Report of Health Protection Advisory Group 2011Advisory Group 2011 Published for the Health Protection Advisory Group by Health Protection Scotland Health Protection Scotland is a

Report of Health Protection Advisory Group 2011

Published for the Health Protection Advisory Group by Health Protection Scotland

Health Protection Scotland is a division of NHS National Services Scotland. Health Protection Scotland website: http://www.hps.scot.nhs.uk Published by Health Protection Scotland, Meridian Court, 5 Cadogan Street, GLASGOW G2 6QE. First published May 2012 © Health Protection Scotland 2012 Health Protection Scotland has made every effort to trace holders of copyright in original material and to seek permission for its use in this document. Should copyrighted material have been inadvertently used without appropriate attribution or permission, the copyright holders are asked to contact Health Protection Scotland so that suitable acknowledgement can be made at the first opportunity. Health Protection Scotland consents to the photocopying of this document for professional use. All other proposals for reproduction of large extracts should be addressed to: Health Protection Scotland Meridian Court 5 Cadogan Street GLASGOW G2 6QE Tel: +44 (0) 141 300 1100 Email: [email protected]

Report of Health Protection Advisory Group 2011 2

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Table of Content Foreword ......................................................................................................................4 Remit of Health Protection Advisory Group .................................................................5 Health Protection Advisory Group and its Work...........................................................6

Workforce education development ...........................................................................7 Epidemiology ........................................................................................................7 Incident management ...........................................................................................8

Health Protection Network........................................................................................8 Port Health Oversight Group ..................................................................................10

Members of HPAG.....................................................................................................12 The work of the HPAG member organisations .......................................................12

Faculty of Public Health ......................................................................................13 Health Protection Agency ...................................................................................13 Scottish Environment Protection Agency............................................................14 Royal Environmental Health Institute of Scotland...............................................15 Scottish Microbiology Forum...............................................................................15 Food Standards Agency .....................................................................................15 Local Authorities and Health Protection..............................................................16 Scottish Government and Health Protection Scotland........................................18

Economic Change and Health Protection ..................................................................19 Introduction.............................................................................................................19 Current economic background ...............................................................................19 Recession and health .............................................................................................19 Local authority ........................................................................................................20 NHS and health protection .....................................................................................20 Recession and health protection ............................................................................20 Summary and conclusions .....................................................................................21 Recommendations..................................................................................................21

Pandemic Influenza....................................................................................................23 National and international coordination ..................................................................23 Surveillance ............................................................................................................24 Public and Service Information...............................................................................24 Coordination of the Scottish Health Services .........................................................24 Public Health Delivery ............................................................................................24

Way Ahead for Health Protection in Scotland ............................................................25


Foreword When the Health Protection Advisory Group (HPAG) was set up in 2005, the aim was to establish an advisory group that represented the wide spectrum of health protection in Scotland. It followed on from the other changes that had been implemented with respect to health protection. It was the first attempt to produce such a comprehensive advisory mechanism at a national level. There was debate at the time about the limited role of a group that was ‘advisory’ and did not have any executive function, or indeed a funded infrastructure. The debate has continued and with the current ‘Stocktake’ review, the future of the group is being examined along with the wider issues of health protection in Scotland. While minor revisions have been made to the remit of HPAG, the group has been able to fulfil its advisory function through preparing papers, commenting on service provision, identifying concerns, outlining priorities and writing to the CMO. In general, HPAG through its regular reviews of health protection in Scotland has concentrated on examining the mortality and morbidity of the main communicable diseases and the impact of environmental factors, and has identified priorities for action within health protection. This has been linked to the capacity and resilience of service provision and the preparation of recommendations for change. At a less formal level, the regular meetings through their consideration of particular current topics and events have brought a broad view that can help to inform action on these particular topics. Similarly through the bringing together of the wide spectrum of membership, improved communication within health protection, has been achieved. It was decided that this report should include information about the role of some of the members and the organisations that they represent. There have been a substantial number of changes since the group was set up, including legislative changes, a flu pandemic and more recently a substantial change in the economic position. Accordingly, the current stocktake is to be welcomed and some further comments relevant to this will be made at the end of this report. It has been a pleasure and a privilege to chair this group since it was established six years ago. The enthusiasm and the commitment of the members remain strong. They have brought an unparalleled range of expertise, which has enabled very useful discussion on health protection issues, and they have all contributed to an enhanced role for health protection within Scotland. Professor Jim McEwen


Remit of Health Protection Advisory Group The remit of the Scottish Health Protection Advisory Group (HPAG) is to: Advise the Chief Medical Officer and National Services Scotland on matters relating to health protection and on the effectiveness, efficiency and quality of the health protection function in Scotland, and support the corporate development of Health Protection Scotland by:

• Advising on a strategic framework and priorities for health protection;

• Assessing and advising on major risks to the public health, and associated risk perception and communication issues;

• Advising on the effectiveness, efficiency and quality of health protection

plans and services, including major epidemic/pandemic and emergency plans;

• Advising on the capacity to prevent and respond to infectious disease and

environmental hazards, which present a risk to public health;

• Advising on research relating to support of the health protection function; and

• Producing an annual report The membership of the Group includes representatives from NHS boards, local authorities, Health Protection Scotland, other national organisations with an interest in health protection and relevant professional and staff bodies.


Health Protection Advisory Group and its Work Since the establishment of HPAG in 2005 there have been some important national changes and developments.

• Public Health Scotland Act 2008. Amongst other things this has established closer and formal links between NHS boards and local authorities.

• International Health Regulations 2005. This including revision of Port Health functions and international coordination.

• Good Places Better Health. 2008. This is an overarching policy initiative on environment and human health.

From 2008 - 2010, the HPAG agreed to identify priorities using the following criteria:

• Public health problems defined as having actual or potential impact on the health of the Scottish people.

