Oral evidence: Public health post-2013 – structures, organisation, funding and delivery, HC 569
Oral evidence, 24 May 2016.
Witnesses
Professor Kate Ardern, Director of Public Health, Wigan Council, Paul Davison, Deputy Director Health Protection, North East Public Health England Centre, Dr Dan Seddon, Public Health Consultant, Screening & Immunisation Lead for Cheshire and Merseyside, and Dominic Hardy, Director of Commissioning for Wessex, NHS England South, NHS England, gave evidence.
Chair
Thank you for coming this afternoon. Could you start by introducing yourselves to those who are following this discussion from outside the room, starting with Professor Ardern?
Professor Ardern
Thank you, Chair. I am Kate Ardern. I am director of public health in Wigan Council. I am also chief officer for emergency planning and civil contingencies and lead DPH on behalf of the Association of Greater Manchester Authorities for health protection and civil contingencies.
Dr Seddon
My name is Dan Seddon. I am screening and immunisation lead for Cheshire and Merseyside, serving 2.5 million people, and managing a team of around 15 people to do that. I work for Public Health England and am embedded in NHS England.
Paul Davison
Good afternoon. My name is Paul Davison. I am deputy director for health protection for the north‑east health protection team, Public Health England.
Dominic Hardy
Good afternoon. My name is Dominic Hardy. I am the director of commissioning operations for NHS England’s Wessex team, covering Hampshire, the Isle of Wight and Dorset. Part of my remit is to include a screening and imms team, of which Dan is a part in a different team in the country.
Chair
Thank you. Welcome this afternoon. Following on from the previous panel, perhaps starting with Professor Ardern, how clear do you feel the roles and responsibilities now are within health protection post‑2013?
Professor Ardern
In Greater Manchester, we started work on setting out roles and responsibilities as part of the transition process from the NHS into local government. We were able to build on some very excellent assets that local authorities had already put together around joining together their emergency planning function. So we thought through what health protection would look like in a local government public health function and had very clear dialogue with both Public Health England and the civil contingencies and resilience unit in Greater Manchester, which had been set up to offer emergency planning support and 24/7 response, which was a very attractive offer to support DPHs going into local government. In Greater Manchester, we were building on existing good practice and existing structures that were firmly embedded within the Association of Greater Manchester Authorities. Clearly, that is much easier in a conurbation like Greater Manchester where you have those existing relationships, but we should recognise that there are some very good systems around the local resilience forums, the local health resilience partnerships, which have themselves statutory functions, and, of course, the health and wellbeing boards at upper‑tier local authority level. It is sometimes about using effectively the systems that we have in place. For example, within my own health and wellbeing board, health protection is a standing agenda item. We bring regular reports on screening and imms, and indeed the local emergency planning and health protection group, as Dr Cameron was saying, reports directly into the health and wellbeing board. Perhaps it is about using existing systems properly and looking at the assets that have been developed within local government.
Chair
Thank you. Having listened to Dr Cameron, one thing he highlighted was the issue of who pays for what. Is that also an issue for your area?
Professor Ardern
No, it is not. In fact, we have been very clear to embed civil contingency and outbreak management support into our commissioned services. For example, working with our community trust, we have embedded it within the school nursing contract and within the health visitor contract. We have surge capacity arrangements set up with our local acute trust where their infection control team will support mine, and, indeed, I think in my written evidence we have also given the example of our health protection confederation across Greater Manchester, which links all the infection‑control nurses in local government and the commissioned services that Mr Razzaq was referring to into a confederation that enables them to give mutual aid across Greater Manchester. If you have an outbreak in Bury, you need to be able to flex a resource from the rest of Greater Manchester to go and give them support.
Chair
Indeed. One issue raised by the previous panel was that the weakness in the system seemed to be in the provider arm. Do you feel that you have now resolved that to your satisfaction?
Professor Ardern
Yes, because we have the ability to call on resources from across the conurbation.
Chair
Having thought about a number of the problems that could have arisen, are there still some outstanding areas that concern you that you feel this Committee should address?
Professor Ardern
Yes. They are twofold. Resourcing issues, in terms of the public health grant reductions, remain a concern. Another example I would give with respect to the screening and imms part of the system is the training of people to undertake screening and imms. That was quite an intensive resource that we had within the NHS, but who pays for and delivers that training is an issue.
Chair
That is an area we are going to return to specifically, so I am not going to press you further on that now. Could I perhaps return to the point about the public health grant and the in‑year cut in the budget as well? Can you give us some examples of how that has practically hit your ability to respond on the health protection side of your responsibilities?
Professor Ardern
It has not directly affected me so far because health protection is what you prioritise; it is the business critical function of public health. You look at other areas where you can more safely make reductions and you protect your health protection resource to be your business critical function; plus, it has been helpful in embedding it within my wider role within Wigan Council, which incorporates the rest of civil contingencies and emergency planning, also to have that resource, so I have a much wider asset to support me. So, no, it has not directly affected me yet.
Chair
What are you doing as a local area to try to spread your experience to other areas that are struggling? We have heard in this Committee that there is still some variation in how confident people feel to respond to public health emergencies.
Professor Ardern
One thing we decided to undertake was a sector‑led improvement review. I am a peer review challenger for the Local Government Association and I find that undertaking peer challenge, going and learning from other areas, but also being able to hold a mirror up and reflect on your own practice, is a really good route to try to look at how you might improve services. We undertook a sector‑led improvement review across the whole of Greater Manchester. We involved all 10 local authorities, all 12 clinical commissioning groups, Public Health England and NHS England, and that was specifically looking at outbreak management and response. We have come up with a set of recommendations for Greater Manchester itself, which we are taking through the local health resilience partnership, which I co‑chair, and reporting into the local resilience forum—Greater Manchester resilience forum—and we have come up with recommendations and advice for each borough and each CCG to work on locally. The assurance framework for that is through the health economy resilience groups, which report back into the local health resilience partnership.
