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colleagues at regional or strategic health authority level. It should be obvious, even on epidemiological grounds alone, that considerable advantages are to be ...
J Nash

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n recent years, infection control teams have been subjected to increasing scrutiny. Inspectors from various external agencies such as the Commission for Healthcare Audit and Inspection and the Clinical Negligence Scheme for Trusts visit and audit compliance with national infection control guidelines. The w o r k involved in preparing for these inspections is considerable, and voluminous folders of evidence must be prepared to show that the various infection control standards are being met. Adding to this pressure on in f e c t i o n co n t r o l te a m s , t h e Department of Health has recently introduced mandatory surveillance of Staphylococcus aureus bacteraemia, published this year as trust ‘MRSA league tables’ and more recently as surveillance of glycopeptide resistant enterococci and Clostridium difficile diarrhoea1. Nor is there any sign that the pressure will lessen; the chief medical officer has just published a comprehensive new strategy on containing hospital infection that will require considerable support from infection control teams as well as local reorganisation to accommodate the new post of director of infection prevention and control, outlined in the guidance2. This strengthening of infection control arrangements in hospitals is welcome, and it comes at a time when a new threat, in the form of extended spectrum beta lactamase producing gram-negative bacilli, is sweeping through the country. Against this background, L King et al, in this issue report on a pilot James Nash is a consultant microbiologist at the East Kent NHS Trust and the Health Protection Agency.

study of the application of a structured peer review process to the evaluation of infection control arrangements in the trusts in the east of England. The authors have hit on the excellent idea of using the mandatory surveillance data referred to above (MRSA league tables) to provide a focus for peer review of infection control arrangements by a suitably constituted multidisciplinary team.

‘The emphasis needs to shift towards measuring and controlling hospital infection rather than the performance of infection control teams.’ The message that emerges is that most participating trust infection control staff have found the exercise beneficial in helping to raise the profile of infection control problems with senior trust personnel. However, reading between the lines of this carefully balanced report, it is clear that a minority found some aspects of the peer review unhelpful – in particular, and perhaps surprisingly, the work required to produce an ‘action plan.’ It is unclear whether this negative reaction on the part of some was because the process was thought to be of questionable

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What should we measure: infection or infection control?

value or because it represented an unnecessary duplication of work already in hand. Handling disagreement within a local assessment of peer review is perhaps a more sensitive issue than is the case when an external assessor is monitoring compliance with objectively defined standards. Given that infection control teams are already subjected to a great deal of scrutiny, one is entitled to ask whether the rather ‘touchy-feely’ approach that characterises the peer review process provides any added value? I believe it does for the following reasons. Unlike the auditing processes referred to above the peer review process a l l o w s a two-way flow of information to take place and creates the potential for infection c o n t r o l t e a m s to pass useful feedback to the review team. Mu c h o f t h e m o r e interesting material included in this report is the information fed b a c k t o t h e r e v i e we r s b y t h e participating infection control teams. Notable is the need for better measurements of hospital acquired infection, including more detailed analysis of the case mix of the bacteraemia group to be found in the mandatory surveillance scheme. Of course passing back information to regional colleagues presupposes that they have a role to play (other than carrying out inspections). In many if not most parts of the country, hospital infection control teams have been left to manage their own problems with very limited help (some would say interference) from their colleagues at regional or strategic health authority level. It should be obvious, even on epidemiological grounds alone, that considerable advantages are to be g a i n ed through cooperative working and greater integration of local and regional infection control activity, and peer review of infection control services could provide a useful step towards this goal. I w o u l d encourage colleagues to take the peer review model yet further as p a r t o f a m o r e f o r m a l c oordination of local and regional activity. Local trusts and laboratories have

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often complained in the past about the one-way flow of communicable disease information to the centre. Encouraging greater dialogue with regional colleagues could correct this problem and enhance the value of the surveillance information collected. As was pointed out by some of the participants in this pilot study, better quality information is also needed. The extraordinary truth is that, despite the energetic focus on inspecting infection control teams, we are failing to measure the basic variables of hospital-acquired infection, much less control them. We have become so accustomed to this situation that we have lost sight of the bigger picture. Why are we not routinely measuring infection rates in our hospitals? Most lay people believe keeping hospitals visibly clean is a fundamental component of providing good care. The National Audit Office report of July 20043 points us in the right direction and is justifiably critical of our failure to introduce more comprehensive surveillance of surgical wound infection rates and infections after discharge from