• Improvements in health protection services that will enhance Scotland’s ability to prevent or respond to threats.

All contributors to HPAG sessions were asked to emphasise these two areas and included later in this reports are details of three sessions. HPAG meetings revealed many examples of positive developments in health protection including:

• Improvements in communication, such as the Health Protection Network and the sharing of evidence based good practice.

• Strengthened health professional networks. • HPV vaccine • Development of workforce education and training strategy for health

protection. • Improved understanding of risk communication.

There are also examples of concerns some of which were identified in the past and still remain, indeed it is possible that they may increase as a result of the current economic changes.

• Inadequate staff resources, recruitment and training – particularly in clinical infectious disease, environmental health and laboratory services.

• Public perception of importance of health protection. • Lack of research into many areas of health protection. • Limitations with respect to leadership, working relationships and collaboration. • Capacity and resilience in services especially in outbreaks.

While it is easy to identify major issues such as the impact of a pandemic or a major outbreak, it is equally important to ensure continuing vigilance for the normal and the routine, such as:

• Health care associated infections • Vaccine preventable disease • Gastro intestinal and zoonotic infections • Specialised laboratory provision • Quality assurance of health protection services

Some issues, although affecting a very small number of individuals may require considerable effort by many professionals and several organisations sometimes over a prolonged period. The outbreak of anthrax amongst drug users in 2009-2010 was a good example of this (see An Outbreak of Anthrax Among Drug Users in Scotland,


December 2009 to December 2010. A report on behalf of the National Anthrax Outbreak Control Team http://www.hps.scot.nhs.uk/pubs/redirect.aspx?id=50107) In addition to the formal membership, the group has links to other groups that have specific roles in coordinating and supporting aspects of health protection, such as the Health Protection Education Advisory Group and the Health Protection Network.

Workforce education development In consultation with service area strategic leads Health Protection Scotland (HPS) has worked jointly with NHS Education Scotland and stakeholders to further develop the health protection workforce. Initiatives have focussed on:

• Developing and implementing the National Framework for Workforce Education Development in Health Protection;

• Developing and implementing educational packages in specific health protection topics;

• Participating in the definition of European and UK knowledge, skills and competencies requirements and coordinating their application to the Scottish health protection workforce.

This work is overseen by the HPS/NES facilitated multidisciplinary/multiagency Health Protection Education Advisory Group (HPEAG) that reports to the Health Protection Advisory Group. In the last two years two key priorities have been identified for developing the health protection workforce:

• Epidemiology • Incident management

Epidemiology The need to strengthen the epidemiology function in Scotland has been highlighted by the health protection community. This has resulted in national work being progressed in relation to workforce development but further work is required. In August 2010 a stakeholder event titled ‘Strengthening epidemiology in public health (health protection) in Scotland – current and future development’ was facilitated by HPS. The aim of the meeting was to explore how health protection epidemiology in Scotland can be strengthened. The key questions asked were:

• What do we need – current and future epidemiology provision? • What are our priorities? • How will we progress in relation to workforce education development?

A report of the day was produced which included the following recommendations:

• In order to progress an enhanced coordination of epidemiological activities in Scotland clarification of the required (national/regional/local) infrastructure for the delivery of such activities is needed.

• The models for delivery of healthcare and environmental epidemiology require to be reviewed as a priority.

• In order to develop a progressive, integrated and cohesive approach to workforce development there should be:


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a) A scoping of current staffing establishment involved in epidemiological activities;

b) A scoping of current health protection epidemiology training and educational opportunities in Scotland.

This work will consider the needs for education and training of the various constituents of the workforce.

• Links with academia and other stakeholder organisations such as the Scottish Public Health Observatory (ScotPHO) and Information Services Division (ISD) require to be reviewed to ensure that maximum benefit is gained from partnership working.

HPAG members have noted these recommendations which we hope will feature in the current Scottish Government Health Protection Stocktake for further action. Current HPEAG work includes:

• Development of knowledge and skills matrix for Epidemiologists (based on ECDC competencies) within HPS. It is hoped that this work will be extended to include the wider epidemiology workforce.

• Continued support of the ECDC European training programme EPIET including hosting an EPIET fellow.

• Supporting the development of a UK Field Epidemiology Training Programme currently led by HPA. The first cohort of students started in Autumn 2011.

Incident management A subgroup of HPEAG has been established to consider this area of work. In order to help to move towards a progressive, integrated and cohesive approach in relation to workforce development two areas are currently being progressed:

• The development of health protection incident management training/educational resources that can be utilised by stakeholders in relation to specific topics e.g. VTEC resource

• Development of a folder of evidence of learning/experience in health protection incident management to allow practitioners/clinicians to prepare a personal profile of achievements in incident management mapped against these required knowledge and skill sets and to equip managers to be able to support staff to develop their knowledge and skills base.

This work will continue to be implemented and monitored by HPEAG.

Health Protection Network The Health Protection Network (HPN) has proved successful, in the last five years, in bringing together a multi-professional and multidisciplinary platform to promote, sustain, and coordinate good practice in health protection across Scotland. 2011 was crucial for the HPN to take a step forward in improving communication and collaboration amongst professionals engaged in health protection, as well as in facilitating increased understanding and respect for the roles of different disciplines in the health protection community across Scotland. In 2011, the HPN published a long hoped-for document that provides guidance and advice on preventing and controlling infection for staff who work with children in childcare facilities (day-care) and childminding services in Scotland (http://www.hps.scot.nhs.uk/haiic/ic/publicationsdetail.aspx?id=47103). This document was developed by a working group led by Health Protection Scotland (HPS) and formed by representatives from the health protection community in Scotland, stakeholders and key users, who considered current scientific evidence