Chair
Thank you very much, Professor Ardern. Do other members of the panel want to add to what Professor Ardern has said or identify particular problems in your own areas?
Paul Davison
Yes, please, Chair, if I could, and it is going back to your first question about public health protection assurance. There are a couple of points I would like to make. One would be that public health and health protection are very broad terms. It is quite a specific set of discussions that we are having this afternoon. We need to recognise that national organisations like the Environment Agency, the Food Standards Agency, local authority EHOs and national colleagues in PHE have a role to play in health protection. You asked about assurance—about roles and responsibilities. From a Public Health England perspective, we are very clear about our health protection roles and responsibilities and very clear about the partnerships that we need to discharge those roles and responsibilities. I manage a team similar to many teams around the country, comprising nurses, practitioners and consultants in health protection, that day to day are dealing with thousands of inquiries, cases, incidences of infectious disease and environmental hazards, and dealing with outbreaks on a day‑to‑day basis. That is our root and branch—our core business. Linking back to the discussions that you had in the previous session, however, the context and complexity play a part in how we discharge those responsibilities. In terms of being clear about roles and responsibilities, we are absolutely clear about those.
Dr Seddon
I would like to complement what my colleagues have said in this respect. Thinking about the screening and immunisation function and the whole section 7A remit of NHS England that I am involved with, broadly, yes, it is very clear. Section 7A is clear around the NHS screening programmes, the NHS immunisation programmes, in which we are responsible for ensuring quality and effectiveness, and the public health services into prisons and sexual assault referral centres. The section 7A remit is clear. There is a difficulty, however, when one gets to the edges of that. For example, as was touched on in the previous session—I think Kate has touched on this as well, and, by implication, Paul has—where there is an outbreak of vaccine‑preventable disease, whose responsibility is it to lead and to write the cheque for a group of immunisers to be provided to immunise rapidly a population of university students, as we had when we had two linked cases of meningitis W? In university students, you can imagine the noise and anxiety that created, and we wanted to take advantage of that in order to accelerate the immunisation programme. The system is not clear about that, but, again, as was touched on with the last panel, the relationships that we have and the commitment to serve the populations that we are there to serve meant that we mobilised and did that. In that circumstance, it was NHS England that underwrote it. In the example that was given earlier this afternoon, it was a local authority DPH that underwrote it. We are having different people underwriting; so there are gaps in there. There are some other gaps where things are less clear. For instance, standards and training for travel vaccinations are not within section 7A. In the advice and support that I and my team provide to front‑line immunisers, when they ring up about travel vaccinations, do I say it is not our remit and tell them to go to someone else, and I cannot tell them who, or do I support them? Of course we support them, but it is not clear. So there are gaps. The fragmentation—a word that has been used—around the system is there, but I would not want you to feel that, because of that, the system is broken. We make the system work well.
Chair
For travel immunisation, there are resources at national level that GPs can call on for advice. Has that continued unaffected by the changes?
Dr Seddon
My understanding is that general practitioners can call on that if they subscribe. I think there is a subscription, yes.
Chair
Those resources are still available, are they?
Dr Seddon
Yes.
Chair
It is a question of whether you feel there is the advice and expertise there if people need to call on it.
Dr Seddon
I think, yes, generally you are able to find it, but the reason I was using that as an illustration is that immunisation services sounds like immunisations.
Chair
Your point would be that there are many aspects to immunisation services; right. Thank you.
Paula Sherriff
I want specifically to look at the fairly recent Ebola issue. Could you tell us briefly a little about the level of preparedness in your areas and whether you were satisfied that had there been more cases, or indeed any significant cases, you would have been prepared to offer a safe service?
Professor Ardern
Yes. When we were first alerted to Ebola becoming a challenge, clearly in Greater Manchester we have an international airport and were part of the PHE screening procedures. Through the Greater Manchester resilience forum, we set up a number of exercises. We rehearsed live exercises at the airport on a multi‑agency basis. We also set up a multi‑agency strategic co‑ordinating group exercise and rehearsed every borough in Greater Manchester. We were rehearsing people arriving through screening, the passage of transport from the airport to the regional infectious disease unit and how we activated a multi‑agency response. We were particularly keen to stress test things like community cohesion, getting messages right and making sure that public awareness was appropriately raised. We used that linking into our Greater Manchester outbreak management arrangements, and we have continued, through the lessons learned from those exercises—in fact, I chaired a strategic co‑ordinating group on the episode at new year when Pauline Cafferkey came back to the UK—to provide assurance back into the system that we had all the resources and capability at Manchester airport to deal with any suspect cases. We have had a number of workers coming through the north‑west, as Mr Razzaq referred to, who have come through our screening procedures. We have learned lessons from that and adapted it for MERS and other high‑impact infectious diseases within the system, and every time now a suspect case potentially comes through, the system is stood up. For example, as lead DPH, I am always alerted if somebody with symptoms is picked up at the airport and taken into the infectious disease unit. We find, in our experience, that it is much easier to stand the system up and be alert, because you can always stand down. If you are ahead of the curve and coms, you, GPs and all the people in the emergency planning response system know about it, then we can respond should tests prove to be an actual case rather than a suspected case.
Paula Sherriff
That sounds really positive. Are you sharing that practice with other towns or cities that may have an airport or ferry ports or such things where the prevalence may be higher?
