Improving the quality of health protection on-call services within regions. (Draft for consultation - responses to Jeremy Hawker by 13/11/03 please.)

Contents 

Background

·        Health Protection (HP) is the prevention and control of communicable disease and the public health response to chemical and radiation hazards to health.

·        HP in each locality is a PCT responsibility discharged with the assistance and support of the Health Protection Agency (HPA).

·        This paper refers to the out-of-hours cover for the HP function ('on-call'). Provision of an on-call service is a joint responsibility between PCTs and the HPA, as agreed by the Faculty of Public Health (FPH) Working Group on HP and reinforced by the national template Memorandum of Understanding between PCTs and the HPA.

·        Out of hours cover for the HP function has usually been part of the local Public Health Medicine on-call rotas: traditionally, these rotas covered both ‘CCDC/Proper Officer’ responsibilities and ‘DPH/PCT' responsibilities (even some HP activities are technically DPH responsibilities, eg HIV-infected healthcare workers or deliberate release JHACs).

·        Until 31/3/03 these rotas were staffed by both the ‘general’ and ‘CDC’ staff of the PCT (formerly HA) Department of Public Health Medicine. The ‘CDC’ staff have now transferred to the HPA.

·        Not all on-call HP problems require CCDC-level skills in Health Protection, but most require familiarity with the local population, agencies and policies.

·        However, some on-call HP problems require familiarity with rare diseases or hazards, the current regional/national situation or special control measures and some require access to additional expert manpower and support.

·        Most PCTs currently share Public Health on-call arrangements with neighbouring PCTs.

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 The ideal situation

Acceptable NHS on-call arrangements should:

·        Provide 24/7 cover

·        Cover all populations and organisations

·        Be a robust system for access to public health on-call service

·        Have an adequate workforce to staff rotas

·        Provide adequate competence in public health

·        Provide adequate knowledge and experience of health protection issues

·        Ensure local responsiveness (eg travel time)

·        Ensure familiarity with local populations and systems

·        Have access to surge capacity

·        Meet the needs of both PCTs and the HPA

·        Not contravene the Working Time Directive

·        Be compatible with extant guidance

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Current issues

 There are a number of issues of potential concern relating to provision of the ideal arrangements to cover all areas of the country:

·        Although it is agreed that on-call is a joint responsibility between PCTs and the HPA, it is not always clear how such a joint responsibility is discharged in practice (eg there are reports of one partner not contributing adequately to a 'joint' rota in some areas).

·        Traditionally, most on-call rotas are not covered by a health protection expert 24-7: the majority of out-of-hours cover for HP is probably provided by individuals who do not carry out health protection duties as part of their normal working day.

·        The CMOs strategy Getting Ahead of the Curve, FPH policy and the NatPaCT PCT Competency Framework are all clear that ‘general’ Public Health Physicians (PHPs) should remain part of on-call rotas. It is the view of the FPH that all practitioners should become competent in HP and that opting out of on-call rotas is not acceptable, but there are instances of this happening.

·        The combined effect of Shifting the Balance of Power and the creation of the HPA means that most general PHPs are not based in the same department as staff specialising in Health Protection: this lack of day to day interaction with HP colleagues is leading to perceived and potentially real worries for the competence and confidence of such staff to undertake on-call without support.

·        There is often a reliance on informal arrangements between the on-call PHP and the local CCDC for expert Health Protection support out-of-hours.

·        There is an insufficient number of public health staff specialising in Health Protection for them to provide an accessible 24-7 expert service at a local level.

·        Some staff that transferred to the HPA had unacceptable on-call commitments (including at least one case of a 1 in 1).

·        Audits occasionally find a non-response or late response to a call. A delayed response would be of particular concern in a chemical incident or a deliberate release.

·        FPH policy is that Specialists in Public Health and Specialist Trainees should participate in on-call rotas: however, there will be some on-call duties that cannot reasonably be performed by non-clinical staff (eg advising on variations in chemoprophylaxis) for which cover will be required. Indeed HSG (93)56 states that "consultant advice should always be available" on-call.

·        There are occasional reports of SpRs on-call without consultant support.

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Suggested model for the future

The problem of providing an on-call service that is both local and expert should be addressed by implementing a two-tier arrangement:

·        The local on-call service should be provided by a combination of PCT Public Health staff, Public Health trainees (both those attached to PCTs and to HPA teams) and possibly other suitable PCT/Trust staff who could receive on-call training.  Certain non-Consultant HPA staff (eg trained Public Health Nurses) could also be made available to help staff these rotas. This would be the first port of call for enquiries, data gathering and local implementation of action in relation to health protection enquiries and for any formal proper officer functions.