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and expert opinion. The Health Protection Network (HPN) facilitated and coordinated the final stages of its development, its adherence to agreed criteria of validation, and its completion. Guidance on exclusion criteria is also available at http://www.hps.scot.nhs.uk/haiic/ic/publicationsdetail.aspx?id=47104. In October 2011, the Scottish Government issued the revised Management of Public Health Incidents; Guidance on the Roles and Responsibilities of NHS led Incident Management Teams (http://www.scotland.gov.uk/Publications/2011/11/09091844/0). The HPN contributed to its development and it is now supporting the implementation of the key principles of Incident Management that relate to education, promotion of best practice and curatorship of incident reports. The 2011 HPN agenda also included, among other initiatives, five guideline development programmes (see snapshot diagram) working towards different delivery plans and timescales; a programme shared with the Health Protection Educational Advisory Group (HPEAG) and the HP Educational Programme Manager (HPS/NES) to support workforce development; and the organisation of the HPN Guidelines in Practice event in Dundee (Ninewells Hospital) in May 2011.

Together with the credibility and the trust gained by the HPN in the last five years, come the increasing demand for new programmes and initiatives to set standards of care (more topics and areas of practice where guidance is needed), to support best practice, and to demonstrate compliance with the highest standards of care. Aware of the times of tighter budgets, reform and reorganisation we currently live in, the HPN is currently working towards securing future developments for the network, either through well funded investments or through other alternatives, e.g. integration with other networks (SIGN, HIS) and/or assimilation of other operational and


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organisational structures set by similar networks with clearinghouse and auditing functions. For further information, please contact [email protected].

Port Health Oversight Group The Port Health Oversight Group (PHOG) was convened, as agreed by HPAG, in 2007 to ‘ensure a seamless port health service’. The need for such a group was identified following publication of the revised World Health Organization International Health Regulations (2005) and after two reviews of Port Health and Medical Inspection (PH&MI) were carried out in England (2006) and Scotland (2007) by HPA and HPS respectively, which acknowledged the potential threat of international spread of disease. PHOG meets once or twice annually to identify priority issues and work streams. In the early stages PHOG identified key national and international stakeholders whose work would likely affect port health in the UK and Scotland in order to establish clear lines of communications. Two key stakeholders identified included the HPA Port Health Management Board, which directs PH&MI strategy for England, and the Scottish Ports Liaison Network, a group of Environmental Health Officers dealing with port health issues. A request for a representative from PHOG to sit on each of these groups was made and acceded. The importance of developing and maintaining such networks was demonstrated during the Scottish response to the H1N1 pandemic in 2009.1 One major task which PHOG has recently completed is the assessment of key Scottish ports as potential Designated Points of Entry (DPE).2, 3 Signatories of the International Health Regulations 2005, of which the UK is one, are required to assess and identify ports by 2013 as suitable DPEs: these ports will be instrumental in handling craft and passengers during Public Health Emergencies of International Concern. In 2010-2011 PHOG oversaw a survey of 5 key ports (2 sea and 3 air), with the aim of assessing their capacities against IHR Standards as defined by WHO. This task involved consulting with relevant personnel from NHS boards, local authorities and port operators. All 5 of the ports were compliant with DPE communication and routine capacity standards. With respect to emergency capacity most standards were met, and a minority were in the process of being met. Issues which were identified for further work locally included co-ordination of stakeholders to oversee any DPE function and specifics on anchoring larger sea vessels. Issues for further work at national level included nomination of the ‘Competent Authority’ for each DPE and clarifying standards with respect to radioactive contamination. The report made several recommendations which have been communicated appropriately including, for the Department of Health, ‘that the UK establishes a body to oversee all DPEs in order to ensure coordination of response to any PHEIC (Public Health Emergency of International Concern) in the future and to be responsible for appropriate training and guidance. This body should have representation from the relevant Public Health/Health Protection bodies for England, Scotland, Wales and Northern Ireland as well as from Department of Health, Department for Transport, Maritime and Coastguard Agency and Association of Port Health Authorities.’ (Recommendation 6 from 3). We are waiting for decision to be made on which UK ports will be designated before further consolidation work can be undertaken. In the interim, whilst waiting decisions on DPEs, PHOG has identified the following priorities for future work:


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1. Assessment of sea traffic to Orkney and Invergordon and any potential threat affected ships from these ports may pose to Leith and Greenock should the latter be identified as DPEs for UK (Recommendation 7 from 3).

2. Identification and involvement in work on improving communication of events and hazards on board ships and aircraft between Scottish Ports and foreign destinations.

3. Carrying out a consultation on standards required for larger Scottish sea and air ports, other than those designated as DPEs.

4. Responding to the Scottish Government consultation on Regulations covering Aircraft and Ships to replace the current Regulations.

5. Strengthening links with the Maritime & Coastguard Agency and the Association of Port Health Authorities.

References 1. Redman, CA, Genasi, FJ, Millar, LA, Smith, CC. Communication networks in a

public health emergency: the value of knowing who to talk to and of making yourself known. Poster: HPA Conference, Warwick, 2009

2. Redman, CA; Penrice, G; Herron, M; Lawrie, B; Smith, CC; House, R; Westacott, S; Black, N; Forteath, B.. Assessment of Key Ports as Designated Points of Entry under IHR 2005: Scottish data. Poster, HPA Conference, Warwick, 2011

3. Port Health Oversight Group. 2010 Assessment of ports as Designated Points of Entry under the International Health Regulations 2005. Health Protection Scotland, 2011


Members of HPAG As has been mentioned in previous reports, we are very fortunate in Scotland in having such a breadth of expertise and experience in the various areas of health protection (see Table 1). While in any committee, it is not possible to have the full range, HPAG has benefited enormously from its diverse membership. While essentially, the membership consists of representatives of organisations, it has been much more than a meeting of representatives. Individuals have brought skills from a wide range of professional backgrounds and experience based on many different work and administrative settings. Thus the Group has been uniquely placed to provide comment, support and advice on the full spectrum of health protection in Scotland. Table 1: HPAG Membership as of March 2012