Professor Ardern
Public Health England colleagues, with whom we very closely work, are sharing it through Public Health England’s systems, but we would be more than happy to share it with other local authorities, because we think it is a very robust and resilient system, linked into both the lead DPH and, of course, the local authority chief exec on‑call arrangements too.
Paula Sherriff
Would anyone else like to comment on the Ebola question?
Paul Davison
Yes, if I may. First—again, this came up in the first session—I would pay tribute to NHS colleagues who responded, but of course they would also say that is what they do. Ebola was not new; the scale was new. They were used to doing this. The concern was what would have happened if an outbreak had happened here or there had been significantly more cases in the UK. I have two things to say in response. One is from a local health protection team perspective. Newcastle played a significant part in this because they were the surge capacity for the Royal Free. We worked very closely from the Public Health England health protection team with not just Newcastle Hospitals Foundation Trust but James Cook as well in order to test what would happen if their infectious disease unit became overstressed with a number of cases, not just in terms of responding to what might have been the potential Ebola threat but the day business as well. The most important thing as well as responding to any immediate threat—it grabs the headlines—is that the day job goes on at the same time. It was not just about how we responded to one or two cases and whether that was possible, but what the surge capacity would have been across the system in order to support that. For example, was moving more highly‑dependent patients around possible and how would we do that? That was a piece of work that took place in conjunction with NHS colleagues in the north‑east, which was very good. We wrote up an incident debrief—lessons identified—that was sent into national colleagues in response to that.
Paula Sherriff
Thank you very much. Moving on, if there was perhaps a pandemic flu or a similar other major outbreak, obviously having at the back of our minds the 2009 flu pandemic and remembering the lessons from that, are you confident that we have structures in place that would enable an effective response, and, if we do not, what do you think needs to be improved in order that we can guarantee an effective response?
Paul Davison
Some things have changed since 2009. I worked at that time for the Health Protection Agency; so we were critical in co‑ordinating some of the response to that. This links to the capacity issue. Some things that have changed have been that we no longer have primary care trusts. I am not saying that is some kind of Utopian past that we should want to hark back to, but it provided a single unifying organisation through the executive power of the director of public health in order to mobilise NHS resource at very quick notice. We do not have that any more, so we have to find a way around it. Also, we have mentioned community services, and certainly from a north‑east perspective I would not want to paint them as not wanting to respond. They were absolutely vital in 2009, and, because of what we found exactly in the response to the previous question, health protection work carried on, and at the same time in the north‑east we had a significant outbreak of measles in the Hartlepool area. We were managing two very significant incidents. As we continued the containment phase, in terms of trying to get antivirus treatment and all the rest of it, there was a lot of work to be done. We drew on NHS colleagues to come and train them, and they came into our response centre and did that. I believe that we still could do that, but how we do that has become much more difficult because people are in different organisations and in different parts of the system. I also think probably—although this is anecdotal and I have no evidence for it other than talking to colleagues who work in that field—that the pressure on them, the reduction in resource in those teams and the increased numbers of targets that they have to meet have caused them to concentrate much more on their core business. When you have an environment where resources are shrinking, people concentrate on their core business, and sometimes you lose those residual skills that are needed in that response situation.
Paula Sherriff
That is fairly similar to what we heard from the other panel. They were discussing a recent hepatitis outbreak in Leeds, and, although we talked about lots of good practice and lots of preparedness, there was an acknowledgment that capacity‑wise there were indeed some challenges remaining. Finally, from me—forgive me if I read this—do you think it is a problem that directors of public health in their own right are not formally part of the response arrangements under the Civil Contingencies Act, although local authorities are as a Category 1 responder?
Professor Ardern
I am a Category 1 responder because I am a chief officer in local government. My response to that would be that DPHs are chief officers in local government. They are part of the Category 1 response. I do not think they need separate categorisation. There are challenges between Category 1 and Category 2, and I think Category 2 designation for CCGs has not always been particularly helpful because people do not necessarily recognise that Category 2 still means you have to respond and you have to be part of that strategic co‑ordinating response. But, in direct response to your question, I am definitely a Cat 1 responder as a DPH.
Chair
Perhaps we should ask Mr Hardy to comment on that.
Dominic Hardy
I have been in post about 15 or 16 months now, and I have to say that, although the CCGs that I work with, historically, in my understanding, may have had some issues at the outset in understanding the responsibilities that went with being a Category 2 responder, the work they do on a day‑to‑day basis to oversee surge capacity for urgent care in particular, or indeed the recent thorough testing of our response system we were able to give it during the junior doctors’ industrial action, showed that they are stepping up to the plate now and playing their role in helping to organise and co‑ordinate what goes on locally, or even more locally than the patch that I cover. I think they are stepping up.
Paul Davison
I think the question was also about system resilience for pandemic planning and response, so I will offer a thought on that. Systems are in place. We do have planning systems. There are plans. You heard in the previous session that those plans are exercised, stress tested and we learn from those, but if there was a pandemic you would move to national command and control. Therefore, the whole rules of engagement change, and that brings into it a kind of political sensitivity as well, which is the second thing I was going to say has changed since 2009. There is increased political awareness. I suspect there is a lower threshold, so everybody wants to know everything straightaway. Reflecting on 2009 and Ebola, there is definitely heightened political and, therefore, public sensitivities around these things, which would change the dynamic. But in terms of response, if there was a pandemic, we would have to look at the national risk register, deploy national resources and consider the health and care system in the whole rather than just in individual localities, because that would trigger a whole different level of response.
