The Royal Society of Edinburgh (RSE) is pleased to respond to the Scottish Executive Health Department's consultation on Health Protection in Scotland. This response has been compiled by the General Secretary, Professor Andrew Miller and the Research Officer, Dr Marc Rands, with the assistance of a number of Fellows with extensive experience of the NHS in Scotland.
The specific questions identified in the consultation paper are now addressed below:
What is health protection?
How might the scope of health protection in Scotland support the established commitment to working within a UK and increasingly international context?
The scope of health protection in Scotland is correct as set out and there can be no doubting that Scotland must work within a UK and international context when it comes to such issues as infection, food borne hazards and bioterrorism. This is not to say that a uniform way of working or organisation has to be imposed.
How might the contribution of local authorities and EHOs to health protection be enhanced?
As the paper points out the local authorities play a very important part in health protection and their role is particularly enhanced when they have a close liaison with the Health Service. This is especially so with the Environmental Health Officers (EHOs). Although the days when the EHOs were on the staff of the Medical Officer of Health are over, there is much to be gained by examination of a policy of having certain designated EHOs sited more closely alongside public health personnel so that the work of both professions can be as complementary as possible.
Microbiologists and EHO’s are also key players in the delivery of surveillance, investigation, risk assessment, management and communication and managing emergencies. As the consultation paper notes, "improving them…. will require investment in organisational and staff development." However, obtaining the additional resources to do this is difficult. Clinical microbiology and environmental health are not budgetary priorities in the plans of NHS Trusts and local authorities even though the problems they address, for example, hospital acquired infections, and food safety, are of great public concern and have high political impact.
Should consideration of change focus on the functions discharged by:
It can be understood why the bodies listed above might be the focus for change, however, not all of these bodies would sit easily within a new Health Protection Agency (HPA). For example, the Information and Statistics Division (ISD) has many important functions over and above health surveillance (e.g. cancer survival rates). While there might be a strong case for linking some of the health surveillance functions of the ISD to the Scottish Centre for Infection and Environmental Health (SCIEH) (notably infection surveillance), the ISD functions extremely well and already links effectively to other organisations.
In addition, the NRPB provides guidance and services encompassing a wide range of medical, occupational and environmental radiation safety issues. For example, they are involved in the collation of patient dose information from all UK hospitals which is used by the Department of Health to set standards for medical diagnostic procedures. It would be of concern if this type of service were to be lost, but it is not clear whether it would fit directly within the remit of the new proposed organisation. Indeed, in the proposals for the HPA, little attention appears to have been paid to the NRPB's work in many areas of radiological protection, including those involving medical and occupational exposure. It is difficult to understand how the new organisation will be more effective in providing general radiological advice throughout the United Kingdom than the existing NRPB.
Should EHOs not be considered for inclusion in any new organisational arrangements for health protection?
EHOs may have an important part to play in health protection, but there is a case for leaving EHOs where they are.
Major issues for health protection in Scotland
Are the health problems outlined the major issues for health protection in Scotland?
The health problems detailed in this section are indeed major issues but the list needs to be kept open. Systems for health protection need to be flexible and able to adapt to new challenges. Who would have predicted HIV/AIDS 30 years ago, identified the likely emergence of E. coli O157, or predicted the development of BSE and vCJD? We must not be complacent about the ability of biology to throw up new and evolving hazards nor must we assume that ‘old’ infections such as TB and syphilis are vanquished. For that matter we cannot assume that ‘beaten’ infections such as smallpox have gone away, given the new enhanced terrorism threat.
What other health problems do you consider to be major issues for health protection, and why?
The potential risk of tropical infections such as malaria and sleeping sickness (Human African Trypanosomiasis) which can be contracted by Europeans working in Africa who then return to Europe with delayed symptoms of the disease should could become important in the future. With increasingly frequent air travel, together with the possibility of microorganisms being introduced to Europe on the aeroplanes themselves, this is something which should be addressed. In Scotland Health professionals should be aware of this danger and there needs to be communication to primary health individuals such as GPs as well as Casualty Departments regarding these issues. Adequate stocks of anti-malarial and anti-sleeping sickness drugs should also be made available. In addition, influenza, when it appears in epidemic form, can have a very high mortality (e.g. in 1919 over 20million deaths occurred). Today, mortality is especially high when it involves the elderly. Because of this and the fact that vaccines are now readily available, influenza seems to be a disease worthy of consideration.
It will also be important to ensure that it is not just those entities which are "measurable" that are catered for. Although mortality is easily counted, laboratory-confirmed infections and morbidity occurring in hospital equally so, illness in the community (e.g. stress, infections and illnesses which have not involved the surveillance organisations within the Health Service) also require attention and may not be fully catered for by the organisations listed, leaving them in danger of "falling through the net". Stress in particular has been highlighted by the Health and Safety Executive, as an area of increasing concern.
