Memorandum by the Faculty of Public Health
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.
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)
and Getting Ahead of the Curve (January 2002).
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
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
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
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,
CDSC's hepatitis C Register, TB outcome surveillance, and linking
up Office for National Statistics death data to laboratory reports
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
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,
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
RECENT ID STRATEGY,
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.
THE UK BENEFITING
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.
THE UK MAKE
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"
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.
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 Englandwhat about
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
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
functionlaboratories 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
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
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
Experience with Foot and Mouth Disease (FMD),
Classical Swine Fever (not zoonoses) and West Nile Virus in the
and most recently bat rabies (EBL)
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
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
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
and that of the Emergency Planning Co-ordination Unit,
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
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
(WHO-CSR) wishes to make greater use of UK capacity.
44 Department of Health Shifting the Balance of Power-securing
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Getting Ahead of the Curve, a strategy for combating infectious
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of Health, England, January 2002 http://www.doh.gov.uk/cmo/idstrategy/idstrategy2002.pdf Back
CDSC Infection Control in the Community Study. June 2002 http://www.phls.co.uk/publications/pdf/ICICreport.pdf Back
The British Paediatric Surveillance Unit, the CJD Surveillance
Unit, the British Neurological Surveillance Unit, the Confidential
Enquiry into Deaths and Stillbirths (CEDSI). Back
RCGP Annual Report. Back