Chair
To pick up on a comment that was made that we do not have the power now, as directors of public health are not directly within the NHS, to direct an NHS response, how much concern should there be about that? We are hearing also a message that the response is good and that there is surge capacity.
Professor Ardern
I will speak on a personal basis and indeed on behalf of Greater Manchester. I do not personally have any problems commanding NHS resources when I need them. I think sometimes that goes back to relationships, being in the same room in terms of planning, doing joint exercises and training. It is very much about how you work on a day‑to‑day basis with your NHS partners, but I can quite assure you that, if I have an outbreak and I am not getting the right response from NHS front‑line staff, then I will be straight on the phone to a chief exec to get it sorted out. It is not an issue. It is really an issue about how good people’s relationships are, how good their planning mechanisms are and how well they train as organisations, but I certainly do not have a problem commanding resources when I need them.
Chair
It is very reassuring to hear that is the case for Greater Manchester, but of course what we as a Committee want to know is that it works everywhere, in which case, what key message should this Committee give to make sure that it happens everywhere?
Professor Ardern
The key message from me—and I was reflecting on what could be helpful to people—is to use the powers of the health and wellbeing board to hold people to account; to use that to support the director of public health in resolving issues; to make sure you are using also the very good emergency planning framework we have—the local resilience forums and the local health resilience partnerships. I think it must be important to ensure that we have director of public health involvement in both of those structures, and perhaps what I am not entirely clear about is whether we have director of public health involvement in those robust statutory planning arrangements. If they are in there, that is where those kinds of discussions can happen.
Chair
Does it also help that you have a very senior position within the council, because I understand that in some areas the directors of public health are seeing their status downgraded?
Professor Ardern
Yes. I think it does help that I also have charge of the council’s corporate emergency planning resource. I have a dual chief officer role. I would say to DPH colleagues that taking on the corporate emergency planning role helps in terms of engaging the rest of the council, particularly in engaging political support. I have extremely strong political support, both from the cabinet member for adult social care and health, but also, in terms of corporate emergency planning, the lead elected member is actually my council leader. Getting really strong buy‑in from corporate senior management and from elected members, taking on that broader remit of emergency planning has been extremely helpful.
Chair
Thank you very much.
Dr Davies
Moving on to screening and immunisation under the new arrangements, could you collectively give your thoughts as to the challenges that face this field since the changes?
Dr Seddon
Thank you very much. As I said, I am a screening and immunisation lead. I was in a primary care trust with particularly a screening remit, not so much an immunisation remit, before that, but I have been a screening and imms lead for three years now, throughout the time of the new changes. First, I would broadly emphasise the things that have come up already. Yes, there has been fragmentation; yes, the system was complex; and, yes, there was in some areas a lack of clarity about who was responsible for what. The thing that has made it work is the relationships and the will to make it work. Kate has outlined in Manchester a lot of the structures that they have. In the Merseyside area, we have less formed structural partnerships but just as much of a history of working together, and that has been how we have done it. Broadly, it has worked because there have been the experts there and the people committed to making it work. I was privileged to have a full team from the start, and that made a big difference. I am very aware that, added to getting to know the new system and making it work, many of my colleagues across the country had very incomplete teams. It is relevant to mention that now because there is stress in the system because of the resource reductions. As you are aware, in Public Health England we have been going through a process of tailoring the size of teams and the grades and numbers of staff to the resources available for well over 12 months now, and we are coming to the end of that in the context of the screening and immunisation function that I lead. Having a full complement of staff will make a difference, but it is fewer than it was. That particularly affects the resilience and the succession planning of the system. We have mentioned things like surge capacity and being able to mobilise for additional things. When we mobilised for Ebola, of course, I had a couple of members of my team who helped in going to Manchester airport and screening, and we supported them from back in the office. It is difficult to see how we could do that and still be safe now because the resilience is affected now. But, broadly, it works; we make it work and we have the right people in place. We are particularly stressed by the number of experts now—the expert leaders. We started off in 2013 with four screening and immunisation leads serving the 6 million people in the north‑west. We now have 1.5, so we have to acknowledge that. We have strengthened other grades in order to pick up some of that. It is not a broken system—I am not scaremongering in any way—but I am saying it does feel like it is very thin. We believe we can cope with steady state well and could cope with a certain amount of escalation, but for anything very big we would find it very difficult indeed.
Dominic Hardy
I recognise the picture that Dan paints but I want to draw out some of the opportunities that it has given us. If you look at the cold hard data around screening coverage, and I do not know how true this is across the country, it is patchy. Some programmes have really improved. Our bowel‑screening coverage has improved over recent years almost in spite of whatever else has happened, so that is testament to the hard work that my team does, both the embedded screening and imms colleagues and my own public health team. I would not want to give the impression that somehow this is all a prophecy of doom. It really is not. There are some big strides being made in increasing take‑up of the HPV vaccine as well in my patch. The bit that we need to continue to reflect on is that the scope of the screening and imms programme has broadened over the last year. I think I counted eight programmes that are either new or significantly different compared with where we were even three years ago. So there is more work, with bigger populations to cover, at least a kind of constrained workforce, if not reduced, but we are still making strides to improve. That is a pretty good story to tell overall, which is not to say we cannot do an awful lot better. The other point about opportunity is that, compared with even the halcyon days of PCTs, there are some things that we do better now. It is fair to say that in the past, certainly in generic terms, the public health team in a PCT was often quite foreign to the contracting and finance team. In my team they sit together, so we get the added benefit of the insight and expertise of our screening and immunisation specialists with people who are very good at contracting, and that means we can get the most out of the work that we do for some of our biggest programmes, like the breast‑screening programmes. I can think of an example where over the last year we have addressed an issue of breast-screening round length with one of our biggest providers, a big trust on the south coast, and they have worked with us through an investigation to improve the way that we provide coverage there. There is a more balanced picture here of improvement and opportunity as well as, undoubtedly, some of the challenges that Dan has mentioned and that were aired in the previous session.