Prof. Jim McEwen Chair HPAG Member Representing Dr Eric Baijal Directors of Public Health Dr Marion Bain National Services Scotland George Brechin NHS Chief Executives Jim Brown Scotland Representative of Heath Protection Agency Jacqueline Campbell Scottish Government Health Directorate Dr Bill Carman Health Protection Network Dr Andrew Carnon Faculty of Public Health Dr Anna Cichowska Heath Protection Agency Dr Martin Donaghy Health Protection Scotland Bernard Forteath REHIS Campbell Gemmell Scottish Environment Protection Agency Dr Mary Hanson Scottish Microbiology Forum Kate Harley Health Protection Scotland Kelly Leishman Consumer Focus Scotland Jayne Leith Health Protection Nurse Specialist Councillor Donald Mcintosh COSLA Peter Midgley Food Standards Agency Dr Ken Oates Consultant Public Health Medicine Dr Andrew Riley Scottish Government Health Directorate Professor Sir Lewis Ritchie Department of General Practice and Primary Care /

Royal College of General Practitioners Dr Charles Saunders Scottish Partnership Forum Dr Andrew Seaton Royal College of Physicians Jim Stirling Society of Chief Officers Vacant Health and Safety Executive

The work of the HPAG member organisations Although the Group has representatives from a number of organisations, they are essentially there in their own right and to provide specialised expertise on health protection issues in Scotland. A few contributions have been included in this report to illustrate the nature of these organisations and the particular skills and approach that they bring. It is evident that the contribution spans the whole community, national and local government, statutory organisations, professional organisations and health services in the community and in NHS boards.


Faculty of Public Health The Faculty of Public Health (FPH) is the leading professional body for public health specialists in the UK. In Scotland the FPH is represented by the Committee of the Faculty of Public Health in Scotland (CFPHS). The main roles of the CFPHS in health protection are advancing knowledge, developing standards and advocacy. Specific examples relate to these areas include: • The CFPHS organises an Annual Scottish Public Health Conference. This year's

conference was held in November 2011 and includes two parallel sessions (seven presentations) on Health Protection topics, where trained and trainee public health professionals have the opportunity to present their work and to advance the knowledge of health protection issues across Scotland. In 2011 there was also a plenary session on the impact of climate change on public health.

• Health protection is also included in the advocacy role of the CFPHS. In spring 2011 the Committee developed a jointly agreed manifesto that called on political parties in Scotland to take steps to ensure that the Scottish population are protected as far as possible against the threats from communicable diseases such as pandemic flu, environmental dangers including climate change and other major public emergencies.

• The UK Faculty of Public Health also sets standards for training in public health, which includes ten public health competencies, one of which is to promote and protect the population's health and wellbeing. Demonstration of this competency requires (amongst others) the trainee to provide evidence of:

- Dealing with the public health consequences of single cases of common communicable disease, for example meningococcal infection, gastro-enteritis, hospital acquired infection, blood borne viruses, tuberculosis and hepatitis A;

- Providing public health management of an outbreak with practical experience of at least two of the following: meningitis, food poisoning, gastro-enteritis, hospital acquired infection, blood borne viruses, tuberculosis and legionella;

- Familiarity with the general principles of investigating allegations of ill-health associated with long-term health exposures to non-infectious environmental hazards.

Health Protection Agency Health protection is clearly not defined by national boundaries and the direct link with the Health Protection Agency (HPA) has been essential. The HPA is represented on HPAG, both by the Board member appointed by Scottish Ministers to represent Scottish interests in the work of the HPA and by a professional staff member. The HPA works collaboratively with its public health counterparts in Scotland and the other devolved administrations on many aspects of health protection, including the response to incidents, which have a cross-border dimension. The Health Protection Agency Act 2004 gives the HPA responsibilities in the radiation protection field, which extend to Scotland. Hence the HPA Centre for Radiation, Chemical and Environmental Hazards (CRCE) has an important input to a range of health protection subjects, including the development of and maintenance of radiation protection emergency response arrangements, the assessment and restriction of radon exposure in homes and the monitoring of levels of radioactivity in the environment. These services are provided either directly from the CRCE headquarters at Chilton, Oxfordshire, or via the CRCE department in Glasgow. Some recent examples of the CRCE work are described below.


• Radon atlas for Scotland – The update to the 2009 radon atlas for Scotland was published in July 2011. Since the first map was produced the CRCE have worked closely with the British Geological Survey to produce a more accurate map. The new technique has led the CRCE to estimate that between 2,000 and 5,000 Scottish homes could have radon concentrations above the radon action level where work would be recommended to protect occupants.

• Radon “find and fix” programme 2009-2012 – CRCE radon programme is targeting Scottish homes in areas where the probability of being over the radon Action Level is 5% or more. Over 10,000 homes have been or will be offered free radon tests. To date, about 40% of householders have taken up the free test offer. Householders with significantly elevated radon levels are invited to local Radon Solution Days – drop in events where householders can learn more about radon, their risk and how they can reduce it. The programme has targeted areas of Aberdeenshire, Moray, Highland, Orkneys, Dumfries and Galloway, Scottish Borders and Shetland. Throughout, the programme has been developed jointly with local authorities and public health teams. The current programme started prior to the completion of the new map but, with agreement from the Scottish Government, the programme was modified to take account of the changes resulting from the new map. Discussions are being held with the Scottish Government to plan further radon work in Scotland.

