Select Committee on Science and Technology Written Evidence

Memorandum by Dr Michael O'Brien, Public Health Physician


  1.1  I welcome the opportunity to comment to The Science and Technology Sub-Committee 1 Fighting Infection. Not only does this give an opportunity to comment on the Chief Medical Officer's document Getting Ahead of the Curve1 but also on its sequel Health Protection: A Consultation Document on creating a health protection agency. 2


  2.1  The timing of proposed changes is worthy of comment.

  2.2  PHLS was created in 1939 when there was a of threat of war which might have had a biological component. It is somewhat ironic that Health Protection (Chapter 4, Paragraph 4.45) 2 proposes its demise at a time of threat of bioterrorism. The uncertainty and insecurity resulting from disruption of existing services, coupled with the lack of both legal duty and clarity of accountability (see below, comments 4 and 5) would present an ideal opportunity to someone bent on mischief to launch an attack.


  3.1  The risks to human health of not making changes are hypothetical (Annex E, Paragraph 2.i). 2 No evidence is adduced either to clarify current failings or to identify issues falling into gaps between services.

  3.2  No firm evidence is adduced that the proposed changes will bring more than theoretical benefits.

  3.3  It is disingenuous to suggest that the creation of a new Agency would facilitate access to specialist advice and services for field workers. At present local people have to access a variety of specialists in a range of organisations and a number of locations. Under the proposed system they would have to access the same specialists in the same locations (or even more if microbiology services are dispersed). The new Agency will merely provide a common letterhead. If it seeks to act as more than a loose employing umbrella it will risk delaying communication between the field and its sources of expertise in times of crisis.

  3.4  The creation of a new Agency will not of itself create generic staff who can deal with infectious, toxicological and radiological problems. It will not even bring specialist staff together under one roof since the proposals are to be cost neutral, militating against acquisition of new premises. The tiny savings resulting from the reduction of quangos will not contribute significantly to either capital or revenue costs.

  3.5  The maintenance of cadres of specialist expertise is of paramount importance.

  3.6  Where adequate training and development of staff do not currently exist (Chapter 6, Paragraph 6.2iii) 2 the solution lies with management action, not in the creation of a new Agency.

  3.7  The creation of a new Agency will not of itself clarify whether a local incident is infectious or toxic (Chapter 6, Paragraph 6.11). 2 The situation will still need to be co-ordinated by people with vital local knowledge. Specialist contacts will still need to be made as stated above (comment 3.3).

  3.8  Current changes spread public health skills too thinly. They rely on networks which have inherent weaknesses because of the tensions between the needs and priorities of employers and those of the wider network.


  4.1  The Committee of Inquiry into the future development of the Public Health function, reporting in January 1988 under the title Public Health in England3, pointed out that some of the relevant legislation on infection control dated from the nineteenth century and most of it predated the establishment of the National Health Service. As a consequence a Review of the Law on Infectious Disease Control4 was published the following year. A significant assertion of this review was that no-one had a statutory duty to control infection. The review process was not taken to a conclusion and the law remains unchanged.

  4.2  Roles in surveillance, the provision of support and advice for other Agencies and the public and the provision of certain national services are proposed for the Health Protection Agency. In other words the latest consultation document does not identify a duty to control infection either for existing organisations or for the new Agency.

  4.3  Instead, it states (Chapter 3, Paragraph 3.32) 2 that there will be a review of public health law once the new Agency is in place; a tacit admission that the position will not have advanced from that of 13 years ago and legislation is long overdue.

  4.4  Ideally, the adage that form follows function would dictate the content and therefore the structure of the service. However, current proposals for the establishment of a Health Protection Agency put structure first; and, at least in part, are simply a hasty reaction to the events of September 11 2001 in New York.

  4.5  In 1999 a Communicable Diseases Strategy Group was convened to help in drafting a strategy to deal with the new and re-emerging infections that were plaguing society. Some months later, with little progress having been made, the Group fell into abeyance. There is a need for such a group to be reconvened to describe:

    (i)  current and foreseeable risks; and

    (ii)  a coherent pattern of relevant services.

  This would set the context within which public health law should be updated to provide for:

    (iii)  a legal duty to investigate and control infection; and

    (iv)  clarification of accountability between local, regional and central authorities.

  4.6  Given past history it is clear that whenever new legislation is enacted it will have to be not only relevant to the public health of the twenty first century but robust enough to remain valid through further service changes and for a long time to come. It will have to achieve a balance between potentially conflicting interests, in particular those of the devolved administrations, local democratic control of services and expert professional control of situations. Enacting law to identify a duty to control infection will call for consideration of the inclusion of enforcement powers in the remit of any new Agency as a feature of control, together with surveillance, investigation, diagnosis, treatment, rehabilitation, continuing care and the supporting research and development.


  5.1  In 1988 The Committee of Inquiry3 found, inter alia, that there was a "lack of unambiguous accountability" in the field of communicable disease control. Current proposals do nothing to clarify accountability.

