NHS Boards are responsible for discharging these duties effectively and efficiently on behalf of their local resident populations. The NHS Act states that " in exercising their respective functions, Health Boards, local authorities and education authorities shall co-operate with one another to secure and advance the health of the people of Scotland". A key component of improving health is protecting the public from hazards which damage their health, including managing incidents.
Should the public health incident be categorised by the NHS Board or its emergency planning partners, as an actual or potential major incident e.g. the deliberate release of a chemical hazard, the police will have responsibility for the overall co-ordination of the activities of all of those responding to this. NHS Boards should discharge their specific health protection responsibilities within this framework.
Under the 1978 Act, NHS Boards should designate a medical officer or officers of the Board for the purpose of exercising on behalf of local authorities such functions as may be assigned to the officer. This medical officer is known by the term 'Designated Medical Officer' (DMO) and may exercise any powers conferred on him/her by the local authority in writing. NHS Boards should ensure that all DMOs have received a letter detailing their responsibilities. A DMO will normally be responsible for leading the NHS Board's response to an incident and co-ordinating that of other agencies involved in responding, including chairing the Incident Control Team.
Should a public health incident occur in a service or establishment belonging to an NHS Trust, when appropriate, responsibility for managing this should pass to the NHS Board. Further detail is provided in Annex 4.
Local authorities
As indicated above, local authorities have a statutory duty to co-operate with NHS Boards in improving health and preventing illness. On a day-to-day basis, Environmental Health Officers working in Environmental Services or other departments, constitute the prime local authority resource in health protection. They also have the principal local responsibility for reducing the risks from many environmental hazards. They liase closely with their NHS colleagues in the investigation and control of outbreaks of infections, often being the enforcement arm of the teams set up to manage these incidents.
Other agencies
Other agencies have statutory responsibilities which overlap with those of NHS Boards and local authorities and may come into play in the investigation and control of communicable diseases. They include:
The responsibilities of these agencies is detailed in Annex 5.
In a public health incident, the NHS Board, in addition to being responsible for its own response, will co-ordinate the activities of other agencies involved in investigating, controlling and communicating about the risks to health. During the incident, each agency will be responsible for discharging its own statutory responsibilities within the framework developed by the NHS Board and agreed with its partners. It should do so in a way which contributes most effectively to the overall management of the incident.
The Scottish Centre for Infection and Environmental Health (SCEIH)
The Scottish Centre for Infection and Environmental Health (SCIEH) is a Division of the Common Services Agency for NHS Scotland. It is responsible for the national surveillance of communicable diseases and environmental health hazards and the provision of expert operational support on infection and environmental health to NHS Boards and local authorities in Scotland. Its aim is to improve the health of the Scottish population by providing the best possible information and expert support to practitioners, policy-makers and others on infectious and environmental hazards.
SCIEH's duties include the collection, analysis and dissemination of information on laboratory reports and outbreaks and incidents. SCIEH can assist with the co-ordination of the investigation and control of outbreaks which cross geographical or organisational boundaries, and provide a mechanism for the collection, collation and dissemination of information from the different areas involved. It may also, where appropriate, provide expertise to assist at NHS Board level, but always at the invitation of the local agencies with whom final responsibility rests. SCIEH also provides advice and support on chemical incidents in its capacity as Regional Service Provider Unit (RSPU) for Scotland.
Scottish Executive Health Department
The SEHD is the main point of Government contact for public health incidents. NHS Boards must notify SEHD about incidents and update the Department on developments in them. This will normally be through the DMO or other nominated person from the ICT informing a member of the Chief Medical Officer's staff. On being notified, SEHD will copy all relevant information to other Executive Departments and liase with the SE press office. Agreement will be reached as to which Department briefs Ministers (normally this will be SEHD). Clear channels of communication will be established between SEHD and the ICT. These channels will be notified to all concerned and will be the sole lines of communication. The SE and ICT will agree the timing and updates on progress.