·        This should be supported by a joint Consultant in Health Protection (CCDC or equivalent) expert rota, generally covering a larger area, which would provide:

a)     second opinion and expert advice, normally by telephone, to local on-call staff on health protection enquiries (thus fulfilling clinical governance needs and providing a learning/updating opportunity and reassurance for general PH staff).

b)     practical support and assistance for larger or unusual events, including on-site when necessary (thus contributing to surge capacity).

c)      liaison with regional and national tiers/organisations, including upward reporting of appropriate HP incidents or cases; and outward contact for health protection alerts/enquiries received from the centre.

d)     failsafe if non-response to urgent problem from local on-call system.

e)     appropriate medical consultant cover if needed.

 Examples of how such a two-tier system would operate for specific scenarios are given in appendix 1.

 Responsibility would then also be clear:

·        The local on-call service would be the responsibility of PCTs. This part of the rota could be two tier (eg trainees and/or nurses and/or any suitably trained PH Specialists first on, CsPHM and DsPH second on) if this is how local PCT Public Health departments/networks wish to organise it.

·        The expert on-call service would be the responsibility of the HPA.

·        The HPA would also take responsibility for the provision of an adequate training and CPD programme for on-call HP issues for all staff on the local rota.

This split would also help us define what skills and experience are necessary to undertake on-call duties: these would not be the same for both of the 2 levels.

 Areas to be covered by each tier would not need to be the same:

·        The PCT/local rota would cover a suitable local population defined by them: perhaps equivalent to former DHA areas, counties or public health networks (if 2-tier, then areas need not be the same size).

·        The HPA/expert rota would ideally be at Strategic Health Authority level (if resources are sufficient), otherwise at regional level.

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Progressing improvements to on-call

 1.    This model has been prepared by a FPH working group, including representatives from the HPA, ADsPH, PHMEG and DH. It is proposed that all areas in England should work towards the type of system described in this paper.

 2.    It needs to be made clear what the PCT staff are responsible for on-call and what competencies in HP they need. Training needs to be easily available to maintain these competencies, and access to information and advice for PCT staff needs to be made as easy as possible:

·        The competencies required for each level of on-call need to be defined (PHMEG suggested competencies for the local tier are given in appendix 2).

·        The HPA needs to make CPD, including refresher training, is available to all relevant PCT staff within each region on a regular basis (suggested topics to be covered are given in appendix 3).

·        SOPs need to be developed for PCT staff to cover the most common on-call issues and on when to refer to the expert rota (draft illustrative examples given in appendix 4: these have been kept deliberately short and do not reproduce existing guidelines and textbooks). The HPA should develop these with appropriate consultation.

·        The HPA local team should be responsible for ensuring an adequate handover takes place from daytime to on-call personnel. The on-call staff are responsible for handover at the end of their on-call period.

·        In addition the HPA needs to consider the best method of regular transmission of information on current problems and new guidelines to all on-call staff (eg 1 page max weekly e-mail with hyperlinks).

·        A single national phone number for access to HPA rotas should be considered.

 3.    Work will be needed to ensure that there is a sufficient skilled workforce to deliver the tiered rotas:

·        A mapping exercise should be done for each region to show the staff numbers that would be available (current and potential), so that appropriate local arrangements can be developed and any necessary action taken to increase number.

·        A maximum acceptable on-call commitment for individual staff should be set (probably1 in 4): however this maximum should not be viewed as the norm.

·        Trainees are often only funded for 1 in 9 on-call by Deaneries. It is open to PCTs to pay them to undertake more on-call (hospital trusts pay clinical SpRs for on-call).

·        Work should commence on increasing the number of Public Health Nurses available to take part in on-call rotas. This should include the HPA (Local and Regional Services Division) ensuring that it maximises the number of nurses employed by the organisation that can take part in on-call: with suitable training on local procedures, these experienced health protection staff could be made available to 'PCT' rotas, providing that suitable arrangements can be made for non-HP issues (eg passing them on to a PCT officer on-call when necessary): a two-tier PCT on-call system would provide this. The HPA would train and pay HPA nurses who take part in on-call.

·        Where PCTs have insufficient consultant level public health staff, other options include involving Consultants/DsPH working in Strategic HAs (as already occurs in some areas), academic institutions or acute Trusts: this would also help such individuals with their revalidation. As responsibility for the rota falls to all PCTs in the area, a cost-sharing arrangement between them might be an appropriate way for PCTs to contribute. In some areas, PCTs that cannot provide sufficient staff for shared rotas already pay a levy that is available to pay others to fill in.