Strengthening health protection services
Does health protection require strengthening in Surveillance, Investigation, Risk Assessment, Risk Management, Risk Communication and Emergency response and management?
Health protection needs constant appraisal and will always be in need of strengthening. Complacency is the greatest danger – the notion that we have the issue ‘sorted out’ is always going to be dangerous. There is great value in joint exercises, which have worked well in the past (e.g. Lothian’s ability to deal with a nuclear catastrophe), to maintain and/or heighten awareness, identify issues and provide for a more robust and effective response to problems. One of the main functions of a newly created HPA would be to collate information; provide linkage between organisations; increase research capacity, co-ordination and utility; and provide education and training (principally for frontline staff but always with an eye to the needs of the public.
What other areas of health protection services do you consider to be deficient and require strengthening and why?
There is a difficult issue of capacity here. For example, the capacity to respond to an outbreak of infectious disease is currently based in Health Boards with advice/support from SCIEH. This is possible in larger Boards with critical mass but the various Health Board areas in Scotland serve populations ranging in size from 20,000 to about one million. The Review of the Public Health Function was very concerned by the plight of smaller Boards. Options to deal with emergencies include the provision of a central task force that can be parachuted in at times of need or enhanced networking in which Boards link with each other to provide appropriate cover. The RSE would be wary of suggesting that the HPA should have some sort of taskforce or be charged with responding operationally to issues of the day as nothing replaces local knowledge and every outbreak/incident has its own peculiarities.
In addition, health education does not seem to feature strongly in the consultation paper although it is referred to in some measure under risk management. There has been a significant increase in skin cancers in Scotland in the past 20 years and health education has been shown to reduce the risk, both of contracting a malignant disease of the skin but also in its severity. In many health protection areas, education can make a difference and should be an additional area requiring strengthening.
The contribution of microbiology services to health protection?
Should no change be made to the organisational arrangements for non-reference microbiology services in Scotland?
The RSE agrees that the organisational arrangements for non-reference microbiology labs should be unchanged, although every microbiology laboratory should have a designated person responsible for onward transmission of significant findings to the appropriate organisation for further action if necessary.
Should national standards be adopted for all NHS laboratories, based on standard operating procedures developed in England and Wales?
There are virtues in having standardised operating procedures throughout the UK. But the inflexible application of standard methods – whose development, agreement and implementation may take quite a long time – could serve as an impediment to progress. Microbiology testing is a dynamic subject, microbes evolve, and brand new pathogens appear on a regular basis. Laboratory accreditation schemes take this into account through ISO 9001, which sets standards for new methods. Developing and applying SOPs is not always, therefore, a simple and straightforward process. Some will be out of date before they are introduced. There could be merit in observing how the system proposed for England and Wales works in practice before considering its adoption.
Should the current network of microbiology reference laboratories be extended to deal with other micro-organisms and; if so, which?
The need to develop further Reference laboratories is unclear, but the system of Review operated by the Scottish Reference Laboratory Working Group operates well in assessing need and selecting the optimal location of each Reference Laboratory.
One group of organisms which current network of microbiology reference laboratories could be extended to deal with are those which cause campylobacter infections. It is the commonest bacterial cause of gastrointestinal infections, but its epidemiology is obscure. It is not know, for example, what proportion of cases contract their infections from food. Until recently typing methods for the organism failed to resolve this problem, probably because of their inability to index genotype. This problem can now be resolved by methods that use DNA sequencing of genome segments. Reference facilities for influenza virus typing and certain tropical diseases should also be available.
Should their remit be extended to test isolates from non-human samples?
Organisms like E.coli O157 and various salmonellae reside primarily in animals and spill over from time to time to humans. There are, therefore, compelling epidemiological arguments for human reference laboratories to examine veterinary material. There are also technological arguments for extending the remit. RFLP testing such as pulsed field gel electrophoresis, still the gold standard test for E.coli O157 strain identification, require the co-electrophoresis of samples on single gels for the establishment of identity. So access to veterinary material is essential for the laboratory if it is to establish any real understanding of the overall population genetics of the organism in Scotland – the identification, enumeration, and establishment of the distribution of clones – an essential prerequisite to understanding its epidemiology.
Overall, circumstances in which it would be advisable to extend the remit would include (a) when there is a possibility that a particular animal viral or bacterial isolates may "cross-over" to cause human disease. (b) Where there is felt to be a strong research interest in studying such non-human samples and (c) when such animal sample testing has clear implications for human health, e.g. where there is the possibility of animal diseases which are known to or which could potentially cause human disease. Such activity would also allow for possible epidemiological linkages to be made, to enhance the expertise of laboratory staff and also have financial benefit.
Is there scope for centralising all, or the majority, of reference laboratories in one NHS Trust or other appropriate service unit?
