§ 5.34 p.m.
§ Baroness Finlay of Llandaff rose to ask Her Majesty's Government what action they are taking to preserve the expertise and quality of the Public Health Laboratory Service.
§ The noble Baroness said: My Lords, I am most grateful to your Lordships for participating in this debate. Questions about the re-organisation of the Public Health Laboratory Service have featured here and in another place in recent months. The Government's responses have been most informative. The object of the debate is to bring to the attention of the Government the serious ongoing concerns about the re-organisation of the Public Health Laboratory Service; to highlight the severe manpower crisis in the recruitment and retention of biomedical officers; to allow debate to complement the deliberations of the Select Committee on Science and Technology on fighting infection, under the expert chairmanship of the noble Lord, Lord Soulsby of Swaffham Prior; and to suggest to the Government that the time of transition in the management of the Public Health Laboratory Service may represent a time of vulnerability in the face of threats of deliberate release and bioterrorism.1177
The debate is about the way in which infections and the threat that they pose are detected and managed. In his report entitled Getting Ahead of the Curve, the Chief Medical Officer for England states:
The problem of infection is never static".
§ The new Health Protection Agency is being established to create a modern system to prevent, detect, investigate and control the infectious diseases threat and address health protection more widely. The Public Health Laboratory Service, a key component of the Health Protection Agency, has been a singly managed entity since 1991, but, in England, it is now being split between NHS trusts and the new agency.
§ Recent examples of the efficacy of the Public Health Laboratory Service in surveillance, disease detection and control include bovine spongiform encephalopathy and variant CJD, meningitis and NHS winter pressures from influenza and bronchitis. Worldwide, several new pathogens and infectious diseases are identified annually. New strains of organisms emerge, such as drug-resistant TB, and we face a massive rise in sexually transmitted diseases. For example, data from Cardiff, I am ashamed to say, indicate that 12 per cent of sexually active young women have chlamydia. We also face unrelated—I hasten to add—salmonella food problems from eggs coming into the UK.
The lessons of history are vital. Some crises were not managed as effectively and rapidly as they might have been. The reports on the Lanarkshire E. coli 0157 outbreak, the Stafford legionnaires' disease outbreak, and the food poisoning at the Stanley Royd Hospital all levelled criticisms at local laboratory services. In all those major outbreaks, the local clinical microbiology laboratories did not involve themselves proactively in the control of communicable disease, and the Public Health Laboratory Service was involved late in the outbreaks in England. In Lanarkshire, the Scottish Regional Hospital Board's provision of microbiology, with its voluntary system of surveillance, was criticised because the microbiology service tended,
to look too much to the hospital side of the NHS and the needs of the local health authorities, [did] not always get sufficient priority … The work of the Regional Laboratory Service in Scotland [was] not seen to extend beyond the walls of the [hospital] laboratories in which it operates".
As Professor Duerden, Director of the Public Health Laboratory Service, said,
The whole point of communicable disease is that it doesn't respect boundaries so we need a system that works locally to regionally to nationally".
The creation of the Health Protection Agency may achieve this end but the transition needs careful management.
§ Concerns exist that the service developments in England—and in Wales, Scotland and Northern Ireland—are becoming increasingly diverse, providing fragmented intelligence. Some specialised functions of the Public Health Laboratory Service, such as food, water and environment testing, may suffer, delaying reports on suspected outbreaks due to competing pressures from clinical work. Culture media production and equipment purchasing may suffer from loss of economy of scale and quality control.1178
§ The special techniques for food, water and environmental testing require a critical mass of personnel able to process specimens rapidly, particularly if the target of the Food Standards Agency to reduce food-bourne infection by 25 per cent is to be attained. Information from such testing must directly link to clinical cases of illness; they cannot be separated. Simply placing Health Protection Agency-employed staff in laboratories with this remit will not be enough. Professional isolation is the greatest threat to keeping up-to-date and staff need infrastructure support in cohesively managed teams.
§ In Wales, the surveillance laboratory network has, by contrast, grown over the past 10 years. Many NHS trusts already had handed over their microbiology laboratories to the Public Health Laboratory Service without tension. Very wide public consultation in Wales on Getting Ahead of the Curve resulted in overwhelming support from the continued existence of the communicable disease surveillance network. The National Public Health Service-Wales is the new managed clinical network which combines the public health laboratories, consultants in communicable disease control and their staff, the Communicable Diseases Surveillance Centre Wales and the resources of public health from the old health authorities. This unified National Public Health Service-Wales is already operational in shadow form, reporting to the Welsh National Assembly.
