CHAPTER 9: COLLABORATION
AND COORDINATION |
Improving infectious disease services requires
flexible multi-disciplinary teams. This involves developing better
collaboration at all levels. This will be complex because of the
breadth of expertise needed. The Minister for Public Health should
take a lead in improving collaboration across all relevant departments.
The HPA, as a new organisation, also has opportunities to set
standards and clarify lines of accountability in the services
and to develop a strategy for collaborative work with those outside
of the HPA.
On a local level there is need to develop both
breadth and depth of expertise. We recommend that the Government
establishes a number of infection centres to provide a critical
mass of expertise and to improve collaboration by including professionals
from universities, hospitals and community settings.
International collaboration provides opportunities
to help tackle some infection at its source before it spreads
across the world. Involvement in international events benefits
national services by developing expertise. We recommend providing
formal means to allow health professionals to be seconded overseas.
and inter-organisational collaboration
9.1 The responsibilities for different aspects of
protection against infectious disease are divided amongst a number
of Government departments and organisations [see Box 14]. Because
of the number of organisations which have broader responsibilities
than just infection we heard that there is a danger that infection
will not always be a high priority. We heard that lines of communication
and accountability are often unclear and collaboration inadequate
[Emery, II p112, Emery, Gelletlie, Hawker, Monk Q229-231].
9.2 Infectious agents do not respect boundaries between
community and hospital settings. Yet we heard that there is very
little collaboration between hospital and community infection
disease services, with microbiologists providing the only formal
link. We note that there are some recently established initiatives
to encourage rotation of infection control nurses between hospital
and community settings in order to broaden experience and develop
collaborative relationships [Naylor, Q672].
Main organisations in England with some responsibility for human infectious disease services
Government Departments (Health, DEFRA, Home Office, DfID)
Health Protection Agency
Veterinary Laboratory Agency
Strategic Health Authorities
Primary Care Trusts
NHS Hospital Trusts
Local Authorities (environmental health)
Food Standards Agency
Health and Safety Executive
Prison Medical Service
9.3 In addition to those Departments listed in Box
14 we note that the Department for Trade and Industry and the
Office of Science and Technology are responsible for technology
development and the research councils respectively. In addition
the Office of the Deputy Prime Minister oversees local government
issues, and thus is ultimately responsible for environmental health.
9.4 We note that the role of Minister for Public
Health was in part developed to ensure cross-departmental working
and whilst we heard some positive reports about improvements in
relation to surveillance it is clear that departmental collaboration
is still insufficient and must be significantly strengthened [see
9.5 We recommend that the Minister for Public
Health should publish an annual account of all progress in cross-departmental
working in relation to infectious disease.
LINES OF COMMUNICATION AND ACCOUNTABILITY
9.6 Lines of communication and accountability between
organisations are complex and unclear [see Boxes 2 and 3]. Witnesses
suggest that this should be addressed, particularly in relation
to the role of Primary Care Trusts [Beeching, II p50; Bradford
MDC, I p34-5; Brit Inf Soc, I p37; Emery, II p112, Q229; Faculty
Pub Health Med, I p52-6; Gelletlie, Q229; Hawker, II p118, Q258;
National Audit Office, II p 372; Roberts, I p139]. We are concerned
that this lack of clarity inhibits full, effective and formal
collaboration. All of those organisations that are involved in
infection control should be clear about their roles and responsibilities
and how they fit into the service as a whole. Whilst the HPA clearly
has a key role in ensuring effective overall infection control
services are in place, it can only achieve this through commitment
and cooperation of others.
9.7 We recommend that the Minister for Public
Health should publish as a matter of urgency a document outlining
roles and responsibilities of all organisations involved in infectious
disease services and should disseminate this to those concerned
in order to facilitate effective communication and collaboration.
9.8 The Health Protection Agency should be able to
provide opportunities to develop closer working relationships
between different areas of the services: indeed many witnesses
welcomed it for that reason. The Health Protection Agency is still
establishing itself and it has a huge task ahead in order to live
up to its promise. We have some concern about the speed in which
it was established with perhaps insufficient consultation but
believe that it is now important to focus on developing the most
effective agency possible.
9.9 We note that there was some concern expressed
about environmental health remaining divorced from public health
following the creation of the HPA [Bradford MDC, I p34; Emery,
II p111; Q232]. The suggestion was made that there perhaps could
have been bolder moves to develop formal links between organisations
responsible for food-borne infection [Humphrey, II p366; Inst
Food Res, I p95].
9.10 Structural changes to organisations may bring
benefits but they can also lead to confusion over lines of responsibility
and thus can disrupt long established collaborative relationships
[Hawker Q231]. The National Audit Office was extremely concerned
that the HPA had been established without clarifying lines of
responsibility between that body, other organisations and individual
professionals [II p372]. Our recommendation above should rectify
9.11 We heard that exchange of information and collaboration
between England, Northern Ireland, Scotland and Wales has historically
been satisfactory, owing to good relations between relevant organisations
[Donaghy, Q701; Salmon, Q700]. However, we note that the House
of Lords Constitution Committee recommended in its report on Devolution
that there should be formal mechanisms for intergovernmental working
in case more informal mechanisms broke down. We support this view
in relation to infection and believe that the HPA has a role to
develop formal collaborative relationships with relevant organisations
in devolved administrations [Soc Gen Microb, I p157].