Dr Seddon
I would like to echo that. Dominic has just stolen the second bit of what I was going to say, which is absolutely fine, but through the screening and immunisation teams in this we have been able to deliver for screening a systematic approach on a bigger footprint, and I could echo exactly the work that Dominic has outlined. In Merseyside, one thing we were able to do early on was recognise the low cancer screening rates that we have in Merseyside despite having very high cancer prevalence and incidence rates. So we were able, under the umbrella of the screening and immunisation team, to pull together partners across the whole system, including some from the private sector and the charitable sector, to ask what we could do about this across Merseyside, pulling together good practice—your point about sharing practice in different areas. We were able to identify good practice in some different areas and, through some of the charity work, to take advantage of Cancer Research UK’s commitment to promoting bowel cancer screening. A particular initiative we were delighted with was Jo’s Cervical Cancer Trust, where they have commissioned on our behalf bus advertising that they have done in other areas and are doing in our area now, but we are adding value through evaluation. Yes, the number of additional programmes that have been introduced is one thing, and the outcome is another in that we are still looking at the screening rates and seeking to see them improve. At present, on big population bases, they are not improving so much, but they are with individual practices. For example, we have a practice where three years ago their cervical screening rate was 80% and now it is 86%, and we are able to identify with them what they did and will seek to spread that through other practices as well.
Professor Ardern
In response, to add to Dan’s point, the opportunity of working in local government is the reach out of local government into local communities, and it is both a challenge and an opportunity. The challenge is that, because you have the screening and imms team working at a bigger footprint, it has advantages in the way that has been described, but perhaps the loss is getting into the intelligence that local communities have about the way in which they receive information and the way in which you can use peer mentors. To support the uptake of both imms and screening very locally, we have used our health champions programme, which is a Royal Society for Public Health programme initially developed for health improvement, but we now use it very much for health protection, and we have merged into that a cancer‑screening champion awareness. That has helped us to get into local communities, and it is using that grassroots approach that was discussed in the previous session to engage with our local communities in ways that they want to be engaged with rather than using the poster, leaflet, health education approach. The opportunity is to marry the expertise of the screening and imms team with that kind of local intelligence and local capacity building.
Dr Davies
Are you concerned, though, about loss of links with GPs, community pharmacists and access to practice‑level data?
Professor Ardern
No. I commission community pharmacists. I have a healthy living pharmacy programme in the borough, which is being used as the model for pharmacy commissioning across Greater Manchester, and something that is quite unique to Wigan but we will be rolling it out, which is called the healthy living dentistry programme. I commission services from the pharmacists and we work with both the local pharmaceutical committee and the local dental committee on screening and imms and other health improvement agendas. I do not have any problems in terms of access to their data. In the previous session, the issue around screening coverage coming back through Public Health England, certainly in the first part of the transition, was a challenge, but that information is now coming through on a regular basis.
Dr Davies
Good, and you feel that your colleagues elsewhere in the country largely agree with that.
Professor Ardern
I am not speaking for my colleagues elsewhere in the country. I can only speak for my own borough and conurbation, but there are opportunities to work with primary care commissioners, work with your CCGs on integrated care and use the opportunities around things like shared care arrangements around sharing intelligence, which perhaps act as a route round some of the data protection challenges that arose at first. They are not challenges for us now.
Dr Davies
Okay. Clearly, incident reporting is critical to all of this process. How satisfied are you that the processes are satisfactory now in terms of directors of public health and Public Health England being aware of what is going on, on the ground?
Professor Ardern
From my own perspective, and I can only echo what Mr Razzaq previously said, I get reports of incidents that happen on my screening programmes, and indeed I am invited to all the QA visits—the quality assurance visits—that happen for local screening programmes, so I am able to be in and hear what the quality assurance team actually says about, for example, our local breast screening or cervical screening programmes.
Dr Seddon
Can I add to that from, if you like, the other side? We inform directors of public health about incidents on their patch; so does NHS England, and occasionally, because of our embedded nature in NHS England, we can be a conduit for that. It is very helpful having that, and the assurance role that the DPH holds is very useful to us in that we need to tell them, for example, about how an incident is going. Inevitably, the response is, “Thank you for telling us. Will you keep us informed?” Particularly when the incidents are politically difficult or there are major performance issues associated with them, it is very useful to have the DPH’s interest in that respect. As to QA visits, it is very helpful bringing those up, because they are an arm of the system that perhaps we have not mentioned. Those are a fantastic aspect of the system; it is an area where NHS England, clinical commissioning groups and local authorities work together and are there at the feedback session, and it is very much a drawing together of lessons about that. That applies to screening programmes, not immunisations.
Dr Davies
You are satisfied in your areas and you do not have any particular suggestions to improve incident reporting on a national level across other parts of the country. No; thank you.
Chair
Before I come on to Philippa, could you clarify, Professor Ardern, what has happened to screening rates across Greater Manchester?
Professor Ardern
Unfortunately, I am not the screening lead, so I would not be able to answer that question in detail. I can tell you that across my own patch in Wigan we have maintained our screening rates; in fact, we have improved our immunisation rates and have particularly good uptake of MMR, for example, in Wigan. But I would have to send back some information about the whole of Greater Manchester.
Chair
Yes, apologies; I should have said Wigan.
