in minimising the amount of Personally Identifiable Information (PII) that comes to and is held by its component parts. However, it also recognises that some PII is necessary for those functions essential for protecting human health: data matching (for example, for investigating and monitoring vaccine safety), contact tracing and during acute investigations. Equally, surveillance data with PII has been required to link with clinical outcomes and the chronic consequences of infections: important examples include not only assessments of vaccine safety, but also AIDS and HIV reporting, the work of clinician based surveillance units[47], CDSC's hepatitis C Register, TB outcome surveillance, and linking up Office for National Statistics death data to laboratory reports etc.

  The Faculty is concerned by some recent reports from the Communicable Disease Surveillance Centre (CDSC) of general practitioners being unwilling to approach their patients to ask if they will contribute to the investigation of a national outbreak of gastrointestinal disease. Professional documentation, such as that of the General Medical Council, has rightly delineated the responsibility of doctors in preserving individual confidentiality. However, there should be counterbalancing documentation outlining the responsibilities of doctors to protect the health of individuals through such actions as voluntary and confidential reporting, contact tracing and outbreak investigation, and the public health responsibilities of doctors.

  Anecdotal accounts and clinical experience indicate that when the process of surveillance and response is explained to members of the public they are very willing to co-operate. However, at present there has been little effective communication with the public, though the Faculty notes that as a condition of its submission to the Patients Information Advisory Group the PHLS is preparing and field testing such material.

  Key Point 6. As regional functions develop and local health protection improves, the effective national co-ordination of surveillance and response provided by bodies such as CDSC (and Central Public Heath Laboratory for reference services) must not be compromised.

  The system of surveillance for communicable disease in the UK is considered amongst the best in the world. One of the reasons for this is its effectiveness of working at local level. It successfully integrates surveillance with action, employing a broad and highly active interpretation of surveillance "providing information for action" is best achieved by close operational involvement in the use of the data and analysis to ensure that both the surveillance and action are fit for purpose and evolve to support each other.

  Surveillance, however, is not static and in the UK it has matured considerably since it relied on routine notifications and laboratory reports alone. Communicable disease surveillance and response now relies on many complementary sources and serves multiple purposes. Getting Ahead of the Curve provides an opportunity to review current systems. The Faculty welcomes this, but would emphasise the importance of building on and improving what already exists (though this does not mean that redundant systems should not be halted), with particular support for developing local networks between laboratories and health protection teams.

  Excellent surveillance of infection in the community and primary care has been provided by the Royal College of General Practitioners Surveillance Unit[48], and latterly this has been joined by novel outputs from the NHS Direct service. However, this work does not receive long term support and needs to be strengthened by funding, which would put the RCGP Unit on a firmer footing. It should also be more closely integrated with the microbiological function.

  Key Point 7. Parliamentary time should be found for revising public health law as envisaged in Getting Ahead of the Curve.

  It has been recognised for some years that public health law is out of date and this was emphasised in Getting Ahead of the Curve. For example, it seems anomalous that legal responsibility for communicable disease control is with local authorities whilst most of the staff engaged in this area of work are working in the health sector, due to the failure to revise the legal position with sequential reorganisation of the NHS. Equally, the legal tools available to those responsible for local communicable disease control are considered inadequate when dealing with serious diseases such as multi-drug resistant infectious tuberculosis.

2.   WILL THESE PROBLEMS BE ADDRESSED BY THE GOVERNMENT'S RECENT ID STRATEGY, GETTING AHEAD OF THE CURVE?

  Potentially it will make a major difference. However, there should be recognition that 14 major initiatives were announced in January 2002, of which forming the HPA was only one. Therefore, answers to this question are inevitably subjective and based on opinion.

  It is important that the new structures in the HPA recognise: the importance of a national system of surveillance and other national networks of expertise; the link between reference and specialist work and routine public health microbiology; the collaboration necessary between epidemiology and public health microbiology at all levels; synergy between analyses for FWE and investigation of human outbreaks; the need to continue work on training, research and development, standards and evaluation, etc; the continuing role for external expert advice/committees; not to increase further the divide between curative and public health microbiology. Relationships with local public health departments are important since many generalists provide on-call cover and support in major incidents.