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hospital. Providing this information nationally in a standardised format will require development of more sophisticated computer software to facilitate the exchange of microbiology and infection control data between local regional a n d national databases. The absence of a widely accepted microbiology computer message format has been a major obstacle to communicable disease surveillance for many years, and several generations of laboratory information systems have come and gone without this problem being adequately addressed. The National Programme for Information Technology 4 provides a crucial opportunity to correct this state of affairs but paradoxically could make the situation much w o r s e i f i t leads to the rapid deployment of new laboratory information management systems that lack even the rudimentary communicable disease reporting capability of the current systems. The emphasis needs to shift towards measuring and controlling hospital infection rather than measuring the performance of infection control teams. Regional

multidisciplinary teams working with local colleagues can help to establish the systems needed to manage this work. I believe the key to achieving this change in direction is not so much resource as commitment to the process, and perhaps that will only come as a result of a central diktat that addresses the need to measure and report hospital-acquired infection as well as the use of a national standard messaging format for public health information.

References 1. Department of Health. Surveillance of healthcare associated infections (PL/CMO/ 2003/4). London: Department of Health,9 June 2003. 2. Donaldson L. Winning ways: working together to reduce healthcare associated infection in England. Report from the Chief Medical Officer. London: Department of Health, 2003. 3 National Audit Office. Improving patient care by reducing the risk of hospital acquired infection. A progress report. London: The Stationery Office; 2004. Available at: 4. National Programme for Information Technology. Available at .

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H Pickles

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ccountability is about responsibilities, with each organisation knowing what is expected of it, and each individual within that organisation understanding what contribution is expected of him or her, and being expected to account for his or her actions. How has the establishment of the Health Protection Agency affected formal accountability for health protection?

Background The main purpose of clarity over accountabilities is to ensure that business is conducted effectively without overlaps or gaps between organisations, teams, or individuals. Some aspects of health protection require a rapid response, and there may not be time to consult and renegotiate accountabilities if these have not been worked out in advance. Where accountabilities are well described and understood, even if it is agreed they are being shared, there can be good prior planning, adequate investment without duplication, and minimisation of risks. One of the key purposes of defining accountabilities is to reassure staff at the front line about the limits of their personal and professional responsibilities. If the buck stops with them, then they need to know that, and to have agreed to it in advance. In the Nolan report, accountability is given as one of the seven Hilary Pickles is director of public health at Hillingdon Primary Care Trust, Middlesex.

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Accountability for health protection in England: how this has been affected by the establishment of the Health Protection Agency

through legislation, circulars, and local agreements 6. Many aspects of it are enshrined in primary legislation, empowering various bodies to discharge functions on behalf of the responsible ministers mentioned in the act. The duties of each public body are further detailed in a management statement, with the chief executive as the accounting officer responsible for delivery 7.

Primary legislation

principles of public life. It is further clarified as follows: ‘Holders of public office are accountable for their decisions and actions to the public and must submit themselves to whatever scrutiny is appropriate to their office’1. This is a reminder that the potential for

‘The net result is a system that has yet to deliver that “clear line of sight” for the Chief Medical Officer’

being held to account is an inevitable part of working in health protection. The public expectation is that any adverse outcomes in this area may need post hoc review, and that for major events this could be by public inquiry or through litigation. This applies to responsibility for advice given as well as for actions taken. Therefore: ‘Establishing before a crisis arises where lead responsibility for advice lies is highly desirable’ 2. A recurring theme in past public inquiries has been the lack of clarity over accountabilities and who was ‘in charge’ 3,4,5. The government has reminded us that accountability is defined