Dr Whitford
In the opening section from the Chair we touched on the issue of training, which is easy to do within the NHS; we have all the structures. What exactly do you feel the issue with training is and how do we provide the skills going forward? You need a stream of people coming through. I am not sure who wants to start.
Professor Ardern
I will start because I raised it. The issue for training is that, clearly, you have colleagues in primary care who have access to training and need to keep up their skills, both in immunisation and screening, and that is particularly true for cervical screening training. It was probably clearer in the previous arrangements about how they accessed that training and who paid for it; but I am not so clear, given the number of requests my team gets to deliver immunisation training, for example, where that responsibility lies or where the resources to fund practice training actually happen. It is a very specific local example I am giving you, but I suspect that is an issue in other parts of the country too.
Dr Whitford
That is something that is not yet resolved.
Professor Ardern
Yes.
Dr Whitford
Does anyone else want to add on that?
Dr Seddon
Can I expand on that? As a ballpark statement, that is fair. When we came into the new arrangements, there was very little provision elsewhere in the system for training front‑line immunisers. For people who worked in screening, there was most of it apart from cervical screening. So as to front‑line immunisers in general practice, principally, and the cervical screeners in general practice, we had to make sure it was a safe system. My colleagues and I, as screening and immunisation leads, approached it in different ways across the country. I am aware that some of my screening and immunisation colleagues said to general practitioners, “This is your responsibility as an employer. I am not going to provide the training.” In those circumstances, training markets have developed. The decision we took in Merseyside and Cheshire was that we needed to maintain a safe system and needed to continue to provide some of that training, and to nurture the market. We had some success so that we have a robust cervical screening training system now, for example, which is paid for by the employers. But with immunisation training, I am describing the same system as Kate, although in a slightly different patch, in that we have a situation where it is clearly not our remit to fully fund and pay for training, but at the same time there is not a market of excellent training around, and, if there was, how could we be assured that the standards in that were excellent? That is still an area where it is not broken in the sense of being a danger but it is an area that stretches us and that we find a challenge.
Dr Whitford
So it is not quite sorted either.
Dr Seddon
Not quite sorted is fair, yes.
Dr Whitford
From the point of view of the public health workforce, many of whom are now inside the local authority, what about the training and skills that they get?
Dr Seddon
I will mention the public health workforce in screening and immunisation now. We will train people coming in, and one opportunity that the approach to cost reductions in Public Health England has allowed us is to have a broader range of grades within the teams so that there are more entry-level grades. That is reasonable for us. We can train our own staff. There is not training in immunisation and screening to local authority staff or to other Public Health England staff particularly.
Dr Whitford
As to people—not just immunisation and screening, but all the other parts of health protection—who now live inside the local authority, what kind of support do they get for training to climb the ladder or maintain their skills?
Paul Davison
The discussion has been about screening and immunisations in the last few years. In health protection teams—
Dr Whitford
I am talking about all the skills now.
Paul Davison
Our health protection teams in Public Health England, as opposed to local authorities, comprise of consultant level and nurses and practitioners. Through the public health training scheme, they get exposed to health protection as a discipline, and many like the discipline. We have found that, generally speaking, we have been able to recruit. It feels a bit thin sometimes, but we are holding. Historically, the health protection teams were staffed by nurses, often with an infection control or community hospital background. Some years ago the decision was taken to broaden that skill mix, to have practitioners, some from environmental health backgrounds and some from scientific backgrounds, whose aptitude was tested through a rigorous selection process. That is the official answer, but getting people through the door is when the learning really starts. A lot of that is done through in-team support—coaching and mentoring people through different situations so that they feel competent. From our health protection point of view, there is an expectation that they will be on call as well and have to work independently out of hours. So we have people on probationary periods, and test and expose them to increasing complexities of work until we are sure that that is okay. In the north‑east we have fewer people within the local authority public health section workforce who are directly health protection. I do not know whether we will discuss in a moment the issue of health and wellbeing boards and all the rest of it, and the differences between that and the picture that Kate has been painting of Manchester and Ian of Leeds, which are big metropolitan authorities. It is different sometimes in other areas and it would be useful for the Committee to understand some of those at some point.
Dr Whitford
Sure. We will follow that, but obviously there was a description in the earlier panel of some of these, like infection-control nurses or vaccinators or whatever, actually living within the local authority.
Paul Davison
And it is variable.
Dr Whitford
Obviously, learning is an ongoing thing. We all know the expense of going on training courses and so on. Is there a budget for those who are not Public Health England and not NHS England but who are now within the local authority? How easily can they access ongoing training?
Professor Ardern
Again, I can only speak for Greater Manchester, as you will understand, but one reason we set up the health protection confederation was precisely to ensure that these staff who were employed in infection prevention control and health protection across Greater Manchester got the opportunity both in continuing professional development—and clearly if you are a nurse you have to keep up your registration—and access and shared good practice. Public Health England’s health protection team strongly supports and is part of that confederation. There is the opportunity to work-shadow within the health protection team as well. We make sure that teams within local authorities get the expert mentoring and support from Public Health England; similarly, within the emergency planning system, we have a series of training programmes run by the civil contingencies and resilience unit, which involve, of course, outbreak planning and response too. Training for outbreaks is part of that process, both within boroughs but also at a Greater Manchester level, and that of course is open to health protection staff.
Dr Whitford
In a way, you are largely providing it in‑house, using a very big house.
Professor Ardern
We are, yes, absolutely. Where necessary, I have a training budget within my own budget that enables me to supplement the local authority training budget. Clearly, things that can be done within the corporate training budget are done, but if it is something like specialist health protection, then I will do that.