·        Suitable top-up training will then need to be provided for those PCT Public Health consultants/specialists who do not meet the competencies set out in appendix 2 (or cover from someone who does). Although the role of PH Specialists on-call is a separate issue to that addressed by this paper, there would also need to be arrangements in on-call systems for them to have access to advice from a medical consultant, eg for certain issues relating to treatment of an individual.

·        Innovative local and regional solutions to staffing the rota  need to be considered, especially on an interim basis, as long as they involve the following being available for all areas:

Ø                  a person with knowledge of local population, agencies and policies and with competencies equivalent to appendix 2, on-call within a reasonable travelling distance of all parts of the area covered.

Ø                  access to a person within the region who has expert knowledge and experience of health protection issues and their management.

Ø                  these 2 functions not being provided by the same individual (this avoids potential conflict of duties and provides surge capacity and a failsafe).

Ø                  no individual undertaking greater than 1 in 4 on-call duties or contravening the Working Time Directive.

Ø                  The relevant RDPH being convinced that the system is robust and safe.

 Some examples of existing or new systems that have been developed in various parts of the country, and which appear to meet these criteria, are given in appendix 5.

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Appendix 1: Examples of responsibilities of different rotas

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Appendix 2: Core competencies for promoting and protecting the population’s health and well-being: First line response by generic public health staff

(Source: PHMEG).

 1.      Understand the relevance, role and scope of health protection including communicable disease control, environmental public health and public health aspects of emergency planning.

 2.      Understand the principles underlying planning for and responding to health protection issues at national, regional and local level, including response outside normal hours.

 3.      Appreciate the general principles of NHS incident and outbreak management and be able to provide support and contribute to the NHS response.

 4.      Understand the role of others in health protection including environmental health, microbiology, occupational health, genito-urinary medicine departments, infection and TB control nurses, hospital infection control teams and emergency planning services.

 5.      Understand basic science related to biological, chemical and radiation hazards e.g. for biological agents this would included methods of transmission and clinical features of common infectious diseases, for chemicals it would include awareness of the range of chemicals and methods by which people might be exposed.

 6.      Deal with initial phase of response to a health protection issue including taking an appropriate history and documenting the issue, defining the problem, giving advice appropriate to one’s skill and knowledge level, and recognising when to seek expert advice and support.

 7.      Be familiar with the general principles of investigating long-term health exposures to non-infectious environmental hazards.  Understand the principles of environmental risk assessment and management, including sources of advice on toxicology and small area statistics.

 8.      Be familiar with the law relating to public health, port health and other relevant legislation.

 9.      Recognise inequity, discrimination and its impact on health.

 10. Understand the theoretical models of behaviour change and their relevance in the context of health promotion.

 11. Identify clear aims and objectives for different health promotion interventions.

 12. Understand the principles involved in immunisation programmes.

 13. Understand the health promotion and health protection aspects of travel and be aware of sources of expert advice regarding travel medicine.

 14. Understand how to relate to the media including preparation of press statements/releases.

 Notes:

 These competencies were the outcome of a PHMEG workshop on standards and competencies on 29/1/02. The discussion was based on adapting competencies for HP training from the FPH 10 key competency areas to define the requirements for suitability to be on-call. This list assume that expert health protection advice is always available to back up an individual with these competencies.

 Accredited Public Health Physicians and others who have satisfactorily completed FPH approved specialist training should have these competencies at completion of their training in Public Health. Maintaining their skills is achieved by a combination of ongoing public health practice (most commonly in 'general' public health) and by regular updating on health protection on-call issues as part of their CPD plan.

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Appendix 3: Key areas for on-call training/updating courses for general public health staff

 1 Principles, including:

1.1 Roles and responsibilities

1.2 Legal issues

1.3 Sources of advice and support

1.4 Dealing with the media

2 Common on-call infections/hazards, including:

2.1 Meningococcal disease and meningitis

2.2 Gastrointestinal infections, including E coli O157 and Cryptosporidium

2.3 Respiratory infection, particularly Legionella and TB

2.4 Bloodborne viruses, including needlesticks and lookbacks

2.5 Imported infections (eg VHF, diphtheria, rabies exposure)

2.6 Infections requiring prophylaxis or advice, (eg chickenpox, rubella, pertussis)

3. Incident management:

3.1 Outbreaks (community and hospital)

3.2 Chemical and radiological incidents

3.3 Major incidents

3.4 Deliberate release

4. Non-HP issues:

4.1 Public Health Link

4.2 Section 47

5. Local background:

5.1 Local on-call procedures

5.2 Local Emergency Planning arrangements

5.3 Local on-call pack and incident plans

5.4 Local agencies and key individuals

5.5 Local information networks and communication channels

Useful background reading and specific advice is available in the Communicable Disease Control Handbook (Oxford: Blackwell Science, 2001) and support materials to help in delivering CPD should become available in the Learning Pack for Health Protection which is currently in draft format.