• Dalgety Bay – CRCE has been involved in providing advice on the ongoing issue of radioactive particles on Dalgety Bay beach. CRCE is represented on the Dalgety Bay Forum and has provided advice to the group on health issues arising from the presence of the contamination on the beach as well as advice on protecting the public. In addition, the Radiochemistry Laboratories at CRCE Scotland have undertaken a number of studies on the radioactivity content of particles found on the beach. This has included assessing the activity of particles, undertaking radioactivity uptake studies in simulated gut fluids and collaborating with Professor Monty Charles (Birmingham University) in assessing potential radiation skin doses to members of the public who may be in contact with these particles.

Scottish Environment Protection Agency The environment plays a significant role in the health and quality of life of individuals and communities in Scotland. The relationship between environmental quality and health is highly complex. The Scottish Environment Protection Agency (SEPA) works closely with partner organisations (the Scottish Government, NHS Scotland, Health Protection Scotland, the Health Protection Agency, NHS boards, the Health and Safety Executive, and other government bodies) to develop the strategic framework for environment and health, to increase our knowledge of the key pressures on the environment which affect health and well-being, and to develop targeted action to address them. This includes looking at the positive impact that the environment has on health through the availability of green space and creating healthier sustainable places. SEPA aims to minimise the impacts of environmental incidents and emergencies, through timely and effective response and routinely respond to over 95% of environmental incidents and pollution reports within 24 hours. SEPA also have several duties under the Control of Major Accidents and Hazards (COMAH) Regulations and will focus on completing the national plan for COMAH inspections and safety case assessments. Specific examples of work on flooding, greenspace, radioactivity and bathing waters can be found in SEPA’s Annual Report 2010-2011 (http://www.sepa.org.uk/about_us/publications/idoc.ashx?docid=1fd56d98-b705-4257-a2b1-a9816fbdb554&version=-1).


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Royal Environmental Health Institute of Scotland Royal Environmental Health Institute of Scotland (REHIS) role in health protection revolves around education, training and qualifications for the profession (EHO professional qualification and CPD events across seven areas of EH) and for the public (community training). Over the last two years REHIS has continued to develop and expand its community training activities. Working closely with a range of partners and service providers the Elementary Control of Infection course, accredited by REHIS, is an important way of developing knowledge, skills and practice in infection prevention and control in the non-NHS care sector. In another joint initiative, this time with the Food Standards Agency Scotland, the Elementary Food Hygiene Course Schools Initiative continues to be presented in schools. On the professional development front professional qualifications for Environmental Health Officers (EHOs) and Food Safety Officers and greater emphasis is being placed on Continuing Professional Development and Chartered status for EHOs.

Scottish Microbiology Forum The Scottish Microbiology Forum brings together brings together all NHS Consultants and senior scientists providing Medical Microbiology and Virology diagnostic, specialist and reference services to NHS Scotland. One of the main building blocks of health protection is the science of medical microbiology and virology. Effective management of public health incidents and outbreaks in general is recognised as a health protection priority. The Medical Microbiology and Virology diagnostic services supported by the specialist and reference laboratories have a major role in this, as demonstrated by several incidents over the last two years. Firstly, the large outbreak of anthrax infection in drug users in Scotland in 2009/2010, where information disseminated through the Scottish Microbiology Forum informed actions to optimise early diagnosis and to provide intensive treatment guided by expert microbiologist advice. Furthermore, public health actions to control a large Scotland-wide cluster of cases infected with an unusual strain of E coli O157 phage type 8 in 2011, clusters of tuberculosis in 6 NHS boards in 2010/2011, and clusters of measles in several NHS board areas in 2011 have relied on timely information provided by effective diagnostic and reference laboratory services. In relation to HAI and antimicrobial resistance, the work of the NHS Board Microbiology services has underpinned the reduction in both Clostridium difficile infection and Staphylococcus aureus bacteraemia to meet national HEAT targets. The Scottish Microbiology Forum has also lead on the implementation of standardised automated antibiotic sensitivity testing and reporting to Health Protection Scotland to support local patient care and national surveillance of antimicrobial resistance. The emergence of novel and unusual pathogens such as verotoxigenic E coli O104:H4, and influenza A (H1N1) and human adenovirus 14 causing severe respiratory infections, has further emphasised the requirement for optimum Medical Microbiology and Virology laboratory capability, especially where a rapid response is required in the event of a major threat.

Food Standards Agency The Food Standards Agency (FSA) is responsible in Scotland for all aspects of policy relating to food and feed law and works in close partnership with Scottish Government to deliver dietary policy in Scotland.


The FSA’s renewed Foodborne Disease Strategy to 2015 aims to tackle foodborne disease by targeting the pathogens that have been identified as causing the greatest burden of disease. The strategy is based on a farm-to-fork approach, with the aim of reducing contamination of foods during production and processing and of promoting good food hygiene practice in the kitchen, both commercially and in the home. Incident management during 2011 has included monitoring across the UK during recent outbreaks involving E. coli O104 in Europe to ensure readiness should affected products have been found to have entered the UK and provision of advice to consumers and businesses. A widespread outbreak of Salmonella bareilly infection in Scotland and England in 2010 provided an excellent example of joint working between local authorities, NHS boards, HPS and the FSA. Local authority investigations in Scotland allowed the FSA to undertake a traceability exercise which conclusively identified beansprouts as the vehicle of infection. Subsequent local authority investigation found that the beansprouts had been mishandled. As a result, the FSA was able to issue specific targeted advice on the handling and labelling of beansprouts, aimed at preventing future incidents. The FSA continues to work with the Scottish Government and key food and drink industry partners in Scotland to improve the Scottish diet through the reduction of salt, fat and sugar in their products. Also the FSA is part of the Food Implementation Group (FIG) which focuses on working with all stakeholders collectively to develop and take forward positive action in relation to energy intake. The FSA’s Hygiene, Healthy Eating and Activity in Primary Schools initiative has developed over 5 years into a successful resource delivering food hygiene, healthy eating and activity messages to P4-6 pupils. Key partnerships have been established with Scottish Rugby, the Scottish Football Association, Tennis Scotland and the Active Schools Network. In the five year period to the end of 2010-11, over 53,000 school children in more than 1000 schools across Scotland had undertaken the HHEAPS programme. The FSA’s Food Hygiene Information Scheme provides consumers with information about the hygiene compliance at catering and retail premises assessed by local authorities as either ‘Pass’ or ‘Improvement Required’ (http://www.food.gov.uk/ratings). The scheme is currently being operated by 20 Scottish local authorities with six more currently intending to launch. FSA is continuing to encourage the remaining six local authorities to participate.

