Memorandum by Professor Jennifer A Roberts,
London School of Hygiene and Tropical Medicine
"The strategy outlined in "Getting Ahead
of the Curve"1 represents a great stride forward. It poses
formidable challenges. The critical issues of governance, resources
and training must be resolved now before health authorities are
dissolved at the end of March". (Roberts and Haworth, 2002).
The above quotation is from a paper that I wrote
with a colleague in March 2002 as a response to the proposed structure
for health protection, outlined in the Strategy Document "Getting
Ahead of the Curve", (GAC) (DOH, 2002). The strategic approach
outlined in GAC is an attempt to orchestrate a system that integrates
the protection of the public from threats of infectious disease,
chemical and radiological disasters and bio-terrorism. The overall
strategy includes improved surveillance and the development of
strategies for many disease groups. Our reservations were not
directed at the grand design but at the practicalities of its
implementation. This memorandum of evidence concentrates on these
organisational issues that are very important if the policy is
to be effective.
The pathways of infection control prior to the
proposed changes were well designed and were supported by a network
of key medical and laboratory professionals. It provided a rapid
and largely effective response to outbreaks of infection and a
framework that limited secondary spread of infection and an effective
mechanism for caring for those affected.
With the demise of Health Authorities and before
the Health Protection Agency is set up in 2003, residual Health
Authorities and Primary Care Trusts (PCTs) are operating the system.
Adequate handover arrangements were lacking and the system has
been held together by the professionalism of the infection control
specialists, many of whom have been located in inappropriate facilities,
often with inadequate telephone and computer lines of communication,
and who are uncertain about the system in which they will be expected
to operate in future.
The Department of Health has been organising
workshops and consultation groups with an aim of achieving good
strategic plans for the various infections and has achieved some
progress in producing such strategy documents, eg the recent Hepatitis
C strategy. However, for any of these strategies to operate effectively
proper accountability and financial support must be in place.
A hard-pressed PCT is unlikely to place infection control high
up on its list of priorities unless it is contracted to provide
it and funded for it. There is already evidence of some PCTs being
unwilling to provide adequate support for hospital acquired infection.
Hospital infectious disease doctors and microbiologists, very
busy and increasingly difficult to recruit professionals, are
spending time trying to persuade PCTs to provide meagre resources
for them to operate effective control teams in hospitals. Yet
hospital infection control is of paramount importance in containing
the spread of antimicrobial resistance such as MRSA. It is unclear
whether the response to community outbreaks will be as rapid or
as effective operating via a number of PCTs that are not clearly
mandated to provide resources. Delays may be encountered. The
reporting of suspicious cases by health professionals could be
sidetracked by internal mechanisms in PCTs before being communicated
to Consultants in Communicable Disease Control (CsCDC). Policies
for control of hospital acquired infection and antibiotic prescribing
need close collaboration between CsCDC, Infection Control Doctors
(ICDs) and the rest of the infection control team. New clinical
governance and quality assurance systems and the specific responsibility
of chief executives for infection control should improve the overall
management of infection control in hospitals (Taylor et al,
2001), but the links with the Health Protection Agency and CsCDC
are not clear. Over the past 10 years contracts or service agreements,
reorganisations, amalgamations and public/private partnerships
have weakened relationships. Fracturing of relationships following
the introduction of managed care and the privatisation of public
health laboratories was identified as a problem in public health
systems in the USA (Davis J R, Lederman J 2000). We must endeavour
not to fracture relationships and to foster new links.
In addition to weakening relationships and networks
the changes have weakened the epidemiological basis for the surveillance
systems and made estimates of coverage for vaccination programmes
difficult to establish as a consistent time series for a defined
The use of generic staff at PCTs to provide
surge capacity and handle health protection, whilst being useful
if there is an outbreak, may not be appropriate for the day-to-day
management of infection control. Such a policy runs counter to
the general trend in the NHS that recommends the use of specialists
with an adequate case load to ensure their technical competence.
To add to the infectious disease burden other complex fields of
chemical, radiological and bioterrorism compounds these problems
and seems to stretch the abilities of front line workers.
The resources to staff the new service seem
to be "neutral" (no more than in the previous system);
no extra funding seems to be forthcoming. However, the staffing
levels in the previous organisation were not adequate. "In
2001, 54 per cent of CsCDC were responsible for populations of
more than 500,000. CsCDC support teams are small, usually a secretary
and perhaps a public health nurse5. In hospitals 30 per cent of
ICDs were responsible for more than one acute hospital and 55
per cent were also responsible for community trusts. They were
supported by only one or two infection control nurses (ICN)"
(Roberts and Haworth, 2002).
It is considered that at least 1,000 environmental
officers are needed to staff this important complementary service.
Both new staff and existing staff who are expected to play a role
in health protection require training. This means more than the
short courses that are taking place.
The provision of health protection is to be
ensured via contracts between the Health Protection Agency and
the Regional Health Authority and the PCTs. Contracts in this
problematic area do not always ensure adequate performance but
contracts not informed by those with expert knowledge in the field
are less likely to be effective. Yet the expertise of CsCDC, ICDs
and ICNs was rarely used to inform contracts in the previous system.
It is unclear how specialist advice and input into contracts will
be obtained. In addition hospital Infection Control Teams found
it difficult to obtain funds from the various budget holders within
the hospital sector. Infection control affects everyone in the
organisation and increasingly those outside the hospital in nursing
homes etc, yet funding was dependent on separate budget holders
who were reluctant to accept the common responsibility for infection
control. In the past Health Authorities used contingency funding
to support outbreak investigation and control. Will PCTs be willing
to underwrite these activities? These budgetary constraints must
be dealt with in both hospitals and PCTs.
Governance within PCTs for infection control
is not clear. It is important that someone has authority and can
take control and mobilise resources if an outbreak occurs. At
present even information is cascading down to staff in what appears
to be a haphazard manner sometimes, to CEO, DrPHs and sometimes
to CsSDC. Apart from the contract between Regions and PCTs governance
is unclear either within PCTs or between PCTs and HPA professionals.
It is essential that someone has the authority to take control
if an incident occurs. But who will have such authority has not
been specified. CsCDC might be expected to have executive responsibility
for health protection at PCT level with access to the PCT board
and supported by the Director of Public Health (DrPH). But they
have no executive authority and may relate to many PCTs. This
issue must be resolved.
Thus if the benefits of GAC are to be recouped
attention must be paid to implementation: governance and accountability,
resources and training.
Alford K Plowman R M, Roberts J A. The Way
Ahead, Progress towards the control of Hospital Acquired Infection,
National Audit Office, London, 2001. ISBN 0-11-702858-4.
Davis JR, Lederman J Public Health systems
and emerging Infections Assessing The Capabilities of the Public
and Private Sectors. Workshop Summary, Institute of Medicine,
National Academy Press Washington DC 2000.
Department of Health "Getting Ahead
of the Curve". A strategy for combating infectious diseases
(including other aspects of health protection) A report by
the Chief Medical Officer http://www.doh.gov.uk/cmo/idstrategy/idstrategy2002.
Roberts J A Haworth "Getting ahead of the
Curve"Lancet Infectious Disease Vol 2 (4) p