Are responsibilities for health protection in England clear? One of the consequences of the 2002 changes to NHS structures was a change in the organisations, and in some cases the individuals, responsible for health protection. Primary Care Trusts (PCTs) took on the previous roles of District Health Authorities, which had been defined in the 1977 National Health Service (NHS) Act [1
]. These included the duty to promote health, to provide services and to prevent and treat illness. Guidance to the health service identified these as including "arrangements for the control of communicable disease and infections, and for dealing with the health aspects of non-communicable environmental hazards" [2
Figure shows how health protection responsibilities have developed in England since 1977. It identifies key reports and consultations, national policy developments, and the organisations and workforce responsible for health protection. In the period up to 2002, responsibility for health protection for any geographical area lay within a single organisation, the District Health Authority. Their functions were clarified and strengthened following two major outbreaks. The first was an outbreak of food poisoning at Stanley Royd Hospital in 1984, which led to the deaths of 19 patients, and the second an outbreak of legionnaires disease in Stafford General Hospital in 1985, which caused the deaths of 22 people. A committee of inquiry into the Stanley Royd outbreak identified a lack of clear accountability for investigation and intervention as a contributory factor [3
], and at the time many District Health Authorities did not have adequate capacity to respond to such outbreaks [4
]. As a result, a Government review of public health (the Acheson report) led to District Health Authorities investing leadership in the post of the Director of Public Health (DPH) with clear responsibility for public health and health protection [5
]. This role was further strengthened by the introduction of specialist Consultants in Communicable Disease Control, who led teams working to the DPH, incorporating surveillance, TB, community infection and outbreak control functions.
Health Protection Responsibilities in England.
Following the 2002 reorganisation of the NHS [6
], the health protection responsibilities of District Health Authorities transferred to PCTs, which retained the statutory role of Director of Public Health [1
]. The specialist health protection workforce initially transferred to PCTs in support of their Directors of Public Health. It had long been recognised, however, that varying approaches had been taken to health protection between Health Authorities, and further dispersal of responsibility across a much larger number of PCTs would be likely to exacerbate this [7
]. The Health Protection Agency (HPA) was established a year later, aiming to create a stronger and more unified health protection system, and intending to bring together the specialists involved in health protection in a single organisation with national specialist functions (such as specialist laboratory and epidemiological services, making these more akin to the Centers for Disease Control in the United States) and local health protection teams [8
]. This development aimed to provide a national focus and consistency to the delivery of health protection. The specialist health protection workforce largely moved into the HPA, apart from those carrying out community infection control functions who remained within PCTs.
On its establishment in 2003 the HPA was responsible for supporting other bodies, including PCTs, in carrying out their health protection roles [9
]. The HPA Act of 2004 also gave it direct responsibility for protecting the community from infectious and non infectious environmental hazards. However, PCTs were still statutorily responsible for arrangements for the control of communicable disease and non-infectious environmental hazards, as defined in the 1993 guidance to the health service [1
Hence up to 2002 there was a single organisation responsible at a local level for health protection, but there was significant variation across England in health protection practice. After 2004, there was a much greater critical mass within the national HPA and the potential for more national consistency of practice, but at a local level both PCTs and the HPA had statutory responsibilities for health protection. Unless the roles of each organisation were clearly defined, there was the potential for individuals locally to be unclear about their leadership and support roles in carrying out different health protection functions.
Prior to the establishment of the HPA and PCTs, Health Authorities employed teams to provide their specialist health protection functions. These included: consultants in communicable disease control responsible for the full range of health protection functions; infection control and TB control nurses, responsible for infection control in primary and community care facilities and for TB control; surveillance staff responsible for surveillance of notifiable and other important infectious diseases; and administrative support staff. Despite PCTs retaining statutory responsibilities for health protection from 2003, they largely relied on local Health Protection Agency teams (Health Protection Units – HPUs) to provide this service on their behalf. HPUs mainly consist of the specialist staff previously employed by Health Authorities, aside from community infection control nurses who mostly remained with PCTs.
The local arrangements to hold HPUs to account for providing this service are based on a Memorandum of Understanding. This is based on a national template but has no legal or statutory basis, and it is not expected on its own to achieve uniformity of arrangements across England. It simply reflects agreements between the HPA and the local NHS, for example identifying the role of the HPU in monitoring and surveillance to give early warning of outbreaks of infection, and the responsibility of the PCT in community infection control. In the case of a community outbreak, it usually identifies the Director of Public Health as having overall responsibility for managing the response to the outbreak, and the HPU for carrying out most outbreak control functions on their behalf.
Anecdotal evidence suggests that, whilst arrangements often work well, implementation has varied across England, partly reflecting the inherited NHS variation in service provision. This variation may also reflect variation in geographical distribution of public health specialists responsible for health protection as well as wider public health functions[10
]. It might also reflect the dispersal of the public health workforce following the 2002 NHS changes, and the skills gaps identified in the wider public health workforce, particularly in health protection[11
]. Alongside the fact that both PCTs and the HPA have statutory health protection roles, these factors may add to a lack of clarity about who is responsible for delivering specific health protection functions locally, and a lack of capacity to deliver those functions. If responsibility for delivery is not clear, significant health protection problems could be unresolved with individuals considering the responsibility to lie with others rather than acting themselves. Inquiries into past health protection incidents in different countries have often identified a lack of clarity as to who is responsible as a major contributing factor [3
]. Equally there is widespread international recognition that systematised responses with clear responsibilities for health protection and other healthcare incidents, are required for responses to be effective. This includes the control of infection [14
], disaster planning [16
] and patient safety [18
The purpose of this survey was to assess the extent of variation in the interpretation of health protection arrangements between PCTs and local health protection teams. In particular it aimed to investigate the perceptions of those who are involved in delivery and oversight of health protection as to whose responsibility it is to deliver specific health protection functions, who delivers them in reality, and to identify issues that need urgent attention. Understanding any differences in perceptions can then inform both the development of the Health Protection Agency and of PCTs, particularly as new arrangements develop in the light of current NHS organisational changes[19
]. It is also of relevance to judging the adequacy of health protection arrangements in different countries.