For a major public health incident, an incident group will be formed within the Scottish Executive led by the Health Department to assess the coherence of the local response, the resources at the local Board's disposal, potential national consequences and the nature of communications from the NHS Board. It will ensure that other appropriate agencies e.g. SCIEH, are involved and will agree communications and briefing to Scottish Ministers, other SE Departments, and when appropriate other UK Health Departments. In the circumstances of national level emergency, the SEHD National Emergency Planning Officer will co-ordinate the efforts of the emergency services and, if necessary, the military. Consideration will also be given to opening the Scottish Executive Emergency Room in St Andrew's House.
Where a major breakdown of local arrangements occurs, or the scale of the incident overwhelms resources including established arrangements for mutual support from other regions, the Scottish Executive would be entitled to deploy reserve powers, normally on the advice of the Chief Medical Officer.
On an on-going basis, SEHD will assess the effectiveness of the management of public health incidents and produce guidance on how to improve it.
Organisational arrangements for managing public health incidents
Accountability and reporting arrangements
NHS Boards share statutory responsibility for improving health with Local Authorities. In addition representatives from other statutory agencies will be involved in planning for and managing public health incidents each fulfilling a remit on behalf of their own organisation and being responsible to it for actions taken in this regard. Each will have its own statutory duties to fulfil with regard to protecting public health. NHS Boards, as lead agency for protecting health, are responsible for the overall performance of the arrangements for planning for and managing public health incidents.
NHS Boards should reach agreement with their partners, especially local authorities, on:
NHS Boards should appoint a lead officer to be responsible for putting these arrangements in place and updating them as appropriate. Normally this would be the Director of Public Health. He/she would also be responsible for ensuring that the NHS Board has efficient procedures to discharge the functions detailed in this guidance.
Occasionally there will be indications that the ICT is not working as effectively as required. In such instances, the lead NHS Board officer for assessing ICT performance should take steps with his senior management counterparts in the other agencies participating in the ICT, to assess and remedy any shortcomings.
Joint planning for public health incidents
NHS Boards should jointly with local authorities and other partners draw up co-ordinated outbreak/incident control plans. Such plans should be reviewed annually and jointly exercised on regular basis. Formal endorsement of joint plans by all agencies involved in them is recommended (see above). Plans should outline a comprehensive approach to the control and investigation of outbreaks of infection and incidents involving exposure to chemical, radiation and other hazardous agents. Further details on the functions to be covered in the plan are included in page of this document.
It is essential that arrangements for handling outbreaks and incidents are integrated with overall multi-agency arrangements for emergency response. This is particularly important should there be any question of any criminal activity being involved in the causation of the outbreak or incident e.g. the illegal supply of drugs. In certain incidents, e.g. those involving the deliberate release of a chemical or biological agent, the NHS Board while retaining its own responsibilities, will be required to play a key part in the overall response led by the Chief Constable of the area in which the incident occurs (or the Police Incident Commander nominated by him/her), and have regard to the potential requirement to protect the crime scene in order to avoid prejudicing prosecutions. When incidents involve or have the potential to involve legal proceedings, it is important that the local Procurator Fiscal's department is kept fully informed. NHS Boards should reach agreement with their emergency planning partners and in particular the relevant police force about emergency response arrangements in the circumstances when criminal activity is implicated.
It is imperative that adequate resources are made available from the outset to investigate the control of the outbreak. An inadequate initial response may have serious consequences for the wider public health. Investigations should never be delayed for financial or contractual reasons. NHS Boards should reach agreement with local agencies with regard to responsibility for the costs of processing samples. Representatives of agencies on the ICT should have sufficient devolved authority to commit agency resources required to investigate and control an outbreak. These issues should be discussed among agencies as part of the arrangements for formally agreeing plans.
