Memorandum by Dr Michael O'Brien, Public
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
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
3. REASONS FOR
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. LAW ON
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
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
(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 healththe 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
6.1.2 What of the single co-ordinated focus
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
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
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. STANDARD PROCEDURES
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.
5. Adak G K, Long S M, O'Brien S J Trends
in Indigenous Foodborne Disease and Deaths, England and Wales1992
to 2000. International Conference on Emerging Infectious Diseases,
Atlanta, Georgia, 2002. http://www.cdc.gov/iceid/program.pdf
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,
8. Zansky S et al Outbreak of Multidrug-Resistant
Salmonella NewportUnited 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.