  5.2  Apart from reference to a "clear line of sight" from field level to the Chief Medical Officer in Getting Ahead of the Curve1 and despite reference to "a sharper focus" in Health Protection (Chapter 6, Paragraph 6.8) 2 current proposals do not identify any lines of accountability within or between Primary Care Trusts, Local Authorities, Hospital Trusts, Regional Offices, Government Departments or the proposed Health Protection Agency.

  5.3  A Health Protection Agency will join the Food Standards Agency and DEFRA, both of which already express a legitimate interest in infection and toxic contamination of food and animals produced for food. This poses a set of questions which need to be settled before any new Agency is established.

  5.3.1  Will accountability for outbreak or incident investigation be from field level directly to the new agency; to one or more Government Departments; to Government regional offices; to strategic Health Authorities or to Local Authorities?

  5.3.2  In particular, who will be responsible for gastro-intestinal infection, not all of which is food borne and some of which is bound up with animal health—the new Agency, the Food Standards Agency, the NHS or DEFRA?

  5.3.3  If there is to be a sharing of responsibility how is it to be apportioned?

  5.3.4  In the event of dispute who will adjudicate?


  6.1  One of the principles suggested in Getting Ahead of the Curve1 was a single co-ordinated focus for surveillance. It is reiterated in the Consultation Document (Chapter 4, Paragraph 4.10 and Chapter 6, Paragraph 6.13) 2.

  6.2  Most infectious disease surveillance is currently undertaken for the Department of Health by PHLS/CDSC.

  6.2.2  In this context gastro-intestinal diseases are of interest. Despite their scale and seriousness5 they are not given priority by the Department of Health in Getting Ahead of the Curve. 1 Understandably, the Food Standards Agency requires surveillance of foodborne human illness and of zoonoses (not in live animals). DEFRA is understood to be developing its surveillance systems, acknowledging the relationship between animal and human health. As with accountability, above, a set of questions arises.

  6.1.2  What of the single co-ordinated focus for surveillance?

  6.1.3  Who will be responsible for surveillance of gastro-intestinal disease? Will it be the new Agency or the Food Standards Agency?

  6.1.4  Will DEFRA have a role in human health because of its interest in zoonoses?

  6.1.5  If more than one surveillance system is to operate who will co-ordinate their outputs?

  6.2  The relationship between preventative strategies, surveillance, diagnosis, treatment of disease, rehabilitation and continuing care is best described in a Health Care Programme (HCP) similar to that developed in the 1990s for the Academy of Medical Royal Colleges. 6 The use of HCPs allows all aspects of health care to be related to each other coherently and in a condition-specific context.

  6.2.1  In late 1999 a working party of the Chief Medical Officer's Communicable Diseases Strategy Group briefly examined the application of the HCP approach to exemplar infections. Because the Group fell into abeyance the work was not taken to a conclusion.

  6.3  The interdependence of specialist advice and surveillance is recognised (Health Protection, Chapter 6, Paragraph 6.14). 2 Somewhat surprisingly the same feeling is not extended to reference microbiology, described merely as of value to surveillance. In fact they are as interdependent as surveillance and advice. The best solution would be the full integration of the surveillance and reference microbiology functions in a single central resource which would consolidate the recently broadcast graphic example of good practice. 7 For the recognition of high risk, low incidence events recognisable and manageable only on a national scale this integration is vital.

  6.3.1  Conversely, the separation of surveillance and reference microbiology and the dispersal of some of the latter functions to other organisations (eg University Departments under a bidding process) would hamper communications and risk the unnoticed emergence of situations like the multidrug-resistant Salm. Newport in the USA. 8


  7.1  The adoption of standard operating procedures for laboratories is to be applauded. In view of the proposals for dispersal of PHLS resources to NHS Trusts2,9 it must be hoped that standard reporting procedures for isolates of public health significance will become mandatory. Although not suggested in the current proposals, the adoption of standard public reporting procedures for outbreak control teams would be another useful measure to aid clinical audit, openness of information and to educate the public.


  1.   Getting Ahead of the Curve: A strategy for combating infectious diseases including other aspects of health protection). A report by the Chief Medical Officer. Department of Health; London, 2002.

  2.   Health protection: A Consultation Document on creating a health protection agency. Department of Health; London 2002.

  3.   Public Health in England: The Report of the Committee of Inquiry into the future development of the Public Health function. HMSO; London. 1988.

  4.   Review of Law on Infectious Disease Control: Consultation Document. Department of Health; London. 1989.

  5.  Adak G K, Long S M, O'Brien S J Trends in Indigenous Foodborne Disease and Deaths, England and Wales—1992 to 2000. International Conference on Emerging Infectious Diseases, Atlanta, Georgia, 2002.

  6.   Health Care Programmes in the NHS. (vols 1 3) Academy of Medical Royal Colleges; London. 1997.

  7.  Fyfield F. Footprints. BBC Radio 4, 7/1/02, 8pm.

  8.  Zansky S et al Outbreak of Multidrug-Resistant Salmonella Newport—United States, Jan-April 2002. MMWR. June 28, 2002/51(25); 545-548.

  9.   Getting Ahead of the Curve: Future arrangements for Microbiology Laboratory Services. Department of Health, London. 2002.

October 2002

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