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Box 1 shows the key primary legislation allocating accountabilities for health protection. In many cases, the lead body with responsibility for health protection is the local authority (LA). As well as communicable disease control, the authority has the prime responsibility for emergency planning and acts as enforcement authority for controlling many of the major involuntary hazards. There has been no intention for the HPA to undermine the responsibilities of local authorities8. For years it has also been recognised that communicable disease law, some of which is based on concepts a century old, is badly in need of updating 9,10 . When Medical Officers of Health moved into the National Health Service (NHS) in 1974, they left their legal powers – the formal base for their accountability – largely behind with local authorities. To overcome this and to ensure functions continue where a medical voice is needed, local authorities have been appointing proper officers from the NHS. These individuals, mostly communicable disease and health protection consultants, will therefore have accountability to the local authority, although not usually backed by any written documentation other than their letter of appointment. A wide range of responsibilities relating to health protection fall under NHS Acts, much covered by the broad duties to promote health and provide services and to prevent and treat illness in the 1977 Act.

Secondary legislation Some

secondary

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BOX 1 The chief primary legislation allocating accountability for health protection

Local Government Act 1972 Local Authority duties Public Health (Control of Disease) Act 1984 Accountability met by local authorities, advised by proper officers National Health Service Act 1977 For accountabilities discharged by the NHS, some affected by subsequent NHS Acts, e.g. the NHS Reform and Health Care Professions Act 2002, which allocated some of the accountabilities previously held by health authorities to primary care trusts Civil Contingencies Act 2004 Emergency planning responsibility on local authorities, but also powers for emergency services in exceptional circumstances Health Protection Agency Act 2004 Accountability for radiation protection, but only advice in other fields Other specific areas covered by other legislation, e.g. Health and Safety at Work etc Act 1974 Medicines Act 1968 Environment Protection Act 1990 and Environment Act 1995 Food Safety Act 1990 and Food Standards Act 1999 Water Industry Act 1991

relevant to health protection is in box 2. The Health Protection Agency was initially set up in this way11, with powers limited to the functions held within the associated primary legislation. The HPA has a formal management statement, which details how the HPA is expected to manage itself, and its relationship with the sponsoring departments 13 . The details of its expected duties are outlined in ministerial directions14 and the business plan agreed with the sponsoring departments.

Departmental circulars Some NHS bodies have specific functions outlined by statute, but Department of Health ministers mostly rely on policy statements, guidance, and specific instructions. In 1993, a key circular on public health accountabilities15 confirmed

BOX 2

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Local documents

that the then district health authorities had responsibilities which included ‘arrangements for the control of communicable disease and infection, and for dealing with the health aspects of non-communicable environmental hazards’. These core responsibilities for the health protection of the population have now been transferred from health authorities to primary care trusts16. Other NHS bodies, such as acute and ambulance trusts, are expected to provide the necessary clinical services such as those required for consequence management. The role of strategic health authorities (SHAs) was initially expected to be limited and not to include health protection, other than performance management to make sure it happened. With the diminishing role of the DH, including the demise of the regional offices,

Examples of secondary legislation relevant to health protection

Under the NHS Act 1977 Health Protection Agency Establishment Order 200311 Under the Public Health (Control of Disease) Act 1984 Public Health (Infectious Diseases) Regulations 1988 Various transport regulations12

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SHAs have had to take on an increasing role, for example in emergency planning17. There has been no recent equivalent of the circular on public health accountabilities issued in November 1993 15 . However, as well as Getting Ahead of the Curve18, policy statements have covered specific areas of health protection, such as emergency planning17 and infection control 19 . These have served to emphasise the key responsibilities of NHS bodies such as acute trusts, Primary Care Trusts (PCTs), and SHAs, confirming the HPA in an advisory role. One area important to health protection, i.e. microbiology, now has its own inspector20.

At a local level, detailed memoranda of understanding (MOUs) outline the expectations of PCTs and health protection units: these are expected to be backed by agreed business plans, work programmes and performance measures. Other aspects of health protection, such as the delivery of specialist microbiology services by the HPA for the NHS, are centrally funded as part of the core functions of the HPA. Yet others, such as the provision of more routine diagnostic microbiology by HPA laboratories, are covered by NHS service level agreements (SLAs).