Incident Control Teams
It will be the responsibility of the NHS Board to call an Incident Control Team. In public health incidents, an officer of the NHS Board, acting as a DMO of the Local Authority, should co-ordinate and lead the investigation and control of the outbreak/incident. Usually this will be a Consultant in Public Health Medicine with responsibility for communicable disease and environmental health. The NHS Board should ensure that DMOs are adequately trained and have demonstrable competencies in communicable disease control and environmental health and in leading multi-agency teams.
The DMO will be responsible for initial action in response to the incident and convening an incident control team. The size and nature of the outbreak will determine the exact arrangements. The ICT is a multidisciplinary, multi-agency group with responsibility for investigating the outbreak/incident and implementing control measures. The remit of the ICT is on behalf on the NHS Board and in co-ordination with other agencies, to:
ensure that systems are in place to collect and collate all relevant information and verify, review and interpret its significance;
carry out a full risk assessment and decide on courses of action necessary to protect the health of the public;
co-ordinate the investigation and management of the incident within the protocols and codes of practice of the agencies involved and having regard to extant legislation;
liase with SCIEH, SEHD and other relevant agencies to draw on their expertise and ensure necessary actions falling with the responsibility of these bodies are put in place;
co-ordinate the issuing of advice and information to the public directly and through the media;
ensure arrangements for the care of patients are in hand and keep all relevant clinical professionals updated;
declare the end of the incident;
produce a timely report on the incident and provide information to SCIEH for outbreak surveillance purposes.
Usually the ICT will also contain officers from other relevant agencies e.g. the State Veterinary Service, Scottish Water, whose input is essential to manage the incident. However it is important that the ICT does not become too large, e.g. more than 10 people.
An ICT usually functions for a single NHS Board area. However there are occasions when an NHS Board will be asked to lead a regional or national ICT which involves other NHS Boards. For example, when an outbreak/incident is affecting more than one NHS Board area or Scotland as a whole. In such instances, discussion should take place between representatives of the boards affected, SCIEH and SEHD (or FSA Scotland in the case of an actual or potential foodborne outbreak/incident) about the need to establish a national/regional ICT, led by a single NHS Board on behalf of the others. If it is decided to proceed with a national/regional ICT, this may act as the single team responsible for managing outbreak/incident or may co-ordinate local teams. If it is the latter, the national team should include the Chairs of local teams. The Chair of the ICT will be accountable to the lead NHS Board for the performance of the national/regional team. With regard to the investigation into the cause and extent of the national/regional outbreak or incident, in both of the above instances, SCIEH will co-ordinate the human health aspects of the investigation.
All members of the ICT must have due regard to the confidentiality of information discussed in the ICT meetings (while bearing in mind the need to demonstrate openness and transparency when reporting the facts to the public). All agencies represented in the ICT must ensure that relevant staff within their own organisations are regularly briefed about the outbreak/incident. Representatives from the individual agencies involved in an outbreak/ICT should only carry out investigations, assess risk to the public health, take control measures and make public statements after full discussion within the ICT or if that is not practical, with the Chairman of the ICT.
Meetings should be kept to a minimum and be as short and efficient as possible without compromising safe working. They will normally be chaired by the DMO. Adequate secretarial support must be provided. Careful consideration should be given to the composition of the agenda, the timing and the duration of meetings. Attention should be paid to the context of public concern in which an incident may be taking place, the different information requirements of the print and broadcast media and the crucial issue of timing, to ensure optimal dissemination of information. Responsibility for this should be clearly assigned.
At the first meeting the Chair should remind the ICT participants of their roles and responsibilities and status as members of the group. Attendees at the first ICT meeting should all be required to declare any possible conflicts of interest as individuals or on behalf of their organisations. Where a declaration of a possible conflict of interest is made, it should be recorded and a decision made by the Chair on that individual's status. Individuals who are not full members may continue to attend the ICT by invitation, but should not expect to have equal rights in terms of determining the conduct of the investigation, the advice given to the public, the content of press statements or the final ICT report.