§ I must declare an interest as this managed clinical network is incorporated into Velindre NHS Trust in which I work and which, apart from cancer services, incorporates the Wales Centre for Health, Health Solutions Wales, cancer screening services, antenatal services and Welsh Blood Service.
§ This network provides pan-Wales multi-agency working, increased equity of provision, decreased variations in practice and wider connections for continuity from individual patients, through to disease control, within a single organisation. Links with environmental health officers are being developed through local health boards, which are coterminous with the local authorities. This provides the vital surveillance that Getting Ahead of the Curve identifies as the cornerstone to control of infectious disease in the population.
§ So Wales has already refocused its service, but will have to work very closely with the Health Protection Agency in England to share specialist services and ensure that epidemiological intelligence is obtained from a UK perspective.
§ Scotland has the Scottish Centre for Infection and Environmental Health. However, the hospital laboratory system and the co-ordination needed for public health are currently under review. The surveillance for Northern Ireland is provided by the Public Health Laboratory Service as part of the Centre for Communicable Disease Control. Its public health microbiological laboratory is located and managed in Belfast with links to the Public Health Laboratory Service in England.1179
§ Transfer of the 31 Public Health Laboratory Service laboratories in English hospitals to their host NHS trusts, with a commission from the Health Protection Agency, should ensure that all clinical microbiology laboratories are involved in public health. However, the danger in a split service is that the clinical pressures from the primary care trust and the hospital will be so great that public health readily falls behind urgent clinical priorities in these laboratories which are, by and large, under-resourced.
§ In the regional Health Protection Agency laboratories public health will be a major part of the service contract, providing a regional resource in medical microbiology alongside the diagnostic clinical service commissioned by the host NHS trust and the primary care trust. The reference laboratories, some of which are not sited in the designated regional laboratories, are a resource that must not be overlooked.
§ In England, while the consultants for communicable disease control are being brought into the Health Protection Agency to strengthen links from local to regional to national level, the local component of the microbiology service is being shed into local trusts, potentially separating it from an integrated system.
§ The changes will be staged with the Health Protection Agency becoming a specialist health authority from April this year and then an executive non-departmental public body a year later following legislation. What are the costs of this two-stage process? Money, instability, artificial divisions, a loss of strategic vision and a decreased ability to respond to sudden surges in demand may be the costs.
§ The transition requires funding. The laboratories in NHS trusts have been a Cinderella service for far too long. In the public eye, front-line clinical services, mostly nurses and doctors, have been in the spotlight. Government targets have pressurised clinical performance in some areas at the expense of others. But without sound pathology services overall, modern clinical practice fails. Accurate diagnosis is essential for correct treatment to occur. Inappropriate treatments cost thousands of pounds in drugs, in repeat investigations and longer hospital stays. Worse still, patients' lives are jeopardised.
§ In microbiology, the biomedical scientists are in very short supply. These honours degree holders are the backbone of the service; they have sophisticated bench-work skills and they provide information that influences life and death decisions. Too few enter training and too few stay. The downward trend in recruitment is not reversing. Government initiatives on pay and flexible work patterns face stiff competition from industry for these scientists. Medical laboratory assistants support them, but at that grade there are insufficient funded posts and job vacancies also exist.
§ The danger in transition is that the workforce is hesitant of change. The Trades Union Liaison Group meetings appear to be addressing the issues for existing staff and to smooth contract-of-employment transfers. Despite regular communications from the Department 1180 of Health, anxieties persist. A demoralised workforce does not work well. The service is then vulnerable to gaps in communication; when communication between parts of the service is slow or ineffective, disease control is jeopardised.
§ The end point is laudable. The whole of the NHS has a public health responsibility. However, the resources for clinical and public health work are inadequate and the programme is not phased with the pathology modernisation programme. In the meantime, the threat of bio-terrorism requires an iron strong network for infectious disease detection, investigation and control. The exercises in scenario planning are highlighting the intense co-ordination that needs to occur. A network in transition often has unforeseen weak points.