Discussion Contrary to what is implied by the term ‘Health Protection Agency’, at a local level it seems that formal accountability for health protection lies elsewhere, chiefly with local authorities and primary care trusts. This is in spite of the HPA employing many of the appropriate specialist staff, and being the organisation with much of the relevant capacity and capability. The main agreements between the HPA and PCTs are MOUs, which are non financial variants of the SLAs used for transactions in the NHS between commissioner and provider. Such agreements are incapable of covering all eventualities, and so inevitably

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net result is a system that has yet to deliver that ‘clear line of sight’ for the Chief Medical Officer 18. Even if the HPA does not have accountability for health protection in most routine areas, perhaps the health response to the challenges raised by the events of 11 September 2001 are matters it can call its own; however it seems not17. The role for the HPA appears advisory even here, to the PCTs at local level, to the regional directors of public health in the Government Offices of the Region, and to the DH at central level. To make the HPA properly accountable for health protection seems to need further primary legislation, carving off accountabilities currently lying with others. Some of this may come about with the projected revision of communicable disease law, but many areas fall outside its scope. An alternative view is that the proper place for accountability for matters as fundamental as health protection does indeed lie with those bodies that are most local, whether local authorities with their elected members, or PCTs sensitive to the health concerns that matter most to local people. At present it seems that there is a risk that ‘there is no agency unambiguously in charge’10, and roles and responsibilities remain unclear to many. This was a major concern of the National Audit Office27 and others, and it was taken up by a House of Lords committee 28 . A recent exercise confirmed that roles and responsibilities still needed to be clarified 29. The DH seems to deny that any clarification of accountabilities is needed 6, but a comprehensive circular, clarifying all aspects of health protection, seems overdue.

Conclusion Accountability for health protection is defined through legislation, circulars and local agreements. The many recent changes in the NHS, including the advent of the HPA, allow scope for confusion to develop. Clarification is overdue, say in a comprehensive circular from the Department of Health.

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These views are the author ’s. They do not necessarily represent the views of Hillingdon Primary Care Trust, nor of the HPA, nor of the accountability workstream engaged in the establishment of the HPA (of which the author was a member).

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incomplete 21 . Having the health protection experts distanced from the organisation holding most of the funds needed for the delivery of local health protection is also less than ideal 22 . The arrangements when proposed were described as having the potential for causing ‘enormous difficulties in horizontal accountability between the HPA and PCTs’ 23 , and were an issue of concern for many24,25. Nevertheless, joint local planning may be able to strengthen informal relationships and networks adequately so that there is good business continuity in health protection whatever the challenge, and worked up scenarios with allocated responsibilities can help prevent misunderstandings25. None of this, however, alters the fact that the prime local accountability does not rest with the HPA. And this knowledge, and the anxiety caused by the propensity of perceived shortfalls in health protection to lead to legal challenge and to public inquiries, may imperil local relationships with the HPA. The risk is one-sided. In 1993 Department of Health (DH) guidance 15 warned that: ‘Confusion about arrangements and lack of co-operation and co-ordination between authorities can impair the effective prevention and management of outbreaks of infectious disease resulting in avoidable risk to the health of the public’. Understanding what accountabilities are held by whom is just as important as it was a decade ago. ‘In establishing the HPA, the need for further clarification of the relative roles of DH and the HPA, and local Health Protection Teams and Primary Care Trusts and Local Authorities has been apparent26.’ The split between the legal regulators (local authorities) and the employers of the main health protection advisors, the Consultants in Communicable Disease Control (CsCDC), predated the creation of the HPA, of course. The HPA was formed during a period of instability and uncertainty resultant on NHS organisational change 27 , and yet further changes have followed, affecting strategic health authorities and the Department of Health. The

