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Health Protection in Scotland - A Consultation Paper
Chapter 4 - Strengthening health protection services
- This chapter considers the various functions involved in health protection
and suggests how they might be strengthened.
Surveillance
- Surveillance involves the collection, collation, analysis and dissemination
of information about health and its determinants. Its purpose is to recognise
a change in the distribution of illnesses, exposures and hazards so as to
alert health protection agencies of the need for specific measures or to inform
them whether current policies are being effective in reducing exposure to
hazards. Surveillance and research underpin risk assessment and the development
of risk reduction measures.
- NHS agencies principally monitor the occurrence of episodes of ill health,
death and the isolation of micro-organisms from samples taken from humans.
A range of non-NHS agencies routinely collect, analyse and disseminate information
on the occurrence of hazards in food, water, the air, and the general environment.
- The effectiveness of surveillance depends upon:
- professional awareness of the value of the early recognition of actual
and potential hazards and their notification to relevant protection agencies
- accurate clinical and laboratory diagnosis of illness linked to hazards
- a strong system of fully accredited diagnostic and reference laboratory
services
- information systems which permit the rapid transfer, processing and dissemination
of data
- the ability to link surveillance data from different sources to develop
an overall picture of the risk presented to the public from exposure to a
hazard.
- Against this background, there is a need for health protection surveillance
to be strengthened in the following areas:
a. Monitoring unusual illnesses or syndromes
Since 11 September 2001, there has been an increased awareness of the need
to detect rapidly outbreaks of communicable disease or clusters of unusual
illness and to identify the implicated hazard. A Working Group has developed
proposals to introduce a surveillance system for the detection of unusual
illness in the population. This initiative is linked to participation in the
development of UK-wide and international programmes to "horizon scan" for
emerging infections.
b. Integrating different surveillance systems
A common criticism of surveillance systems is that they place greater importance
on collecting than using information and thus become "data warehouses". One
way of overcoming this would be through better linkage between datasets to
facilitate their use in assessing the risk from exposures and their effects,
in particular:
- linking NHS information on episodes of ill health with that held on microbiological
isolates;
- developing an environmental health surveillance system which connects data
on hazards and exposures with the occurrence of ill health;
c. Modernising the system for notifying communicable diseases
The Public Health (Notification of Infectious Diseases) (Scotland) Regulations
1989 place a duty on medical practitioners to notify the Chief Administrative
Medical Officer (CAMO, now known as the Director of Public Health) of any
patient they believe to be suffering from a notifiable disease which is specified
in the regulations. There is a consensus that there is a need to expand notifiable
diseases to include pathogenic micro-organisms and this is proposed within
the current review of public health legislation.
d. Improving information technology for data transfer
There is a need to ensure that the gap between exposure of the population
to hazards and the detection and diagnosis of any resultant illness is as
small as possible. Key to this is the introduction of information systems
which attempt to achieve "real time" surveillance by facilitating the rapid
transfer of data on cases of ill health and their possible reasons for falling
ill.
Investigation
- There are two approaches to health protection investigations. The first
is the investigation of outbreak or incident; the second is specifically commissioned
research. Epidemiological investigations attempt to establish the pattern
of ill health associated with exposure to a hazard and its association with
likely causes. Other types of investigation try to detail the ways in which
the person was exposed to the hazard, or characterise the nature and properties
of an implicated hazard. Health protection investigations are often multi-disciplinary
and their utility depends on the collation of different types of data. Areas
where further development of health protection investigations could take place
are:
a. Improving capability to carry out investigations
into outbreaks or incidents
Many NHS Boards lack the capacity to undertake structured
investigations into outbreaks and incidents. There is a need for improved
support from national agencies.
b. Defining strategic priorities for research into
health protection issues in Scotland
The need for a more concerted and co-ordinated approach from
research centres in Scotland to optimise output from research into health
protection has long been recognised.
c. Making better use of the findings from investigation
and research
A recent review of outbreak management has highlighted the
need for improved collation of investigation findings from outbreak and incident
investigation. The establishment of the Public Health Institute of Scotland
provides a focus for the development of evidence-based practice in health
protection.
Risk Assessment
- Rigorously assessing the risk to the public health from exposures to hazards
should be the cornerstone of advice to policymakers and regulators, the basis
for accurately informing and communicating with the public and the platform
for developing and evaluating control measures designed to reduce risk.
- Risk assessment is a key element of the practice of many of the agencies
involved in health protection. However although its use is extensive, it has
not been formally adopted as a tool for ongoing application in many areas,
particularly those concerned with communicable disease control. Because of
this it is proposed that health protection services should continue to:
- develop guidance on good practice in risk assessment in health protection
agencies, particularly those working within the NHS;
- ensure that all policies developed to protect the public are formally
founded on a rigorous approach to risk assessment.