On occasion e.g. in a major incident, a representative of SEHD or other SE Department will attend an ICT to facilitate liaison between the ICT and SE. In such instances, unless otherwise indicated, his/her status on the team will be as an observer.
Outbreak/Incident Management Support Team
If the situation develops into a very large-scale incident/outbreak or one with considerable national interest, pressures may be brought to bear on the ICT, which could distract it from its core purpose of managing the incident. An example is when there is a sustained, large volume of enquiries about the outbreak from the public, media and politicians. Very large outbreaks can have secondary impacts on a range of services e.g. hospital care, food and water supply and may lead to the need for increased expenditure with money being reallocated from existing budgets. In large and/or lengthy outbreaks, there will be a need to make appropriate provisions for relieving ICT members who may become fatigued. In such instances, the Chair of the ICT, liasing closely with NHS Board lead officer for incident management, should discuss setting up an incident management support team (IMST).
The purpose of the IMST is to enable the ICT to fulfil its remit detailed in paragraph 38, more effectively by:
In circumstances when there are a large volume of enquiries the IMST, liasing with the ICT, should provide a focal point of contact with SEHD and for briefing Scottish Executive officials and local and national politicians. It should also advise the CMO and SE officials on the need to deploy reserve powers if incident management arrangements are overwhelmed.
The IMST should consist of representatives of senior management from the agencies involved in the ICT. Normally it should be led by an NHS Board senior officer and must include the DPH or other officer to whom the DMO is reporting on the management of the incident and a senior Local Authority representative. The ICT Chair should liase closely with the lead IMST officer in co-ordinating the different functions.
The end and aftermath of an outbreak/incident
The ICT must decide when an outbreak/incident is over and make a statement to this effect for release to the general public and other interested parties. This should be based on a risk assessment which reaches a conclusion that there is no longer a significant risk to the public health. Subsequent to this decision being taken, and within as short a time-scale as possible, a debriefing meeting of the ICT should be convened to consider lessons learned about managing the incident and any further preventive action required. These should be recorded in a note and key lessons learnt should form part of the subsequent ICT report.
A full, but anonymised report should be prepared by the ICT. . The Chair of the ICT has overall responsibility for its production. As far as possible, the ICT report should be the product of agreement of all full members of the team. If this is not possible, areas of disagreement should be noted. Officers of the constituent agencies in the ICT who were not ICT members should not edit the report after its production. A template for the report is provided in Annex 6. The report should, in addition to describing the outbreak/incident, consider the effectiveness of the investigation and the control measures taken. It may in some instances be necessary to delay or limit the circulation of the final report pending legal action. In such cases legal advice should be sought.
Based on the results of the incident investigation, risk assessment and debriefing, the ICT should formulate targeted recommendations. The Chair of the ICT should ensure that the report and specifically the section dealing with the recommendation, is communicated to the targeted organisation. NHS Boards are responsible for ensuring that ICT recommendations are followed up. The NHS Board to which the ICT is accountable should ensure that there is a response to the recommendation from that organisation for its implementation. If it has statutory responsibilities, it must reply to the NHS Board laying out its response to the recommendation.
ICT reports should be sent for formal review to a Board meeting. The reports should also be made available to appropriate individuals, the local authority, SCIEH and the Scottish Executive Health Department or other SE Department with responsibility for aspects of the outbreak/incident. Other relevant regulatory agencies (e.g. Food Standards Agency (Scotland), Scottish Water) should receive a copy.
As indicated above, the NHS Board is responsible for approving an action plan to follow up the recommendations contained in the report. The action plan should be appended to the copies of the report submitted to the Scottish Executive Health Department. If a recommendation has major policy implications or if the response from the agency to which an action is recommended is deemed by the NHS Board to be inadequate, the NHS Board should inform SEHD who will review the issue further.
In addition to a full outbreak/incident team report, all relevant outbreaks or incidents should be summarised in the appropriate standard summary form for submission in timely fashion to SCIEH for the purposes of outbreak/incident surveillance.