References 1. Standards in Public Life. First report of the committee on Standards in Public Life (Nolan report) vol 1( Cmd 2850). ISBN 0 10 128502 7. 2. Response to the Report of the BSE Inquiry. HM Government in consultation with the devolved administrations. London: Stationery Office; 2001. 3. The 2001 Outbreak of Foot and Mouth Disease. London: National Audit Office; 2002. 4. Naylor D (chair). National Advisory Committee on SARS and Public Health. Learning from SARS. Renewal of Public Health in Canada. Ottawa: Health Canada; 2003. 5. Chantler C, Griffiths S, Joint Chairs of SARS Expert Committee. SARS in Hong Kong: from experience to action. 2003. Available at: www.sarsexpertcom.gov.hk 6. The Government Response to ‘Fighting Infection’, Cm 6012 2003. Available at www.doh.gov.uk/ infection 7. Government Accounting. Available at: www.government-accounting.gov.uk 8. Health Protection. A consultation document on creating a health protection agency . London: Department of Health; 2002. 9. Review of Law on Infectious Disease Control. Consultation document. Department of Health; 1989. ISBN 1 85197 4415. 10. Monaghan S. The State of Communicable Disease Law 2002. Nuffield Trust; 2002. ISBN 1-902089-68-5. 11. The Health Protection Agency (Yr Asiantaeth Diogelu Iechyd) (Establishment) Order 2003. SI 2003 no 505. 12. Public Health (Aircraft) Regulations 1979, Public Health (Ships) Regulations 1979, Public Health (International trains) Regulations 1994, Public Health (Canal Boat Regulations) 1878. 13. Health Protection Agency Management statement 15 January 2004. Available at < w w w. h p a . o r g . u k / h p a / b o a r d _ meetings/docs_2004/030115/mgt_ statement.pdf>. 14. Directions to the HPA from the Department of Health and the National Assembly for Wales, quoted by the chairman in minute 3.3 in the minutes of the Board meeting of 5 June 2003. Available at: www.hpa.org.uk/ board_meetings/board_meeting5-603_minutes.htm 15. Public Health: responsibilities of the

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NHS and the roles of others. HSG(93) 56. Department of Health and Department of the Environment. The NHS Reform and Health Care Professions Act 2002. London: The Stationery Office; 2002. Available at: < h t t p : / / w w w. h m s o . g o v. u k / a c t s / acts2002/20020017.htm> Department of Health. Handling major incidents: an operational doctrine. January 2004. Available at: w w w. d o h . g o v. u k / e p c u / opdoctrine.htm Getting Ahead of the Curve. Depart-ment of Health. 2002. Available at: www.doh. gov.uk/cmo/publications.htm Chief Medical Officer. Winning Ways. Working together to reduce health care associated infection in England. Department of Health; December 2003. Duerden B. Inspector of Microbiology. Comm Dis Public Health 2004; 7 (1): 2-4. Allen P, Croxson B, Roberts JA, Archibald K, Crawshaw S, Taylor L.

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The use of contracts in the management of infectious disease related risk in the NHS internal market. Health Policy 2002; 59: 257-81. 22. Crawshaw SC, Allen P, Roberts JA. Managing the risk of infectious disease: the context of organisational accountability. Health, Risk and Society 2000; 2: 125-41. 23. Association of Directors of Public Health. 2002. Response to the Consultation Document on Creating a Health Protection Agency. [Available on request from the Department of Health (communicable diseases branch) – Hansard 10 Feb 2003 WA90.] 24. Responses to the Consultation Document on Creating a Health Protection Agency. 2002. [Available on request from the Department of Health (communicable diseases branch) – Hansard 10 Feb 2003 WA90.] For example those from the Faculty of Public Health Medicine, the Royal Institute of Public Health and the Public Health Medicine Environmental Group.

25. Close N. Health protection – getting it together. Public Health News 5April 2004, p9. 26. Dr Pat Troop, in her Chief Executive’s report to the HPA Board. June 2003. Available at: www.hpa.org.uk/ board_meetings/board_meeting-5-603_cereport.htm 27. National Audit Office. House of Lords Science and Technology Committee, 4th report Fighting Infection. July 2003. Oral evidence and written evidence from 18 February 2003. Pp 367-376. ISBN 0-10-400264-6. 28. House of Lords Select Committe on Science and Technology. 4th report 2002-2003. Fighting Infection. London: The Stationery Office; July 2003. ISBN 0-10-400262-X. 29. Health Protection Agency. Lessons learned from Exercise Magpie. (Press release.) London: Health Protection Agency; June 2004. Available at: .

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