Risk Management
- Risk management involves implementing and co-ordinating a series of interventions
designed to reduce the risk from exposures to hazards. These include:
- providing advice on how to avoid and minimise risks;
- education and training about risks and how to reduce them;
- producing guidance on good practice, policies and procedures to reduce
the risk of exposure to hazards;
- providing services which prevent the transmission and development of infections
or their complications ;
- providing hygiene services which reduce or eliminate contamination with
hazards;
- defining organisational and individual responsibility with regard to reducing
risk and their consequent liabilities
- setting standards to measure the performance of agencies and the quality
of their services in reducing risk to the public
- formulating and enacting regulations.
- NHS agencies are key players in managing the risks from exposure to hazards
and in particular those related to the person-to-person transmission of micro-organisms.
However, most measures to reduce the risk of exposure to hazards fall within
the remit of other agencies.
- The following are highlighted as areas where developments in risk management
could take place:
a. Partnership working on health protection
The recent introduction of community planning provides a
focus for developing strong alliances to tackle issues such as accident prevention
at a local level. The Public Health Institute of Scotland is taking forward
the creation of a Healthy Environments Network, which will bring together
key partners at national and local level, in order to develop environmental
health policy, taking account of best practice arising from local initiatives,
and contribute to ongoing work on health protection.
b. Education on hygiene
The growing numbers of healthcare associated infections and
worries about the person-to-person spread of childhood infections have once
more highlighted the need for improving hygiene education in the pre-school
sector and in training programmes for healthcare professionals.
c. Development of indicators to assess the performance
of NHS agencies with health protection responsibilities and the impact of
risk reduction measures on health
There are few outcome measures to assess the overall impact
on health of risk management programmes. Recently, the Food Standards Agency
has developed a target for reduction in foodborne infections. There are opportunities
to extend this model to other areas.
Risk Communication
- Communicating about risk to the public health is of vital importance. People
need to understand risks to make decisions about their and their families’
health and to make proper enquiries of public bodies, which are charged with
making decisions on their behalf. Communication needs to be considered by
all those dealing with actual or potential public health risks, at all stages
of the health protection processes. How to communicate about risk depends
upon an understanding of how the population perceives risks and how the media
and other factors exert an influence.
- The BSE Inquiry highlighted the dangers from what has been termed "communication
by sedation", i.e. professionals and Government downplaying unknown risks.
A key matter for health protection agencies is handling uncertainty and, in
doing this, they require to be open and transparent to the public and their
representatives.
- Priorities for the development of risk communication include:
- Developing guidance on risk communication for NHS agencies involved
in health protection to be used in establishing communication plans and
procedures.
- Commissioning research into understanding how certain risks become
amplified and how the public can develop better means of comparing and contrasting
risks which affect their personal life (risk literacy).
Emergency response and management
- The importance of this function has been given added priority after the
events of 11 September. Extensive planning and guidance have already been
put in place, including detailed guidance to health and local authority and
other emergency services, raising clinical awareness and producing guidelines
on the recognition and management of infections and exposures to chemical
agents which give rise to unusual clinical presentations. The Scottish Executive
Health Department has participated in establishing strategic stockpiles of
drugs and vaccines and putting in place plans for their distribution.
- The multi-agency response to an emergency involving the deliberate release
of a biological, chemical or radiological agent is in most ways the same as
one arising accidentally or naturally. The key aim is to reduce to a minimum
the number of cases of illness by recognising promptly the outbreak of the
incident, defining how cases have been exposed and identifying and controlling
the source of the exposure. Health protection agencies should strive to keep
the public and media informed of the health risks associated with an incident.
- Incidents and outbreaks also provide an opportunity to collect information
which will be of use in better understanding the nature and origin of exposure
to toxic hazards and how best to present them.
- Experience suggests that emergency response and management could be strengthened
by:
- Carrying out more regular joint exercises in all relevant types of
incidents and improving the sharing of lessons learnt from them.
- Continuing to develop and improve the reporting of outbreaks and incident
management and the collation of the key lessons learnt from them.
- Developing standards to audit organisations’ performance in managing
outbreaks and incidents.
- Developing on-going training for frontline staff in recognising and
dealing with incidents.
Conclusion
- Surveillance, investigation, risk assessment, management and communication
and managing emergencies are the key health protection functions. Improving
them entails a series of developments, many of which are detailed in this
chapter. It will require investment in organisational and staff development.
To succeed in making health protection services more effective, more transparent
and effective organisational, accountability and performance management arrangements
need to be put in place.
Key Questions
- Do consultees agree that health protection requires strengthening in
the areas outlined above?
- Could consultees indicate any other areas for health protection services,
which they consider to be deficient and require strengthening and give the
reasons why.
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