9.12 We recommend that the HPA publishes by April
2004 a proposal for developing collaborative relationships with
organisations concerned with tackling infection, including the
devolved administrations, environmental health departments and
the Food Standards Agency.
and deepening expertise
9.13 We note that one of the difficulties with fighting
infection is that it is difficult to predict when and where infection
will arise. The first sign of a major epidemic may present to
a GP, an epidemiologist, an outpatients' clinic, an ID physician
or a veterinarian. Therefore breadth of expertise in infection
is required. It is also fundamental to have collaborative structures
in place. If, for example, a GP sees something unusual, they should
know how to access the appropriate expert.
9.14 One of the properties of infectious disease
is its potential for sudden unexpected increases in cases, outbreaks
and epidemics. If significant numbers of people are exposed to
an infectious agent they are potentially infected and may require
investigation, preventative treatment and reassurance. This means
that services need surge capacity. Surge capacity should exist
at all levels: in clinical, laboratory and epidemiological services,
and in the production and delivery of interventions such as vaccines
[AcMedSci, II p353-4].
9.15 Surge capacity can be provided if all staff
are well trained. There is also a need for improved collaboration,
so that areas of the country under increased pressure can receive
assistance from other areas.
9.16 We recommend that the Government recognises
and addresses the fact that, although England has not experienced
major epidemics of infection in recent years, this owes as much
to good fortune as to good management. Without improvements we
fear that this country will suffer from major epidemics and will
continue to see infectious disease take its toll in economic terms,
in suffering and in lives.
ANTHROPOLOGISTS AND INSECT EXPERTS
9.17 Throughout this inquiry we heard that the infection
team should not be confined to medical nursing infection specialists.
In part broadening expertise can be tackled by improving education
and training in infectious disease of all health professionals
medical and nursing specialists and we have discussed this in
chapter six. Relevant expertise is however wider than doctors,
nurses and basic scientists. Many different people have played
key roles in identifying and helping to control infections including
mothers and anthropologists.
9.18 In Connecticut, USA,
mothers helped to identify Lyme disease when they spoke to the
local epidemiologist about the unusual number of children in a
small area diagnosed with juvenile rheumatoid arthritisa
rare condition. The epidemiologist investigated further and found
that all these children had been exposed to ticks and suffered
from an unusual rash. This led to identifying Lyme Disease.
Anthropologists working amongst women in New Guinea highlighted
the way that Kuru disease, a rare degenerative, and fatal brain
disorder is transmitted, when they described the practice of eating
and smearing on their bodies the brains of dead relatives.
9.19 There are concerns about shortages of specialists
who could provide help to infection services. For example, we
heard in the US that entomologists are necessary to help understand
and control insect-borne diseases such as West Nile virus, yet
there is a nationwide shortage [USA, II p386]. The situation in
the United Kingdom is much the same, as we outlined in our reports
Systematic Biology Research
and What on Earth?.
The need for such expertise was recently highlighted in the Chief
Medical Officer's Annual Report 2002, Health Check: On the
State of the Public Health.
centres: improving communication, developing teams and expertise
9.20 Whilst broadening understanding may be necessary,
we heard that national expertise in infectious disease should
also be improved and access to that expertise made easier [Bri
Infect Soc, I p37-8]. The Academy of Medical Sciences and others
raised the idea of developing "infection centres" [Cohen,
Q55; Lachmann, Q54, Birmingham, II p394]. These would be similar
to the model used to develop cancer services and should be placed
within a geographical area such as that served by a Strategic
9.21 We support the establishment of infection centres
as they would provide an excellent opportunity to
(a) develop expertise in clinical services and
(b) improve collaboration between hospital, community
and university settings
(c) provide training of infection specialists
9.22 We envisage that infection centres should be
associated with an academic institution and should provide a clinical
infection service for adults and children to the local district.
In addition they should provide high quality training in order
to ensure a supply of sufficient well trained health professionals
to meet current and future requirements. Research should be actively
encouraged and should span clinical infection (adult and paediatric),
microbiology (including infection control), virology, and public
9.23 Centres should be closely allied to the HPA
in order to improve the interface between clinical, laboratory
and public health based infectious disease services. Ideally there
should be close collaboration with other relevant specialists
such as in hepatitis, HIV, tuberculosis and paediatrics. These
centres should also seek to facilitate relationships between specialists
in human and animal infection and others who could help with outbreaks,
such as entomologists.
9.24 We recommend that the Department of Health
encourages and facilitates the development of infection centres
which integrate scientists (virologists, microbiologists), clinicians
and epidemiologists. These should be associated with academic
and tertiary referral centres and the regional HPA laboratories.
Each Strategic Health Authority should have access to services
of one of these.