Local Authorities and Health Protection Local authorities play a vital role in protecting the health of individuals and groups in our communities. Their part in helping to implement public health policy at a local level is key to a successful national health protection strategy. In addition to their operational contribution local authorities also have a role in helping to shape the development of public health protection policy. Whilst Local Authority Environmental Health Services are mainly regulatory, the core activities of which are required by statute, services tend to be whole area rather than locality, age or gender specific. The services provide protection through reactive activities, i.e. investigation and resolution of sporadic public health enquiries; and also through preventative activities such as planned interventions, monitoring of food, air, water and workplace safety. In common with other public sector organisations local authorities are facing extremely challenging times and budgetary pressures are


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tending to draw focus on the need to make sure the statutory obligations and functions local authorities have in regards to Health Protection are given priority. The challenges also mean every avenue to improve efficiency is explored and that partnership working is maximised to this end. To this end local authorities and local partners are moving toward more assets based and collaborative approaches to achieve local outcomes in regard to health protection. As well as working with local health boards and other organisations toward the health protection function, local authorities coordinate service departments internally in order to deliver the environmental health, food safety, health and safety, health protection and licensing duties and services as efficiently as possible. It has long been acknowledged that the local arrangements currently in place for health protection work well. A central element of the local health protection function is the Joint Health Protection Plan (JHPP) which was introduced by the Public Health (Scotland) Bill 2008, this is enhancing the links between local partners.

Convention of Scottish Local Authorities (COSLA) COSLA’s purpose is to be the national voice for local government in Scotland and its high priority work areas reflect its commitment to promote the position of local government as the legitimate sphere of governance closest to the people of Scotland and, very importantly, to take the lead in shaping the future of local government and ensuring that local Councils remain at the heart of public service delivery. COSLA's aim is to enable elected members of different political groups to have the opportunity to contribute to COSLA’s work and to participate fully in the development of policies for local government. Responsibility for development of key policies rests with seven spokespersons, each of whom has responsibility for a major policy area as follows:

• Community Safety • Community Well-being and Safety • Education, Children and Young People • Health and Well-being • Regeneration and Sustainable Development • Resources and Capacity • Strategic Human Resource Management

Public Health and more specifically Health Protection links the remits of a number of these groups, for example, the licensing aspects of health protection are progressed by Community Well-being and Safety. Staffing and workforce issues are dealt with by Strategic Human Resource Management. Health issues are progressed by Health and Well-being and Environmental Health issues are dealt with through Environment and Regeneration. The strong links COSLA has with its networks of advisors throughout Scottish councils are one of the sources it relies upon as teams progress matters of policy development on Public Health issues. COSLA has played an important role in a number of high profile public health episodes including incident management ofH1N1, Clostridium difficile, as well as contributing to policy development for example through Public Health Bill and the Health Protection Stocktake.


Scottish Government and Health Protection Scotland The Scottish Government and Health Protection Scotland play very key roles in the deliberations and the working of HPAG. The meetings of HPAG provide a regular opportunity for updates from both and for direct comments on all aspects of the HPAG agendas. Thus, it is possible to have comprehensive discussion on the national implications of all issues, and to outline further work that is required and identify topics for future discussion. Their special contribution has included: vaccine preventable disease especially influenza and Human Papilloma immunisation campaigns; Healthcare associated infections, MRSA screening and action on C. difficile; sexual health, blood borne virus and sexually transmitted infections; pandemic influenza and influenza H1N1; anthrax infection in drug users; gastro- intestinal and food borne infections; tuberculosis. The illustrative examples show the importance of the development of national policy, through the Scottish Government, the leadership role of Health Protection Scotland, the relevance of national organisations such as SEPA and FSA, the key role of local government and the contributions of professional organisations such as environmental health, public health, laboratory science, clinical infectious disease and primary care. Also the importance of collaborative working with health protection agencies cannot be overstated as it is only by working together with the common goal of improving and protecting Scotland’s health that the needs of the people can be met. Another benefit to the group has been the opportunity to invite contributors on specific topics. A summary of the findings from two recent sessions at HPAG meetings is included in the following section of this report.


Economic Change and Health Protection

Introduction There was a lack of a clear picture as to the existing and potential impact that the deteriorating economic situation would have on health protection. HPAG commissioned three papers to be presented to the group. It was felt that this was a very important area for wide debate while recognising that this only covers some of the areas relevant to health protection and future detailed discussion of some other topics and areas will be required. The effect of the economic situation on the long-term provision of health protection and the effect on the health of the population of Scottish has yet to be seen. The issues selected, drew attention to the many aspects of the current economic position that may affect health protection, but sought to set these in the wider setting. The presentations covering three the following topics:

1. Public health impact of recession: evidence and implications. 2. Economic impact on health protection (one view). 3. NHS budgets: the implications for public health / health protection.

The presentations 2 and 3 focused on particular geographical settings, but similar issues are found elsewhere, as confirmed by members of HPAG in the discussion. While it was accepted that the majority of effects from the changes were likely to be negative, through reduction in services and staffing, and would lead to potentially adverse effects on health, it was also recognised that the resulting critical review of health protection services, provision and functions could lead to improvements. It is hoped that this initial consideration could be followed up at future HPAG meetings.