Dr Whitford
You do have access. I would like to come back, Paul, to your point about the structure. That was a comment I had made on the first panel. It does seem very fragmented and sounds as if each place is having to slightly reinvent the wheel. As you touched on, the big conurbations can more easily do that. I am always a bit worried about all the bits that are not a big bit. Do you think the idea of the health protection board sitting under the health and wellbeing board is something that is widespread, or what kind of solutions are there? Or do you think there are places that maybe have not worked it out because they have not had a crisis in the last three years?
Paul Davison
There are two responses I have to that, and I was trying to work out, if you asked me the question from the previous session, what my response would be. I think there is a practical issue. For example, in the north‑east, our population size is probably pretty similar to Greater Manchester, but we have 12 local authorities. The devolution combined authority discussion is taking place within the north‑east quite strongly for a north and south, but if every local authority had a health and wellbeing board and a health protection committee that reported to the health and wellbeing board, other consultants in my team and I would have to attend 12 sub‑committees, meeting three or four times a year. That is 48 meetings a year. You start to think what the value of that is that could also be got in different ways. I would personally urge caution about having a structural approach to a problem and saying, “This seems to fit. We will just have that everywhere.” Another common theme has been the nature of the relationships. They are by and large very strong and I would certainly have to report that in the north‑east. The Committee was a bit concerned earlier about it resting on goodwill. The relationship is important because it is a relationship built on a common set of values—our single‑minded determination to serve the public, because that is who we are here to serve. Therefore, there is a kind of unifying effect of wanting to do the best you possibly can for the populations that you are here to serve. In the north‑east we do not have those sub-boards but we meet regularly with directors of public health. We have annual update sessions for them on incident outbreaks, STAC training, which was mentioned earlier, and an ongoing discussion with all of them about notification of incident outbreaks or just things such as, “This is going on. It is probably not going to go anywhere, but just be aware.” Of course, when we get to incident outbreak management, when there is something very specific to control and mitigate, directors of public health are members of the outbreak control team. So there are different ways of doing things without making a suggestion that it needs to be the same. It is critically important that it is understood locally and that the process is delivering the right outcome, if not by the same process.
Dr Whitford
Is there a national forum within which these different solutions can be shared? Kate, you were saying that, for you, the data sharing around immunisation and screening is not an issue. We have heard evidence from public health practitioners and DPHs who say it is an issue. The thing that strikes me is that everyone is having to find their way and we have been lucky that something catastrophic has not happened in that time. Is there a way of accelerating everyone to arrive at solutions, even if it is different ones? Do you have a national space in which all of this learning can be shared?
Professor Ardern
Yes, there is.
Paul Davison
We could definitely do that. Going back to the funding issue we talked about earlier, Kate said she had no problem commanding the resource, and that is fine, but she is not the one who is going to pick up the tab sometimes for those resources—
Professor Ardern
Oh I am.
Paul Davison
That is by discussion. I think what you are reflecting on is the complexity that we now find ourselves in, and we are still working our way through that in terms of how we share good practice. But, hand on heart, I do not think, nationally, we are terribly good at that. We are good at learning it in localities; at a national level we find that more difficult.
Dr Whitford
Sometimes an event where everyone is in a room saying, “This is how we did it. We are big.” “This is how we did it; We are small”—
Paul Davison
We do that through exercising and things like pandemic flu and Ebola. For those high-intensity, high-level things, we do do that, but for a lot of the day job we could learn from each other as well. We do that through quality programmes.
Professor Ardern
There is a national forum. The Local Government Association has a public health conference every February, for example, and both Public Health England nationally and the LGA have a very key role to play in making sure we share good practice. I referred earlier to my role as a peer reviewer, and the peer challenge process for health and wellbeing boards is an excellent process.
Dr Whitford
Was that not just within Greater Manchester?
Professor Ardern
No; it is a national English programme. For example, I have recently done Hull and I previously did Peterborough. Using that process, and I think adding in a very strong element around the health protection and emergency planning, would be a good route to go down. That would make sure we have a conversation between PHE and the LGA, and, of course, the LGA’s focus with local authorities is extremely helpful. They are fully engaged also in things like the emergency planning agenda.
Dr Whitford
Thank you very much.
Chair
You may not wish to answer this, Professor Ardern, but in your national role with peer review are there some areas where you identify that things are not working well?
Professor Ardern
In terms of when I have done peer challenges, one thing I certainly have observed is the need for health and wellbeing boards to be assured about health protection and emergency planning. That could be reinforced through the health and wellbeing board chairs network.
Chair
Thank you. Mr Davison, could I ask you to reflect on something that the north‑east was well known for, which was the public health observatory work on alcohol? Is that something you would like to make a comment on in terms of the changes since 2013?
Paul Davison
It is not something I am involved with on a day-to-day basis, so I would prefer not to, if that is okay.
Chair
That is fine. Members of the panel, are there any areas that you have not been asked about that you feel you would like to comment on and recommendations you would like to see from this inquiry?
Dr Seddon
Yes. There are two areas that I would like to mention. One is in response to the last discussion around learning from events and people getting together nationally. One thing that has happened within screening and immunisation since 2013, a little ad hoc early on and now much more consistently, is national meetings of screening and immunisation leads with the central people in PHE and NHS England. Those are particular areas where there is a lot of learning and sharing of good practice, sharing of solutions and challenges, and it is a tribute to the work of NHS England. If I can be frank, initially, NHS England and PHE looked like they talked at the top and there was no talking at all between the two organisations all the way down. That is how it felt, but it is not like that at all now, and the two organisations are talking to each other at each level and work together. What Dominic said about screening and immunisation performance illustrates that really. That is one area. Then can I just clarify my perception and what I would say is the national picture around the data analysis? Yes, there is a question and some barriers around sharing of practice‑level data in its unpublished form. NHS England and Public Health England are working on that at a senior level. There are some restrictions around the way the data is collected, which affects how it can be shared routinely. However, the other aspect around data and data availability to our DPH colleagues, in particular, is our ability in screening and immunisation teams to handle and process that data. That is the more important barrier. Again, it is something that we are all aware of in the system and working on with NHS England colleagues, and a different solution has been found in different teams.