Combining all Reference Labs into one location could lose more than it would gain. It would withdraw a flagship feel from existing Reference Labs and fail to take fullest advantage of existing expertise. It might critically weaken microbiology services on some sites. It would remove the element of competition from the existing selection process and increase the difficulty of creating a new Reference Laboratory for a given micro-organism in the event of suboptimal performance.
However, developments in DNA sequencing technology both wet and dry, and sequence databases, now means that this very powerful tool can be readily applied to the fingerprinting of any organism. Bringing together a reference laboratory in association with a state of the art DNA sequencing/data analysis facility would be a highlydesirable development. Several Scottish universities have such facilities and setting up such an association would enable each laboratory, rather than setting up its own systems (usually for a small workload), to tap into a large facility.
Is there a role in Scotland for the Inspector of Microbiology, expected to be appointed in England, and what that role might be?
It is difficult to see what added value an Inspector of Microbiology would bring when existing laboratory accreditation systems are taken into account. Inspection schemes are an integral part of the schemes run by Clinical Pathology Accreditation (UK) Ltd, the United Kingdom Accreditation Service, and British Standards Institute, which use the internationally recognised standards BS EN 9001, BS EN 9002, and BS EN ISO/IEC 17025.
What are the arguments for and against having the same standard operating procedures throughout the UK?
The advantages of having the same standard operation procedures throughout the UK would include centralised purchasing; the augmentation of expertise and the ability to compare and contrast. A disadvantage would be the diminution of incentive to innovate.
Options for Organisational Arrangements for Health Protection in Scotland?
Which option is preferred and for what reasons?
The recent reorganisations in England have greatly weakened public health and adversely affected morale in a speciality already under threat. One of the strengths of Scotland is the fact that Directors of Public Health and their Consultants in Communicable Disease remain as part of Health Boards. This strengthens the public health role of Boards and facilitates linkage to Local Authorities except where these are not co-terminus. In principle, however, improvements in co-ordination, efficiency, ability to collaborate with counterparts elsewhere, and career development opportunities could follow the creation of a larger organisation. Comments on the different options are detailed below:
Options 1 and 2: These options transfer all or most of the Scottish health protection functions to an organisation planned for England and Wales that, for some time yet, will be spending a good deal of its time working out new structures to cope with the decision to abolish the Public Health Laboratory Service, an organisation that had no laboratories in Scotland. The different public health legal background in Scotland would be an added complication. Option 1 also removes major functions from Health Boards and so weakens their public health function and ability to act as organisations committed to safeguarding and enhancing the public health. In addition, not all of the functions in the new HPA in these options are bound together by strong logic which could result in implementation and interface problems. For instance, while there might be justification in linking SCIEH and ISD, the Scottish Poisons Bureau (which is primarily a resource that provides advice, although it may have some surveillance function) does not sits easily with the other functions.
Option 3: This option is closest to the status quo, although one weakness would be that that it creates an HPA that is probably too small to justify its existence or develop fighting weight and critical mass. If it were adopted, careful attention would need to be paid to establishing which areas of the HPA should interface with Scotland and which should not.
Option 4: In this option, it is difficult to see the justification for splitting the functions of a new HPA from the ‘Scottish Health Protection Organisation’. In addition, if the Scottish Health Protection Organisation proposed for the remaining Scotland-wide services were simply a small administrative organisation providing co-ordination of the work carried out, then it might provide a reasonable alternative. If a major restructuring is proposed, then the option may not improve the services currently provided. More information on the status of the proposed agency would be needed before a considered judgement could be made.
Options 5 and 6: These options bring chemical, radiological, poisons and communicable diseases together into a new Scottish HPA. The notion that chemical and biological threats and the responses to them are so similar generically that they can be readily handled by a single "chembio" enterprise has been described by D.A. Henderson, a US expert in bioterrorism, as "a serious misapprehension." (Science 283 1280 1999). As with Option 1, Option 6 also removes major functions from Health Boards and so weakens their public health function and ability to act as organisations committed to safeguarding and enhancing the public health. In addition, from the perspective of providing a sound radiological protection infrastructure in Scotland, it is unlikely that a stand-alone Scottish NRPB would be able to provide the level of expertise or range of activities currently provided by the UK organisation.
Should the role of the Advisory Group on Infection be enhanced to provide an overview of health protection arrangements in Scotland? Are there any other functions the Group might discharge?
Whichever option is selected, great virtue can be seen in having an Advisory Group on Infection to provide an overview of health protection arrangements in Scotland. This Group would be an important resource with a monitoring function. It could be called on periodically to give advice/analysis on relevant issues and would be available to pronounce on effectiveness and response to various urgent and emerging issues. Environmental public health hazards could also be added to this Group’s responsibilities.
In responding to this inquiry the Society would like to draw attention to the following Royal Society of Edinburgh responses which are of relevance to this subject: Healthcare in 2020 (September 2000), Fighting Infection (October 2002) and A Vision for the Future (December 2002).