§ 5.46 p.m.
§ Lord Lucas
My Lords, I want briefly to intervene in the gap to congratulate the noble Baroness, Lady Finlay of Llandaff, on that stirring speech, with which I completely agree. My interest in this area is in bio-terrorism. I am sure that we all know that we should expect and plan for such an attack. It is so easy to make a pathogen which would have such an effect. I am sure that the Minister knows that we know how to make a version of smallpox which destroys the immune system. Many other potential recipes are known about. All one needs to achieve it is a supply of the raw materials and a laboratory. There are a great number of those around the world and, sadly, a large number of people have the religious-based motivation which allows them not to care for the continuation of life in this world if they can hurry us all into the next. We should expect this kind of thing to happen and we need to have the systems in place in this country to react swiftly and effectively should we be hit with an attack.
The Public Health Laboratory Service is the key to that. It is the service which will detect what has happened. The difference between detecting a disease on day five and detecting on day 15 is crucial. On day five, one may have a hope of containing it; on day 15, one has none. As we saw with the foot and mouth outbreak, if one leaves it too late, the disease is distributed all over and is beyond the capacity of the authorities.
We would then be faced with a crisis which we would probably not survive because the reaction of the outside world to us having a run-away killer infection such as smallpox would be to isolate the UK. It would be an easy thing to do: they need just stick a few boats around the outside and shoot anything that moves. In fact, we would probably be one of the few places in the world which could be so isolated and other countries would certainly do so. We know from the fuel strike exactly how long we would survive under those circumstances: the whole of civil society would start to fall apart after a couple of weeks.
We therefore need some strong systems in this country to ensure that when a bio-terrorist attack happens to us—and we must expect it to happen to us—we catch it fast and deal with it effectively. Having a Public Health 1181 Laboratory Service which is integrated, effective and able to move from the first detection straight through to the overall reaction of the system with great speed is essential. We should not at this time be risking our ability to respond to a bio-terrorist attack in this way.
§ 5.50 p.m.
§ Lord Clement-Jones
My Lords, I, too, thank the noble Baroness, Lady Finlay, for initiating the debate. She put her considerable medical knowledge at our disposal—I found her comparison with Wales extremely helpful —in very calmly and cogently putting the case against the current proposed changes set out in the Chief Medical Officer's report of last January. I hope to be as cogent —I do not promise to be as calm—about these proposals.
This month marks the anniversary of the CMO's report. Getting Ahead of the Curve. It has emerged more starkly than it did at the time that today's debate in regard to these proposals is not purely about routine response to public health issues but also about the crucial response to public health emergencies, as the noble Lord, Lord Lucas, emphasised, in terms of action against bio-terrorism and chemical terrorism.
The PHLS has a long and distinguished history. It was established in 1947, but it was based on the emergency PHLS which was set up in the Second World War by Winston Churchill to combat what was then described as bacteriological warfare.
Despite the long-standing nature of the PHLS, however, it is clear that a number of aspects of its reorganisation heralded by the report have some great advantages. The report rightly identifies many of the gaps in the system— particularly relating to emergencies in biological and chemical terrorism, where there has been no comprehensive surveillance system and where response has potentially been highly fragmented—and it puts forward welcome proposals to remedy the situation.
In particular, I welcome the integration within the Health Protection Agency of the Centre for Applied Microbiology and Research (CAMR) at Porton Down with the Central Public Health Laboratory (CPHL) at Colindale. It is a crucial relationship.
In this context, when researching for this debate I came across a very interesting debate which took place in this House in 1969, at the height of the Vietnam War, on Porton Down and the dangers of the development of chemical and biological weapons. It was initiated by my late cousin, Michael Gresford-Jones, who was then the Bishop of St Albans. Pursuing a major national campaign, supported by the Church Times among others, he advocated the transfer of Porton Down to the Department of Health from the Ministry of Defence. He was insistent at the time that Porton Down should be engaged in tackling biological and chemical threats, not creating them. He would, I know, have been pleased with these proposals, which see his proposals bearing fruit after more than 30 years have elapsed.
The new Health Protection Agency will also, very usefully in my view, subsume the National Forum for Chemical Incidents, originally set up in 1996; the 1182 National Poisons Information Service; and the National Radiological Protection Board, which advises and provides emergency response on radiation incidents. It is also welcome that consultants in communicable disease control will transfer to the new HPA.
