| Chapter 12
Arrangements for the Handling and Control of Outbreaks |
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| 12.1 As
indicated in paragraph 2.4, revised guidelines on
"The Investigation and Control of Outbreaks of
Foodborne Disease in Scotland" were published by The
Scottish Office Department of Health Advisory Group on
Infection at the beginning of 1996. They set out the
statutory requirements for Health Boards and local
authorities to co-operate and the shared and individual
responsibilities for outbreak management and control. |
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| 12.2 As
indicated in our interim report the guidelines, and the
arrangements which were put in place locally to deal with
the Central Scotland outbreak, apparently worked
reasonably well - albeit that some lessons have been
learned. On that basis, we made recommendations a) to
ensure that local authorities and Health Boards have in
place integrated outbreak management plans setting out
mechanisms, procedures and responsibilities; b) that
outbreak control teams should be free to take decisions
and act as necessary to investigate and control
outbreaks; and c) suggesting that The Scottish Office
should review the guidelines on the investigation and
control of outbreaks and its internal arrangements for
dealing with outbreaks when they occur. |
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| 12.3 Again,
we were informed that measures have been taken to take
these issues forward. A review of the guidelines is, we
understand, well underway. On the need for emergency
plans, The Scottish Office has written to every Health
Board and local authority to request confirmation that
arrangements are currently in place. We understand that
the responses confirm that plans are in place throughout
Scotland and that a working group has been set up to
consider and discuss further any issues arising out of
that. |
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| Further
Consideration |
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| 12.4 Nothing
that we have heard subsequent to the submission of our
interim report has served to change substantively the
views which we expressed earlier. Outbreak control teams
in recent outbreaks appear to have followed guidelines
and good team work between public health, local
authority, clinical and laboratory staff has been
evident. We commend this level of co-operation. |
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| Media and
Public Relations |
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| 12.5 Some of
the issues covered in our interim report have however
been considered further. A recurring theme has been the
influence and extent of public and, notably in the
current climate, media and political interest. There is
no suggestion that this interest is anything other than
legitimate. Nonetheless, all of those responsible for the
investigation of outbreaks reported that media demands
can distract attention and scarce human resources from
the main task of outbreak management and control; that
sometimes ill-informed media commentary or speculation
can fuel public anxiety, place additional pressure on
already stretched public health and environmental health
resources and, indeed, hamper outbreak investigations.It
can also sow uncertainty and concern amongst the partners
in outbreak management. As a result, the task of
providing the desired and accurate information to the
public may be hampered. |
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| 12.6 This
has reinforced our view of the need in outbreak
situations for careful crisis management, including a
clear and proactive media management and public relations
strategy for the agencies involved, as well as the rapid
dissemination of relevant information to GPs and NHS
trusts. Appropriate consideration and priority should be
given to media and public relations interests and the aim
should be to educate and inform the public and
commentators on the circumstances of the outbreak and
issues related to it. The genuine difficulties and
uncertainties that can be encountered in outbreak control
(many of the reasons for which are set out earlier in
this report), and the evolving nature of outbreak
evidence and circumstances, need to be understood if
there is to be informed commentary. All of these issues
are, we understand, being looked at in the context of the
further review of the outbreak management and control
guidelines that is currently underway. |
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| The Role
of Public Health Medicine |
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| 12.7 We
devoted some time to discussion of public health medicine
issues and the roles of Directors of Public Health and
Consultants in Public Health Medicine (CD/EH) - not only
in outbreak management and control but also in the
broader context of disease control as "Designated
Medical Officers" (DMOs) to the relevant local
authorities. |
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| 12.8 The
role and position of public health practitioners have to
be seen against a background of progressive change in the
health service over decades. Changing demands and
imperatives have meant changes in their functions and
responsibilities and there is some apparent concern that
their role and status, particularly as protectors of
public health, have eroded and may be taken for granted.
In particular, there is concern that the imposition of a
ceiling on the management costs of Health Boards will
further reduce their capacity to provide the 24 hour
response required for effective outbreak control. |
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| 12.9 From
our review there was evidence of a clear commitment to
outbreak control by each of the health authorities.
However, there are concerns that other demands mean that
public health practitioners are unable to spend as much
time as they should actively engaged in preventive health
measures; and that they may not be involved early or
frequently enough with their EHO and microbiology
colleagues on matters that may impinge upon public health
and safety issues. It was suggested to us that, despite
competing demands on their time, they would wish to be
more widely involved in, for example, relevant Council
committees, in the investigation of potential health
hazards and in training (perhaps jointly with EHOs) in
food safety issues. Evidence also suggested there is a
less than clear or complete understanding, including
amongst EHOs, of the role and responsibilities of CsPHM
as DMOs to local authorities - including their
responsibility to exercise powers on behalf of the
authority. That needs to be clarified. |
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| 12.10 We
noted in our interim report the need for clarification of
the roles of SCIEH and The Scottish Office in outbreak
management and control. There would seem to be a need to
clarify in that context also the role of the Consultant
in Public Health Medicine (CD/EH), the need to include
him/her as appropriate in wider food safety issues which
may have a bearing on public health and the implications
of DMO status. Representations were received that we
should return to the situation which existed prior to
1974 when each local authority had a Medical Officer of
Health. Those representations highlight the lack of
clarity which exists in the present role of the DMO, both
in practical terms and in relation to the existing
legislation. We hope that our interim recommendation
relating to outbreak management plans will be fully
implemented and this should help to clarify the roles and
responsibilities of the people and organisations
involved. It might also be helpful for further advice and
clarification on these issues to be set out in a
Management Executive Letter at an appropriate stage. |
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| Public
Health Laboratories |
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| 12.11 As
noted in the Surveillance chapter of this report, we also
see a need to ensure the appropriate availability and use
of laboratory facilities and expertise. It is necessary,
in outbreak situations, to ensure the rapid availability
of accurate, consistent results of tests on cases and
food samples. That information will be required quickly
by outbreak control teams (OCTs) so that they can manage
the outbreak effectively. OCTs should therefore consider
carefully the best use of the laboratory resources
available and, by making appropriate use of local
laboratories, public health laboratories and reference
laboratories, try to ensure that the last of these in
particular do not get burdened down with inappropriate
work. Outbreak control plans could usefully consider, for
example, the availability of funds or access to
contingency funds to cover additional costs of testing
and protocols for submitting samples to appropriate
laboratories. |
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| Recommendations |
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| 12.12 Taking
all of the above into account, we recommend:- a. that Health Boards and local
authorities ensure that Designated Medical Officers have
adequate time and opportunity to contribute, with their
EHO colleagues, to the public health activities of local
authorities; and that they should be expected to report
on their work as DMOs at least annually to both the
relevant Council committees and the Health Board; and
b. that local
authorities and Health Boards ensure the availability of
adequate numbers of personnel with appropriate skills in
public health medicine and environmental health, together
with the laboratory facilities and resources they will
require to meet their obligations for disease control and
environmental health as defined in the Shields Report.
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