Memorandum by Bradford Metropolitan District
1. What are the main problems facing the
surveillance, treatment and prevention of human infectious disease
in the UK?
Under resourcing of Public Health
particularly for investigative and surveillance work at local
level. Much investigative and surveillance work is carried out
by Environmental Health Officers employed within Local Authority
Departments. There is an ever increasing workload of ever increasing
complexity placed upon these departments. The work does not enjoy
the high profile of, for example, Education and therefore funding
is difficult to attract or keep. Staffing levels are often inadequate
to ensure proper surveillance leading to the possibility of clusters
of disease not being properly identified with the consequence
that preventive measures are not put in place.
Marginalisation of Local Authorities
in the proposal for Public Health reform. The work done by Local
Authorities through their Environmental Health Officers is not
reflected in this document. They seem to be included almost as
an after thought. To remove Local Authorities from Public Health
involvement is to remove the local dimension from surveillance,
cut out important links with the food industry and to remove local
Attention not proportionate to clinical/public
health. The main thrust of the document seems to be on fixing
it when it is broken, Public Health is about not letting it break
in the first place. Public Health needs to be in partnership with
Primary Care, not subservient to it.
Surveillance is often ponderous,
timescales need to be shortened for passing information between
various partners. Information Technology is not used to full potential,
various parts of the service cannot transfer information to other
parts quickly and securely. Results of analysis are often slow
to reach the surveillance agencies, often leaving a cold trail
to follow when investigating possible sources and vehicles of
infection. Limited staffing resources exacerbate such problems
as often the urgent takes precedent over the important, that is
we attend to today's crisis without having the time to fully evaluate
yesterday's crisis, possibly missing important links between the
two. Simply changing the personnel who undertake these tasks will
not solve these problems, it is the system which needs changing
and adequately resourcing.
Issues around medical confidentiality
can cause difficulties. There are occasions when the clinical
arm is reluctant to share information with the Local Authority
side of the surveillance arm on the grounds of medical confidentiality.
There needs to be better definition of medical confidentiality
so that Environmental Health Officers can have access to the information
they need. These are professional officers who deal in confidential
information as a matter of course in their working lives and can
be trusted with the limited amount of information that would be
required to ensure thorough investigation and surveillance.
An urgent review is needed of the
outdated legislation that is being used. Present legislation dates
beck to the 1980's but has its roots much further back in time.
Legislation is needed that reflects the global nature of 21st
Century lifestyles and that balances the rights of the individual
with the right and duty of the state to protect the health of
all its citizens.
2. Are these problems adequately addressed
by Getting Ahead of the Curve?
Resourcing issues are not addressed.
The development of the regional aspect of public health working
is welcome and important but unless adequately resourced will
not achieve its full or desired potential. The greater the number
of channels of communication that need to be maintained the greater
is the need for adequate staff numbers with satisfactory means
of communication. To provide compatible information technology
is a huge, resource intensive issue which does not seem to have
been addressed by this document
Existing systems are either fragmented
or subsumed into clinical areas. There is potential for diminution
of service from PHLS with diminishing expertise in and importance
given to, food and environmental sampling and analysis. This expertise
is fundamental to Local Authority investigative and surveillance
work, it provides the link between the food we eat or the environmental
conditions in which we work with the diseases that affect the
public, often in large numbers. The logistics involved in transporting
specimens to an appropriate laboratory could prevent some Local
Authorities from taking samples as they would not be able to comply
with time limits from sampling to laboratory. There will no doubt
be advantages to the detection of hospital acquired infection
but this seems to be at the cost of diminution of service to the
Local Authorities. If the existing expertise in Public Health
is fully utilised then there are major benefits to be had, if
not valuable time will be lost as new staff find the pitfalls
by falling into them.
3. Is the UK benefiting from advances in
surveillance and diagnostic technologies: if not what are the
obstacles to its doing so?
Information is transferred slowly,
better and more importantly compatible IT is needed. Surveillance
and diagnostic technologies are developing and there is little
doubt that the UK is benefiting from them. The caveat is that
we do not move the information about in a suitable manner. The
issues surrounding this have been discussed above.
Better understanding of what each
part of the service needs to know and why they need to know it.
There is a need for each part of the Public Health Alliance to
know what its partners do and why they do it. It is a fairly straightforward
communication or public relations issue. It may well be that the
"clear line of sight" resolves this issue. Obviously
the "clear line of sight" needs to be established and
this should provide the impetus to clear up this issue.
Trust that each part of the service
will deal with the information professionally and sensitively.
As stated above there are occasions when free transfer of information
is blocked or made more difficult than is perhaps necessary. If
we all know what the other parts of the partnership do and why
they do it this bond of trust is more likely to be developed.
Without it we shall not be as effective as we could otherwise
The acceptance that each part has
a role to play and that the whole is greater than the sum of the
parts. There is a tendency for each part to operate within its
own sphere of influence and/or competence. There are vast stores
of knowledge and expertise that can be brought together for the
benefit of the service. These proposals should assist that process.
4. Should the UK make greater use of vaccines?
This is a medical issue outside the
scope of the Local Authority.
5. Which infectious diseases pose the biggest
threats in the foreseeable future?
Some of the old onesmeasles
because it is not deemed by the public to be serious, Tuberculosis
because it is endemic still in parts of the world visited by many
of our residents. Conditions for its spread still exist in this
country and the people who live in those conditions are disenfranchised
through lack of knowledge. Development of antibiotic resistance
in existing pathogens either through veterinary use or in human
medicine is likely to pose an increasing threat.
New onesE.coli O157 suddenly
appeared as a human pathogen with devastating results. It adds
a new dimension to investigation and surveillance because of its
ubiquitous nature and low infective dose. Salmonella species have
been known to change their usual pattern of infectivity and this
may happen at any time. Surveillance is essential to ensure these
developments are picked up.
6. What policy interventions would have the
greatest impact on preventing outbreaks of and damage caused by
infectious disease in the UK?
Put adequate resources into combating
family outbreaks with an emphasis on a proactive approach. This
is a largely neglected area of work. There is no agency with outright
responsibility for it, though doubtless the Health Protection
Agency will be in a position to change that. Much of the communicable
disease investigation work is based in the home but resources
in terms of both staff and time are too limited to be able to
spend the amount time needed to gain the required results.
Increased food and personal hygiene
education in schools. If we are to cut the cycle of infection
we need to ensure that people are given the type of information
they need to keep themselves safe from infection. Though the school
curriculum is a crowded vehicle it does give access to a captive
audience, one that is hopefully receptive and not set in bad habits
and one that can be reached at various stages of development.
Introduce licensing for all food businesses
(with appropriate lead in times). It seems strange that a licence
is needed to look after someone's pet cat whilst they take a holiday
but anyone (apart from a butcher who sells both raw and cooked
meat) can set up in business selling food to other people. It
would be prudent to start with those whose business constitutes
the highest risk and work forward on a rolling programme. Exemptions
for those who sell only wrapped sweets would be acceptable. Fees
charged should be ring fenced to ensure that the licensing process
is largely self- financing. Equally we should ensure that anyone
who wishes to run a food business is trained to at least intermediate
food hygiene standard prior to opening and that all food workers
are trained to at least basic standard within three months of
starting employment. A great deal of misery is caused through
ignorance of basic hygiene techniques.