It is clear, too, following the conclusions of the Phillips report on BSE in 2000, that the communication of risk and the use of appropriate language is of key importance. A single body will be much better placed to do this.
But there is a huge hole in these plans which has been emphasised by the replies the Minister has given to my Written Questions over the past month—that is, the failure to ensure that the Health Protection Agency will retain the managed network of PHLS microbiology laboratories which has built up high standards for the benefit of public health over many years. The proposal to transfer some 31 of these to NHS trusts has been decried by every relevant stakeholder involved, including the PHLS board, UNISON and laboratory managers. The critique by the Laboratory Managers Forum—which, I dare say, nearly all of us have had the benefit of reading—is, in my view, particularly devastating.
This failure will be exacerbated by the fact that the new HPA will have no more resources, it appears, than were previously available, and it is not clear who will be financially supporting the PHLS laboratories after the transfer. The suspicion is growing that the transfer plans are a pure cost-cutting measure by the Government, and yet, paradoxically, moving these laboratories to a more fragmented arrangement may cost more.
The essence of argument of the CMO, and now of the Department of Health, is that only specialist laboratories such as Colindale and those dealing with food, water and the environment need to be brought within the ambit of the new HPA. Clinical laboratories with diagnostic functions will transfer to the NHS. But without the 31 laboratories, the ability of the HPA to engage in surveillance, diagnosis, control and investigation of microbiological public health hazards and terrorist incidents will be gravely weakened.
Effectively, the arms and legs of the HPA are being cut off. The strength of the PHLS laboratories has been the fact that they constitute a network with good inter-communication and common standards. This is appallingly short-sighted—especially when the United States wants to emulate our national network.
The intention is that the laboratories will be grafted on to NHS trusts. But as Sir John Lilleyman, the president of the Royal College of Pathologists, pointed out in November, NHS laboratory services will collapse without further investment. There is a huge shortage, as the noble Baroness, Lady Finlay, pointed out, of technical staff in NHS laboratories, particularly of laboratory scientific officers.
The proposal to move the network of laboratories into the NHS was rightly described in a letter to The Times in September by a consultant microbiologist, Dr David Weldon, as an act of vandalism. The Department of 1183 Health appears to be claiming that transfer of PHLS laboratories will strengthen the NHS laboratories. But has it considered that the opposite could be the case?
The activities of those laboratories are highly interdependent—both with each other and with the specialist laboratories. A strong network of laboratories, for public health purposes in particular in terms of diagnosis of infectious diseases as well as in respect of anti-terrorism, is crucial. For instance, as the Minister confirmed to me in a Written Answer, in the recent outbreak of legionella in Barrow-in-Furness the PHLS laboratories played a key role, in processing environmental specimens and in the typification of patient-derived legionella specimens for matching to the environmental evidence.
How do we know that, once in the NHS, these laboratories will retain the same skills and the same high standards? Standard methods do not appear to have been adopted in the NHS. Indeed, very little information is available on the subject—in stark contrast to the standard methods that have been adopted within the PHLS.
The Department of Health claims that the transfers are essential to create a comprehensive, coherent surveillance and outbreak response system. Surely, again, it will provide precisely the opposite.
Has the Department of Health taken heed? Will it now rethink its proposals, so that the laboratories can go into the Health Protection Agency intact—at least for a period of time? Will it engage in further consultation on a revised model of the Health Protection Agency? Will it ensure that greater resources are allocated to the HPA? We look to the Minister for answers to all these questions.
Furthermore, I hope that the Minister will answer this crucial question. What legal authority has been granted to carry out these reforms? It seems extraordinary that the Government are setting up the agency this April and still believe that only regulations will eventually be required to bring the new body into being and to transfer the PHLS laboratories to the NHS. Surely primary legislation will be required—among other things at least to ensure the integration of the NRPB, which was set up by statute, into the new HPA, and for the integration of the PHLS, which itself was originally set up by statute, into the HPA. Again, we look to the Minister for replies to these questions.