Current economic background Within the UK, there is a predicted overspend in the current year (2011) on top of a substantial debt. There is likely to be a slow economic recovery and in general, planning is based on a reduced budget over the next three years. In addition, there are significant cost pressures relating to such items as fuel, care of the elderly, school provision, land fill tax and carbon tax that will add to the concerns over funding in Scotland. Also it is important to note that health spend tends to increases because of demography, technology and expectations.

Recession and health Four main points were made with respect to the overall effects of recession:

• Economic recession affects health • The effects can be positive as well as negative • The effects are specific to different risk factors, health topics and the length,

severity and causes of recession • The effects can be mediated by policy response

Evidence suggests that for high income countries, it is unlikely that the recession will have major negative health effects on overall population health indicators, such as all-cause mortality, but there is potentially an increase in health inequalities between socio-economic groups. Different groups (such as the unemployed, unskilled and low


income families) are affected differently and the impact of recession is not evenly distributed, nor its effects. Specific diseases and cause specific mortality rates may rise – especially infectious diseases and mental health problems. Impact on behaviour may lead to reduced uptake of protection for infectious disease and increased risk of infectious diseases associated with behaviours that may increase during recession, such as drug abuse. However it should also be noted that there are likely to be some positive effects – reduction in road traffic accidents and reduced alcohol consumption.

Local authority Local authorities have already made substantial changes as a result of the recession. With respect to environmental health, there is a very wide range of activities and the recession has highlighted the dilemma between fulfilling a statutory duty and protecting health. Making decisions about local authority services is complex, including officer proposals, elected member decisions and public and staff consultation. Three related areas are affected – staff resources, ways of working and service provision. Generally the aim has been to avoid redundancy, but introduce voluntary severance, pay restraint, freezing of posts, investigation of shared services, new forms of working such as mobile and flexible working, building rationalisation and the removal of new training posts. With respect to service provision, this includes reduction on pest control, removal of consumer advice, removal of out of hours provision, reduction in inspections and sampling. Overall there is reduced capacity and reprioritisation of services. It should be noted that the current changes with respect to environmental health services come on top of years of reduction. It is now not about what we are not doing, but ensuring that what we continue to do is targeted to deliver the maximum protection, within the overall reduced capacity. There is concern about resilience, capacity and forward planning. Inevitably, there is inconsistency across authorities.

NHS and health protection Within the NHS, there is already an impact on all services, although with identified savings, the aim is to produce a balanced budget. There are increased costs and these are likely to continue to increase over the next three years – drug costs, tax changes, clinical negligence, pay increments and committed developments. There is a reduction in capital spending, but the main impact on health protection comes from a reduction in staff and capacity. A substantial amount of the provision related to health protection is located within the Public Health Departments, where there are already reductions in staff, although generally health protection has been relatively protected, as have screening programmes. In addition we should not forget the public health role of all NHS staff (which may be diminished if their tasks are prioritised, and the role of e.g. public health nurses/health visitors with their direct role in public health/health protection (and are not located in Public Health Departments).Some areas of health protection have ring fenced funding. There is also the impact of changes in the clinical and laboratory services which relate to health protection. Planning has, and is continuing to mitigate the effects through changes to working practices, enhanced cooperation with other health boards and through new national project links.

Recession and health protection There is a need to recognise the great breadth of health protection (as is evident from the membership of HPAG). Many authorities, organisations and professional


groups are all affected by the economic changes and this will inevitably limit their contribution to the overall work of health protection. The health protection functions of both local authorities and health boards are not isolated from the wider provision in their localities. Equally, where there are close links to other organisations such as FSA or SEPA, service changes by one authority can adversely affect relations and service provision. Authorities have the flexibility to prioritise delivery areas that would be most likely to have an impact on health. As increased efficiency alone could not meet the current and projected budget cuts, it might be better to cut out some services completely than to run them badly. Within the NHS, health protection covers many other services not directly considered in this initial discussion – such as laboratory services, infection control, clinical provision for communicable disease, primary care, health promotion and immunisation and vaccination. There is particular anxiety related to the fact that the impact is not immediate and that this may lead to a continuing gradual reduction in the quality and quantity of health protection, with the removal of services that have been developed over many years and have been proven worthwhile. Even the impact of the considerable changes that have already taken place are not yet evident. It may be necessary to consider, as in some other countries, paying for services that have previously been provided e.g. refuse collection. A common theme is that health protection is often invisible until something goes wrong. Special consideration should be given to the groups that would be most adversely affected by the recession and any associated reduction in services, to ensure impacts are minimised. The population groups, affected by the general economic recession are at greatest risk from the health effects. Health protection generally has most impact on those who are already marginalized. Cuts now, could lead to increased health problems in the future. While at present HPAG is not in a position to recommend detailed health protection priorities, they believe that it is urgent for the CMO to recognise the need for this to take place at a national level. It is recommended that this initial discussion is continued and extended. We need to remind policy makers that good health is good for the economy.

Summary and conclusions • Impact not immediate • Reduced interventions and concerns about, capacity, resilience and forward

planning • Emphasis on fulfilling statutory duties rather than protecting health • Inconsistency of provision across the country

There are some possible positive effects through new forms of collaboration (such as Joint Health Protection Plans (JHPPs)), service reviews and restructuring of service delivery.

Recommendations As it is accepted that policy changes can affect the impact of recession, the aim should be to:

• Avoid cutting prevention and health protection services • Examine the potential gain from new ways of working


• Use evidence of cost effectiveness to focus on systems, interventions and client groups e.g. unemployed, unskilled and low income families that can have maximum impact

• Look at the whole field of health protection. • Review at the national level, key functions, and priorities for health protection

and the best ways of working.