Dr Whitford
Did you have that problem before? The way the problem was described to us was that it was much more to do with data protection and DPHs now being outside the NHS. Do you suddenly now have a problem analysing or processing it that you did not have before?
Dr Seddon
Yes; the screening and immunisation teams have little data-handling capacity.
Dr Whitford
They had that before.
Dr Seddon
In the past they were part of primary care trusts, which owned the data anyway and could handle it; so, yes. We are finding solutions to this, all of us in different ways, but it is fair to say that it remains a challenge.
Chair
What would you like to see that would make it easier for this to happen, not with workarounds in different local areas? What would make it easier?
Dr Seddon
NHS England and Public Health England at the local team level need to continue to work to find solutions to providing the data-handling capacity that is necessary to provide regular detailed data reports to DPH.
Chair
It is the data-handling capacity rather than, now, the barrier being with them being prevented from sharing the information.
Dr Seddon
Yes. There are some restrictions on sharing information, which PHE and NHS England are working on in terms of being able to process and handle the data at a local level.
Chair
They are seeking to do it. It has not been solved yet.
Dr Seddon
Yes. It is fair to say it is not solved yet, but I know that everyone is aware of it and working hard on it.
Chair
To be absolutely clear, because it would be helpful to have clarity here, if you were starting from now and designing how it should look, what changes would you be recommending are made?
Dr Seddon
I would ensure that there is explicit data-handling capacity within screening and immunisation teams in NHS England. The agreement between Public Health England and NHS England was that that element would be provided by NHS England. It was not really in place at the start of the three years. There are many ways in which it is being put in place now, but it is not consistent.
Dr Whitford
What happened to all the data-processing people who were in the primary care trusts? Were these people who were let go, who are not doing it, or are they doing something else?
Professor Ardern
Most of those types of individuals went into the commissioning support units, so they were neither transferred into the sort of team that Dr Seddon leads nor, indeed, into local government.
Chair
Thank you.
Paul Davison
I have two things, briefly, if I may: to promote the work of health protection teams and Public Health England, full of skilled, inquisitive people, who are not just doing incident case management but are contributing to research and doing academic studies. Picking up a point that Dan made much earlier, resource reduction is starting to eat into the capacity. What will happen is that we will just default more to doing case and incident outbreak management, which is the more visible bit, but we run the risk of losing, as we reduce capacity, that additionality, which, as an aspiring world‑class organisation, PHE needs to keep in its armoury. Secondly, in terms of assuring the Committee on a whole range of response issues, I still need to say that the funding issue for incident outbreak management and response is not sorted out yet uniformly. I know that Public Health England is working at a national level to support and provide evidence to NHS England on their new or revamped “Who Pays?” documents. So we will be making our contributions to—
Chair
The “Who pays for what?” question that was raised in the panel.
Paul Davison
Yes.
Chair
That works well in your own area, Professor Ardern.
Professor Ardern
Yes.
Chair
You are seeing variation in that.
Paul Davison
Yes.
Chair
Thank you very much for coming this afternoon.
Professor Ardern
I have a couple of things, if I may. This afternoon we have not touched on the subject of antimicrobial resistance. That is a significant opportunity and a challenge. We have put it into our risk register for Greater Manchester and are working through that as part of devolution, but that is a challenge we need to focus on and, in terms of a risk to the system, it is a big health protection challenge for us. Making use of both integrated care organisations and the opportunities for working with local government on AMR is an important subject perhaps to come back to. Secondly, there are the opportunities we have not just around the specialist workforce but to broaden out and use the very recent workforce report that has come out of both PHE and the Royal Society for Public Health, looking at the workforce to 2035, looking at where we might need to skill up people in terms of health protection and use a skills escalator: what skills do the community need to have, through to that specialist workforce element? That is a challenge because I do not think we are necessarily that good at workforce planning. There is succession planning in terms of the demographics of the existing workforce. Through Greater Manchester, we are looking at how we work with Health Education England to look at succession and workforce planning around the whole gamut of health protection skills. That brings in, for example, the environmental health workforce and the trading standards workforce too.
Chair
Thank you. Was the interest in the drug resistance triggered partly because of resistant gonorrhoea? Was that one of the issues in your area?
Professor Ardern
No. CPE is an issue for Greater Manchester, but the real trigger—
Chair
Can you say CPE in full for those following from outside this room?
Professor Ardern
I apologise. I am going to look at Paul now because he is the expert on this.
Paul Davison
It is an organism that is resistant to normal antibiotics.
Professor Ardern
Oral antibiotics. That has been a challenge for Greater Manchester, but the bigger push for Greater Manchester was recognising the work of the O’Neill report and linking antimicrobial resistance into the economic agenda for Greater Manchester, recognising it as a challenge to the economy and building it into our UN resilient cities programme.
Chair
Thank you. Just to clarify the acronym, what does that stand for?
Paul Davison
I will try and get this right. It is Carbapenemase-producing Enterobacteriaceae
Chair
It was just for people following from outside the room. Thank you very much for coming this afternoon. We really appreciate it. Oral evidence: Public health post-2013 – structures, organisation, funding and delivery, HC 4