In conclusion, far from their proposal providing a sound and welcome piece of organisational integration which will ensure that we are well equipped to combat terrorist threats, this Government, by their refusal to listen, risk ensuring that we are less prepared. All this is confirmed by the risk assessment paper written by Keith Saunders, the deputy director of the PHLS, referring to staffing meltdown and to the fact that public health laboratories may not be able to cope if there is a deliberate release of chemicals or biological weapons within the next three months.
1184 As it is, the National Audit Office produced a report in November on NHS emergency planning in England. It found that there were weaknesses in planning for post-September 11th incidents such as chemical and biological and mass casualty incidents. It is clear that these changes to the PHLS lab network, allied to the assumption of responsibility by PCTs in October for emergency planning, will only exacerbate the weaknesses.
To date, the Secretary of State and Mr Nigel Crisp appear to have taken no notice of any criticism of the proposals. Genuine consultation on the transfer of the network of laboratories has been non-existent. I sincerely hope that the Minister and his colleagues will finally have the courage to do an about-turn and that they will not leave us all at unnecessary risk in the future.
§ 6 p.m.
§ Earl Howe
My Lords, I, too, congratulate the noble Baroness on so ably introducing this timely debate on a subject that has generated great concern both in Parliament and more widely. It is not the first time that the proposed reform of the Public Health Laboratory Service has been raised in your Lordships' House. But today's chorus of agreement that this debate is now so necessary and pressing is, I am afraid, a reflection of the decidedly unsatisfactory answers given by Ministers on the matter to date. I hope that the noble Lord, Lord Hunt, who, I have no doubt, is sincere in backing the proposals, will be able to persuade us that they have been properly thought through and are without question in the national interest.
Examining what Ministers have said to date, it is perhaps instructive to start with what they perceive the current problem to be. The Government's analysis of the issue—in other words, the reason why, in their opinion, we need to reform the system—is not particularly controversial. In the document Getting Ahead of the Curve they refer to the need to create an integrated and comprehensive approach to health protection at national level down to regional and local levels. They also point out that, following the reorganisation of the NHS, our public health structure had to reflect the role that the different agencies should play. Microbiology laboratories, for example, are currently subject to a variety of management arrangements without the degree of security that they should properly have in current circumstances.
I have no quarrel with those observations. Indeed, the aim of bringing together the work of the PHLS, the NRPB, Porton Down and the National Focus for Chemical Incidents under the single umbrella of a new agency is not in itself a concept with which I have a difficulty. Whether it represents the best possible way forward is another question. As the noble Lord, Lord Clement-Jones, remarks, many people, particularly those most closely involved in the delivery of public health, do not feel that they have been properly consulted on the issue. One must admit that the consultation period last summer was brief.
Nevertheless, establishing a new health protection agency seems a sensible way to achieve the Government's perfectly valid aims. We should not set our faces against 1185 any change whatever. But, having constructed the edifice and justified the concept, the Government promptly proceeded to undermine it by specifying that the majority of public health laboratories are not to be absorbed by the new agency, but instead consigned, individually, to the control of NHS trusts. I have said before that our antennae ought to start twitching whenever we see the word "modernisation" in a government document. Here it is again in Getting Ahead of the Curve:Building on the existing strengths of this public health system, the proposals in the strategy aim to modernise it".It is a word that aims to reassure us and lull us along, but it means everything and nothing.
Quite rightly, the Government insist that good surveillance is the cornerstone of any system for the control of infectious diseases, a point emphasised cogently by the noble Baroness, Lady Finlay of Llandaff. Without it, one cannot forecast threats, track diseases and disease trends, identify serious outbreaks or monitor how diseases are being brought under control.
That sort of activity has to be co-ordinated across large geographic areas, often across the whole country, and even sometimes internationally. Yet by wanting to split up the existing network of laboratories the Government appear to be travelling in precisely the opposite direction. Yes, it is certainly true that about half of the activity of PHLS laboratories is currently accounted for by analytical and diagnostic work performed on behalf of NHS trusts. One could argue—and doubtless the Minister will—that by giving most of the microbiology labs to NHS trusts we would simply be recognising that, managerially speaking, it makes sense for a laboratory to be part of the organisation on which it depends for a large slice of its day-to-day work and which therefore has a direct interest in ensuring its efficiency and effectiveness. But that argument begs the very question which needs to be analysed, which is how best disease surveillance should be achieved. I suggest that it is the argument of the management consultant; the kind of logic which is generated from behind a desk rather than from any real appreciation of what the PHLS as a whole actually does.