  There are legitimate concerns about whether the capacity within both the HPA and local departments will be sufficient to respond to surges. This recognises the truism that health protection is too important to be left to the HPA alone.

3.   IS THE UK BENEFITING FROM ADVANCES IN SURVEILLANCE AND DIAGNOSTIC TECHNOLOGIES?

  Key Point 8. Investments in new surveillance and diagnostic technologies should include specifications for meeting public health needs.

  There are many advances that have been made in both surveillance and diagnostic technologies, for example the use of web-based technology for surveillance and response and near patient testing. What does not always seem to be grasped by those commissioning these systems is that capacity to meet public health needs have to be built into these systems if they are to adequately protect, such as ensuring that infectious disease reporting is sustained when microbiological diagnoses are made at the bed-side rather than through a laboratory.

4.   SHOULD THE UK MAKE GREATER USE OF VACCINES?

  The mechanism in the UK for developing, introducing, implementing and monitoring vaccination programmes and introducing new vaccinations at a population level is one of the best in the world. Examples of good practice are the global first by the Department of Health in introducing a conjugate meningococcal C vaccine in 1999, which was praised by the Public Accounts Committee. The timely investigation and refutation of suggested adverse reactions associated with MMR has been far more effective than when concerns were raised over whooping cough vaccination in the 1970s and 1980s. In this respect the role of the Joint Committee on Vaccination and Immunisation is central for addressing decisions on vaccination. The PHLS and academic partners have also played a pivotal role in consortia for undertaking field trials of new vaccines, conducting surveillance relating to the programme and detecting and/or investigating possible adverse events.

  Nevertheless, the public remain sceptical about the safety of vaccines and many doctors and other health professionals have only a hazy notion of the scientific and epidemiological basis of official advice on vaccination and how it is arrived at. This is an unfortunate combination as the public has a healthy scepticism over what it reads in the papers and usually turns to their local CCDC, GP or health visitor for advice. There should be greater use of the internet in making information available for professionals and public alike. The new DoH web-site "mmrthefacts"[49] is one such example of good practice. However, the Faculty recognises that there is always public suspicion of "official" bodies and would wish that such initiatives should have demonstrable scientific independence. It also notes that the majority of the public still seek advice on vaccination from their primary care team and therefore believes that there should be more investment in training professionals on the front line to promulgate this information and respond to public concerns.

  The mechanisms for discreetly investigating plausible adverse vaccine effects have been developed and the response to the recent concern about MMR vaccine was far superior but these require long-term funding.

5.   WHICH INFECTIOUS DISEASES POSE THE BIGGEST THREATS IN THE FORESEEABLE FUTURE?

  An inevitable threat is influenza and it is inconceivable that there will not be another influenza pandemic in the coming years. What is uncertain is the degree of virulence and pathogenicity of any novel strain. With NHS health economies run with increasing efficiency on a "just in time" basis and with very high bed occupancy there is an increased likelihood that a pandemic could severely disrupt effects. Equally the ageing demographics of the UK population and the growing number of people living with chronic conditions means that it will be more vulnerable than in previous decades. An important issue is whether the UK would have the national industrial capacity to rapidly produce the right vaccine combination.

  Important areas under-emphasised in Getting Ahead of the Curve were gastrointestinal infections and bacterial sexually transmitted infections. The public health impact of gastrointestinal infection (comprising a large array of bacteria, viruses, protozoa and parasites) in England is considerable: one in five members of the population are affected by infectious intestinal disease per year. The annual cost to the UK is in the region of three-quarters of a billion pounds.

  Foodborne infection accounted for around 1.4 million cases of disease in 2000 with over 350,000 GP consultations and nearly 21,000 hospital admissions accounting for over 88,000 bed days. This disease burden is reflected in the Food Standards Agency's target to reduce foodborne illness by 20 per cent by April 2006, echoing public opinion and political concern.

  Genital chlamydia represents a major possible health gain through opportunistic screening in primary care which would reduce chronic ill-health and secondary infertility in women. Pilot studies in the Wirral and Portsmouth have demonstrated that these interventions are highly acceptable to the young adult population and professionals alike. The Faculty feels there is a clear case for the progressive roll out of these pilots in primary care (with careful monitoring) across the rest of England—what about Wales.