Pandemic Influenza The pandemic influenza in 2009 was clearly the most significant event with regard to health protection for the public, all health authorities, local government, the media and national and international organisations. This was a major concern for HPAG. It considered that the preparation and planning within Scotland at all levels and involving all services had been of the highest standard. Many authoritative national, international and local reports have been produced and HPAG considered that it would review these, as without an infrastructure it would not have been possible (nor indeed desirable), to prepare it own independent report. It identified a few key points and recommendations for future action and these are reproduced here. It is interesting to note that in our first report, the first identified priority was ‘enhancing preparedness for a potential influenza pandemic and outbreaks of avian influenza’, although the actual influenza was different. HPAG has now considered the various reports that have been prepared on the Influenza A(H1N1) pandemic and did not feel that it should add to the recommendations and comments that have been produced, but considered that it would identify a small number of issues that might be particularly useful for future planning. These issues have all been identified in formal national and local reports and are simply listed below. These reports contain a vast amount of carefully researched and documented evidence with clear conclusions and recommendations. The range of coverage in the reports from detailed technical comments to aspects of communication to the public, shows the expertise and thoroughness that has been available in the preparation of the reports. As a small group with no infrastructure, HPAG wishes to commend the work that has been done on the management of the pandemic and is aware that the lessons learnt are already being incorporated into planning at national and local levels. It was agreed that the Scottish Government had been well prepared and the overall response by all the relevant organisations involved had been appropriate and timely. The enormous commitment of all staff involved, their willingness to undertake huge tasks without consideration of time, is recognised and HPAG pays tribute to all that was done by many different organisations and individuals.

National and international coordination It was considered that while, the overall coordination had been effective, well planned and useful, the scope for further modifying the application of the general UK approach to Scottish circumstances should be assessed. In particular, there was concern that the containment phase had been inappropriately prolonged and should have stopped earlier. This had resulted in a very considerable workload and uncertainty in many categories of staff. It was agreed that there was need for better clinical information and a strengthened public health advisory structure at a national level. This second could perhaps, in part, be met in future, by a revised role for HPAG, which would include a current advisory role in such situations, rather than one that comments after an event. A standing mechanism/structure for expert scientific advice on national outbreaks and other health protection emergencies needs to be established at national level in Scotland. This could be called rapidly into immediate action when needed.


Surveillance While there was extensive preparatory work on this, it is hoped that the lessons learnt from the pandemic will lead to enhanced emphasis on better assuring the quality of data systems and standard testing. We agree that there should be consideration of greater comparability and where appropriate harmonisation of surveillance systems within UK and a common framework for reporting findings. This should not be to the detriment of existing high quality Scottish data systems.

Public and Service Information It was agreed that there could be an improved system of information for professionals and the relevant professional bodies. This could help to overcome the problem of lack of consistency with respect to advice about issues such as safety and efficacy of vaccines. While noting the very good public communications work undertaken, additional thought should be given to ensure that the media are provided with accurate information about risk especially in relation to the current position of the outbreak and the planned for ‘worst case scenario’. Other issues that should be considered are communications on vaccine effectiveness and safety; the value of mass vaccination and the need for care providers to receive vaccination.

Coordination of the Scottish Health Services Much has been learnt from the pandemic relating to management structures, cooperation between different parts of the health service and the need to estimate in advance service capacity and resilience, (particularly in the smaller NHS boards) along with the importance of priority planning. A review of the process of identification of leadership at all levels should be undertaken.

Public Health Delivery Common data sets and staff for data management were identified as a priority to achieving consistent and effective delivery to case and contact management. The need to be able to link data from primary care and the potential for immunisation lifelong records were also raised. Thought needs to be given to the need for patient identified data and what can be achieved without it. What is required at both local and national levels for effective public health practice and health protection? Further consideration also needs to be given, where appropriate and in compliance with legal requirements and Caldicott procedures, to the rapid access to patient-identifiable data in investigating outbreaks, when patient identifiable is considered necessary. Effective communication to public health departments and recognition of their role in briefing the local media are vital. It is recognised that a future health protection challenge may be very different from the Influenza A(H1N1) pandemic, and that it is important that the lessons learnt from this can be used to ensure a flexible and appropriate response in the future, whatever the challenge is.



Way Ahead for Health Protection in Scotland The current Health Protection Stocktake Working Group will be making recommendations that would affect the future role of HPAG. The changes, and lessons learnt since HPAG was established, indicate that such a review is timely. Just as the role of HPAG was related to the structures and provision in 2005, so any new group should be related to overall proposed changes to health protection in Scotland. The new structure of the Health Protection Agency (HPA) is also relevant. HPAG has discussed options for the future and has contributed to the Stocktake process. The group considers that it is essential that any future national advisory group retains the breadth of representation, as this has proved to be the key strength of the present position. It should also retain ‘the independence’ that enables it to comment on any aspect of health protection. However, it believes that the function of the group would be strengthened, if there was some funded infrastructure, and that it did not have to rely on the goodwill of others (particularly HPS) for such things as meeting arrangements, minutes and preparation of papers. The inability to undertake even very small scale ‘research‘, prepare review papers, etc. is a disadvantage. While there are, through the membership, close working relationships between NHS and local government, HPAG believes that these could be strengthened. In addition, the wider group membership has enabled a more coordinated and integrated view of health protection and this also needs to be continued and developed. We believe that the aim should continue to be ‘to ensure a consistent and coordinated health protection response across Scotland’. It is also vital that close contact is maintained with HPA and all relevant UK and international agencies. It is hoped that any new group will be able to draw on the same expertise, but may have a strengthened role in advice.

Documents

Report of Health Protection Advisory Group 2011Advisory Group 2011 Published for the Health Protection Advisory Group by Health Protection Scotland Health Protection Scotland is a