There are perhaps two main worries in this context, which the noble Baroness has already covered. They are the model itself and the speed of its implementation. I do not know how many of your Lordships saw a letter in The Times last September from David Weldon, the honorary consultant microbiologist at Bedford General Hospital. He is a man with considerable experience of both the NHS and of public health laboratories. He pointed out that the NHS is too stretched and too under-resourced to devote adequate time to epidemiology. Indeed, on the one hand, a hospital laboratory is answerable to an organisation which sees no direct gain in such work. On the other hand, public health laboratories are answerable to an authority that is not local and which understands and values epidemiology. That structure encourages openness and objectivity. The net result, David Weldon says, of splitting up the PHLS in the manner proposed will be the demotion of surveillance.
1186 I believe that those are issues which deserve at least some debate yet I have not seen the Government even address them neither have I seen them address the parallel concerns raised by Professor Hugh Pennington who fears that we are in danger of losing not only the expertise which has existed in the PHLS since the 1940s, but also the national network of laboratories and, crucially, the training function that the service performs. I believe that we must question the wisdom of dismantling that national network, an asset which has been regarded with envy from across the Atlantic. The noble Lord, Lord Clement-Jones, rightly pointed out that in the United States the absence of a networked service has proved directly responsible for the unmonitored and uncontrolled outbreak of epidemics.
Of course, the Minister will tell us that core funding will be channelled to those laboratories that are transferred to the NHS to enable their public health work to continue. But what about national co-ordination? The networks so carefully built up over years will be destroyed. While it is hoped that new ones will spring up in their place, the almost inevitable discontinuity is, I suggest, an alarming prospect, lit is a large step into the unknown. As my noble friend Lord Lucas so graphically pointed out, we are living in a time when the risk of a deliberate release of biological agents into the general population is of the highest order. In addition, there are several extremely serious infectious diseases which, if not detected in a timely way, could hit large sections of the population at any time and for which the country needs to be on heightened alert. For goodness sake, now is not the time to compromise our national public health capability. Having last year reformed the structure of the NHS, the Government are going all out to shoehorn public health into the NHS structure that they have created. They are doing so against a very tight timetable for implementation by 1st April 2003. At the very least, the risks of such reform should be openly admitted. At worst, the reform is foolhardy.
One begins to appreciate the scale of the risk when one reads, as I have, the document that I have in front of me which is entitled, Report to HPA Steering Group on HPA Business Continuity: Risk Assessment. I hesitate before quoting selectively from such a document, which I believe has been prepared for departmental consumption, because I do not wish to be accused of distortion or of exaggeration. However, the executive summary has this to say:It seems inevitable, if the timetable of 1st April 2003 for the HPA is to be delivered, some level of risk will have to be tolerated. Were there to be a severe external challenge over the next few months such as deliberate release, the situation and expected forward timetable would need rapid reappraisal".Those statements can only fill one with the utmost foreboding. The risk factors detailed in the paper are discussed one by one; some are not particularly significant, or else have been adequately covered. But when it comes to the PHLS, high risks are identified following potential loss of staff, leading to inadequate safeguards, poor service in routine microbiology, and a reduced commitment to public health work. There are "considerable" risks associated with destabilising the production of biological media, considered vital to 1187 ensure the correct diagnosis of disease. Reaching a solution on this issue is described as being "of the utmost urgency".
The transfer of the laboratories to the NHS puts the bulk procurement discounts of the PHLS seriously at risk, leading, obviously, to an escalation in costs. The passage in the document that deals with the fragmentation of the national network is unequivocal. The network brings,added value to the control of communicable disease over and above what can be provided by local authorities and the NHS … Throughout the PHLS are located individuals and units with unique specialist expertise … Integration between centre and periphery, and between microbiology and epidemiology, all within a clear policy framework, underpins the delivery of successful communicable disease control programmes. This is put at risk by separation of the laboratory network from the other functions".Two examples, pneumococcal disease and salmonella entiriditis are then given to demonstrate the importance of the integrated network. Then follows a paragraph labelled "Action", which says:It is unclear how the totality of this integration could be recreated post April 2003. At least this will require complex service level agreements, professional networking meetings with dedicated resources and creative use of development funds".The Minister has said on at least one occasion in this House that it is better to get on with the proposed reforms than to create uncertainty. This document, which, no doubt, I was not expected to see, stands as an indictment of the Government's policies on public health. I have to ask the Minister which of the following two possibilities is worse: a continuing measure of uncertainty, or the real risk of a serious gap in the country's public health provision—one serious enough to lead the board of the PHLS to insist on a ministerial direction before implementing the changes?