9.25 It is a truism that infectious diseases do not
respect borders. Whilst the focus of our inquiry and of this report
is infectious disease as it affects England, it is not possible
to ignore the global dimension [AcMedSci, II p33-4; Stewart, II
p316]. Every year sixty-four million passengers pass through Heathrow
Airport alone. Significant amounts of food and other goods arrive
in the UK daily from all parts of the world. This global movement
of people and goods also provides opportunities for global movement
of infections, whether through spread of infections such as influenza
viruses or through global travellers and immigrants importing
unusual "exotic" infections [Int Org Migration, II p392,
see Box 16].
9.26 International collaboration and aid brings significant
benefits to the donors as well and improves chances of a country
being able to adequately fight infection. A successful infection
disease service needs to accept that disease can, and will, be
imported and thus health care professionals need to be able to
identify, advise and protect individuals from exotic diseases
[Blears, Q863-9; PHLS, Q322; Troop, Q818-9]. The US Congress acknowledged
the importance of such international collaboration and formally
established a budget to allow the Centers for Disease Control
to engage in international work [USA, II p387].
9.27 As was recently exemplified by SARS, contributing
to international work helps to provide early warning of emergence
of possible epidemics, thus allowing implementation of control
9.28 England currently collaborates significantly
on the international stage, in particular through support to the
World Health Organization (WHO) which DfID and the Department
of Health support [DfID, II p360; WHO, II p391]. England also
houses one of WHO's collaborating centres on influenza, based
in the World Influenza Centre (WIC) at Mill Hill. There is, at
present, some discussion as to whether the WIC should be moved.
We suggest that when making this decision, consideration should
be given to ensuring that expertise is maintained in order to
continue such high-profile collaboration.
9.29 In response to the threat from infectious disease,
WHO has developed an international network of experts who alert
others to possible outbreaks and provide response services to
those outbreaks. The Communicable Disease Surveillance Centre,
HPA is a member of this Global Outbreak and Response Network (GOARN)
[WHO, II p391].
9.30 WHO told us that it was imperative that GOARN
could access short term aid from partners, such as through providing
laboratory analysis support and experts on secondment. The UK
has helped to facilitate this and has provided "excellent
support" to GOARN in relation to the recent SARS outbreak
[WHO, II p377, 391].
9.31 We also heard that much collaboration with WHO
is through individual HPA staff who have formed ad hoc
relationships [Duerden, Q322, Troop, Q818-9]. It has, in the past,
often been difficult to release PHLS staff to enable further international
collaboration. Dr Troop, Chief Executive of the HPA, told us that
in order to increase international activity "we either need
to create some internal capacity or we need to increase funding
in order to free up more people to be able to do it in a more
systematic way" [Q766].
9.32 We were pleased to hear that Dr Troop was committed
to improving formal means by which the HPA could both benefit
from and assist in international collaboration [Troop, Q766] and
that the Minister was committed to the infection community making
a "proper contribution" to international collaboration
in this sphere [Blears, Q863-9]. We note that there is also expertise
outside the HPA, such as at the Schools of Hygiene and Tropical
Medicine, which could be drawn upon.
9.33 We recommend that the Government enables
the HPA to second health professionals to international bodies
such as WHO and provides the resources to make this possible.
9.34 Infection is spread not only by movement of
people but also by food and animal trade. This has recently been
highlighted by an outbreak of monkeypox in the US (see Box 11).
9.35 When we visited the WHO we heard that many trade
agreements do not adequately consider public health implications
[WHO, II p391]. Defra take the lead in relevant World Trade Organization
meetings, with the Food Standards Agency providing public health
aspect [Defra, II p355]. We are concerned that the views of the
Department of Health are not sought as standard and suggest that
this should be addressed.
9.36 At present there is a significant amount of
discussion about the nature of EU wide collaboration [Brussels,
II p381]. Closer relationships between EU countries have led to
increased ease of movement of people and goods and means that
the risks of infectious diseases within Europe are increasing.
This risk may increase following the entrance of new countries
where there are higher rates of various infectious disease and
lower levels of disease control than other EU countries [Nicoll,
9.37 The EU is considering developing a European
centre for infectious disease to enable closer collaboration relating
to surveillance and control measures. This is an important component
of fighting infection but we note that a large, heavily staffed,
CDC-type venture could contribute to loss of experts in infectious
disease from nation states. As of present experts in England are
in short supply. Furthermore the response to SARS demonstrated
to us that much could be achieved through facilitating collaboration
between laboratories. Duplicating facilities by creating European
level laboratories may not produce further significant benefit
to effective collaboration.
18 House of Lords Select Committee on the Constitution,
Devolution: Inter-Institutional Relations in the United Kingdom,
Second Report 2002-03, HL Paper 28 Back
House of Lords Select Committee on Science and Technology, Systematic
Biology Research, First Report 1991-92,
HL 22-I Back
House of Lords Select Committee on Science and Technology, What
on Earth: The threat to the science underpinning conservation,
Third Report 2001-02, HL 118 Back