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Appendix  4: Examples of draft on-call SOPs

On-call SOP1: Case of meningococcal infection

(Meningitis, septicaemia or other invasive meningococcal disease)

Action

1. Collect details of case, contacts illness and health care on standard meningitis form.

2. Decide, in consultation with clinician and/or microbiologist, whether case is definite, probable or possible meningococcal infection  (see box 1: reproduce box on p193 of national guidelines).

3. Organise prophylaxis for household, kissing and any other relevant contacts of definite or probable case: chemoprophylaxis for all (see box 2: box on p194-5 of guidelines) and vaccine if known to be groups A/C/W-135/Y (see box 3: box on p197 of guidelines). Add local policy for who actually gives prophylaxis to contacts here.

4. Ensure someone has spoken to family to let them know what prophylaxis is necessary and why (or why not).

5. Ensure appropriate laboratory investigations undertaken (see box 4: box on p190 of guidelines).

6. Inform other relevant local individuals/organisations (eg GPs or nursery) if appropriate (see box 5: box on p198 of guidelines).

7. Inform local HPA Team next working day.

When to call HPA Consultant rota:

Possibility of linked cases

Public concern over case in nursery or school

Possible contra-indication to prophylaxis in a contact

Unclear from guidelines whether to prophylax contact(s).

Any other aspect of management that you are unsure of.

References:

Guidelines for public health management of meningococcal disease in the UK Commun Dis Public Health 2002; 5 (3): 177-264. <http://www.phls.co.uk/publications/cdph/issues/CDPHVol5/no3/Meningococcal_Guidelines. pdf>

Communicable Disease Control Handbook (1^st Ed). Oxford: Blackwell Science, 2001. P15-18 (meningitis) and 141-5 (meningococcal infection).

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On-call SOP2: Case of typhoid

Action

1.      Collect relevant clinical, laboratory and epidemiological information on standard form.

2.  If case in risk group for further transmission (foodhandler, healthworker, child under 5 or person with poor hygiene) then ensure that:

3. Inform local Health Protection Team first thing next working day.

 When to call HPA Consultant rota:

 If case thought to be part of a cluster in UK or may represent a possible outbreak.

Any case known not to have travelled abroad in incubation period.

Any other aspect of management that you are unsure of, particularly as to whether to exclude from work.

 References

PHLS Salmonella Subcommittee.  The Prevention of Human Transmission of Gastrointestinal Infections, Infestations and Bacterial Infections.  Commun Dis Rep CDR Rev 1995:  5:  R158-172.

 Communicable Disease Control Handbook (1^st Ed). Oxford: Blackwell Science, 2001. P202-4 (typhoid), p21 (risk groups) and p9-11 (enteric precautions).

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On-call SOP3: Case of viral haemorrhagic fever.

Includes Ebola, Lassa, Marburg and Crimean-Congo haemorrhagic fevers.

 Action

 1.      Collect relevant clinical, laboratory and epidemiological information plus contact details of reporter of case on standard form.

 2.      Hand over case to HPA Consultant on-call asap

3.      Be prepared to help if necessary.

When to call HPA Consultant rota:

All reported possible cases (no matter how weak the evidence).

References

Department of Health and Social Security and the Welsh Office. (1996) Memorandum on the Control of Viral Haemorrhagic Fevers. HMSO, London. ISBN: 0-11-321860-5.

 Communicable Disease Control Handbook (1^st Ed). Oxford: Blackwell Science, 2001. p207-12 gives specific advice for public health management of cases in England and Wales.

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Appendix  5: Examples of some existing or new on-call systems

1. Trent StHA

 Training programme for non-medical Public Health staff being developed.  

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2. North West Region

There is also a Regional Epidemiologist on-call rota in this region, although this currently involves postholders in a 1 in 2 rota.

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3.  Thames Valley StHA 

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4.      South East London StHA

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