  Verotoxin producing E.coli (O157) is an uncommon infection in the UK, nevertheless infections result in a high burden of illness and subsequent chronic ill health especially in children (where it is the commonest source of acquired renal disease) and there is an ever present threat of outbreaks.

  The burden of infection caused by the blood borne hepatitis viruses hepatitis B and C is becoming apparent as treatment of these infections improves (and costs of treatment mount), and the extent of prevalent infections acquired in the 1980s through intravenous drug use becomes clearer. Hospital acquired infections are also a major public health concern and burden on the NHS.

6.   WHAT POLICY INTERVENTIONS WOULD HAVE THE GREATEST IMPACT ON PREVENTING OUTBREAKS OF AND DAMAGE CAUSED BY INFECTIOUS DISEASE IN THE UK?

  Key Point 9. The training aspects of communicable disease control need to be robust under the Getting Ahead of the Curve initiative. This should include manpower-planning linked to regional schemes for public health training in health protection of medical and non-medical trainees. There should be some joint training in public health and microbiology.

  The key roles of the Faculty are standards setting, education and training and it is concerned that there should be enough skilled personnel to deliver communicable disease control in every region. The need for this is acute, as many of the CsCDC appointed after the Acheson Report (1988) move towards the end of their working lives.

  Key Point 10. Health Protection requires partnership between the HPA, NHS, local government and other bodies. Consideration should be given to how each Regional Director of Public Health (RDPH) co-ordinates relevant parties and actions at the required level. There is a need to bring the two together. National standards should also be created which RDPHs would then be required to apply at a regional level.

  Communicable disease control is unusual because of the major role of clinicians and laboratory colleagues in delivering public health functions. Some, but not all, regions have established representative over-sight committees for communicable disease control and these are proving useful.

  Key Point 11. There needs to be robust local, regional and national safeguards to ensure that communicable disease control and public health microbiology functions and capacity are preserved during the major changes envisaged.

  The Faculty welcomes the changes in Getting Ahead of the Curve and that these are already going through with some pace. However, it has concerns that the safeguards in place to ensure that communicable disease control and public health microbiology functions may not be adequately protected. For example, close scrutiny at local, regional and national level will be needed to ensure that the transfer of public health microbiology from the PHLS to the NHS will not result in the loss of capacity and function—laboratories which have a public health ethos will enter into a working environment where clinical diagnosis and care are paramount priorities. Opportunities for training and research must be maintained. These are particular dangers when so much else is changing and the ability to monitor individual changes is reduced.

  Key Point 12. Provision of data for surveillance purposes should be seen as a central activity of the NHS Informatics, with appropriate investment for the development of public health as well as clinical care purposes. There will be a need for considerable investment early on in the life of the HPA to hold it together and to wire it into the NHS and other contributors to health protection.

  There is generally inadequate use of information communication technology (ICT) for electronic reporting. To a certain extent this represents a general under-use of the electronic communication needs in the heath services, and bodies like CDSC (national and regional) cannot run too far ahead of the rest of the NHS.

  Health protection suffers from a general lack of investment in the NHS. However, there has also been a lack of recognition of the need to include bodies like the PHLS in NHS investment. Investment in ICT is needed to improve feedback to those providing health protection at a local level if surveillance and response are to be improved. This will be especially important in the new HPA where substantial early investment will be needed to allow local health protection units to communicate with their colleagues in health protection partnerships. This is especially vital for some CsCDC who will risk losing their IT support as general public health administration moves away.

  The "cascade" philosophy (sending messages down a "chain of command") does not work well for urgent health protection messages. Much like a child's "slinky" sent down the stairs the message almost always gets stuck on one step, with the health protection practitioner or clinician actually getting the news from the media. Urgent messages should be agreed quickly but carefully (perhaps best achieved in discussion with one or two front-line staff) and then sent out electronically in parallel.

  Key Point 13. Work on human and animal health continues to need improved links with joint work programmes and budgets for surveillance and control at regional and local levels.

  Experience with Foot and Mouth Disease (FMD), Classical Swine Fever (not zoonoses) and West Nile Virus in the USA[50], and most recently bat rabies (EBL)[51] indicate that the UK has to be alert to the risk of the introduction of zoonotic animal diseases.

  Despite the experience of BSE and FMD, the degree of joined-up working on zoonoses between animal and human health needs further improvement. This is especially the case when an animal disease may have little economic importance but has major consequences for human health, such as West Nile Virus and bat rabies.

  Key Point 14. Planning for deliberate release has been successful but much remains to be done. Plans and training for deliberate release and for other health protection events and emergencies (for example, the next influenza pandemic) should, as far as is possible, be integrated. Plans for the response to the unlikely event of a smallpox release should be made more public.

  The UK has made a good start in its planning for deliberate release. The materials that have been prepared are impressive and are used or copied across Europe. It is important that plans are readily and publicly available on websites, such as the PHLS website[52] and that of the Emergency Planning Co-ordination Unit,[53] as this is almost the only way of ensuring that plans are available when they are urgently needed. However, there is still a clear need for training and priority should be given to ensuring that deliberate release work does not become a separate activity, as is the case in some countries and at the European Commission. The recent announcement by the Chief Medical Officer on smallpox vaccination revealed one anomaly in that the detailed plans for this are not available (in contrast to those for the United States and some other countries). It would be helpful to know what the intention is to make the developing UK plans public.

  Key Point 15. An element of overseas development funding should be used to allow contributions of NHS bodies and bodies in the HPA (the CDSC, the Central Public Health Laboratory and the Regional Units of the HPA including the Regional Laboratory Services) to international work on communicable disease control.

  Key Point 16. The Department for International Development (DFID) and the DoH should have funding mechanisms that allow public health and microbiology bodies like the PHLS to make real contributions to international health.

  The Committee asked about the international dimension. It is recognised that communicable diseases must be tackled on an international level and the UK has membership of a number of key international bodies. On the technical side the PHLS has membership of formal and informal bodies such as The Five Nations Meetings (where the heads of the disease control centres for the UK and the Republic of Ireland meet up), the Network Committee of the European Commission and the Global Outbreak and Response Network (WHO-CSR). The NHS and the PHLS-HPA make some contributions to international work in developing countries and there are good examples of this such as tuberculosis control in Russia, the limited information management contribution from CDSC (and the larger clinical contribution of the NHS) to the recent epidemic of Ebola in Uganda.

  These contributions are not just altruistic. The global spread of infection is important to the UK and the only way that its laboratories and public health bodies can be exercised in dealing with exotic infections is through receipt of specimens from foreign countries and experience in the field.

  However, the contributions are minor compared to those that are made by other industrialised countries, notably France, the Nordic countries and the USA. This is partly due to the funding mechanisms of the DFID which either funds international bodies (such as WHO and UNAIDS) or supports short-term consultancies and projects through "resource centres". Bodies such as the PHLS and NHS, which are primarily supported to work in the UK cannot readily send staff to the developing world without prejudicing services in the UK. There should be more creative mechanisms developed by DFID, the DoH and the HPA to find ways of securing investment so that bodies such as CDSC and CPHL have the dedicated capacity to support international bodies such as WHO. We understand this would be welcomed by WHO whose Communicable Disease Surveillance and Response section[54] (WHO-CSR) wishes to make greater use of UK capacity.

October 2002













44   Department of Health Shifting the Balance of Power-securing delivery http://www.doh.gov.uk/shiftingthebalance/initialconsult.htm Back

45   Getting Ahead of the Curve, a strategy for combating infectious diseases (including other aspects of health protection) Department of Health, England, January 2002 http://www.doh.gov.uk/cmo/idstrategy/idstrategy2002.pdf Back

46   CDSC Infection Control in the Community Study. June 2002 http://www.phls.co.uk/publications/pdf/ICICreport.pdf Back

47   The British Paediatric Surveillance Unit, the CJD Surveillance Unit, the British Neurological Surveillance Unit, the Confidential Enquiry into Deaths and Stillbirths (CEDSI). Back

48   RCGP Annual Report. Back

49   http://www.mmrthefacts.nhs.uk/ Back

50   http://www.phls.co.uk/publications/cdr/archive02/News/news3502.html#WNV Back

51   http://www.phls.co.uk/publications/cdr/pages/news.html#bats Back

52   http://www.phls.co.uk/topics-az/deliberate-release/menu.htm Back

53   http://www.doh.gov.uk/epcu/cbr/intro.htm Back

54   http://www.who.int/emc/index.html Back


 
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