In Ministers' minds there should be no contest. Let us forget for a moment about whether the Government are ahead of the curve. It is crystal clear that they are way, way ahead of themselves.
§ 6.14 p.m.
§ The Parliamentary Under-Secretary of State, Department of Health (Lord Hunt of Kings Heath)
My Lords, I am grateful to the noble Baroness, Lady Finlay, for allowing us to debate once again the question of the creation of the HPA, as well as some of the issues raised by other speakers. From the content of the debate, it is interesting to note that there is consensus around, first, the essential urgency of reviewing the current arrangements to ensure that we are prepared for some of the new threats that have been so graphically described this evening by noble Lords.
Secondly, I take it that the broad thrust of the Chief Medical Officer's proposals in his report of some 12 months ago is widely accepted and that the concerns held are about the speed of the transition and the laboratories that are to be transferred to the NHS. I am confident that the proposals are right. Speed is of the essence. It is important that in transferring and making the changes we make sure that the risks are minimised as far as possible.
1188 But I make no apology for the fact that a proper risk assessment has been undertaken. We would rightly be criticised if it had not been. The fact that it has taken place enables the people taking forward the changes to make sure that those risks are minimised. There is no question that we start from a general agreement that the PHLS has a significant level of expertise and quality that it is essential to preserve. But we cannot be complacent about our current arrangements.
It is clear that no matter where we live in the United Kingdom we are only hours away from any traveller or food that may have come from exotic countries; we are having to deal with new technologies that may increase the risk of infection; and we have a greater number of patients with immunodeficiencies that make them more susceptible and vulnerable to infection. On top of these natural threats, we now have the spectre of deliberate release of pathogenic organisms such as anthrax and smallpox, which has made us all look afresh at how we may be able to respond and protect our population. I agree with the noble Lord, Lord Lucas, about the need for strong systems, but I do not accept that the proposals before the House put those systems at risk.
This country has surveillance arrangements which achieve standards to match anywhere in the world. But we cannot run away from the weaknesses identified by the Chief Medical Officer. All noble Lords who have spoken have identified some of those problems. The noble Baroness, Lady Finlay, did so in her introductory remarks. They include reportable data being incomplete and not always reported on time; datasets not including particular pieces of information that are now thought to be important, such as antimicrobial susceptibility of certain organisms; that too much of the reporting chain is paper-based; and the limited linkage between human, veterinary, food, water, environmental and clinical surveillance systems so that interrelated emerging trends or incidents are not always recognised as promptly as they might be. It is my experience of the wonderful world of the National Health Service that it will always be argued that it is never a good time to change, but I believe it is the right time to address those weaknesses.
The Chief Medical Officer's report, Getting Ahead of the Curve, and the strategy are the way forward. Anyone who knows the Chief Medical Officer knows that he has a deserved world-wide reputation. Does anyone believe that with his awesome public health responsibilities he would put forward proposals that would put at risk necessary surveillance in this country?
The strategy increases the profile of infections in the eyes of the public and the NHS. It proposes a systematic approach to preventing and controlling infectious diseases that builds on current strengths in the PHLS but also in the NHS and related non-departmental public bodies. Crucially, it seeks to align the control of infections, chemical hazards and radiation hazards in a single coherent system so that we tackle problems in a structured way, especially where the nature of the problem might not be clear at the outset. That is surely a crucial aspect of dealing 1189 with the prospect of deliberate release of dangerous agents, an issue very much to the fore since September 11th 2001.
The centrepiece of the Chief Medical Officer's strategy is the creation of the Health Protection Agency, the aim of which is to provide integrated, specialist advice and support to the NHS and other key bodies. That support is important and is one way in which the integrity of the current network will be preserved and enhanced. It will harness the epidemiological and specialist and reference facilities of the PHLS, the Centre for Applied Microbiology and Research—I listened with great interest to the remarks of the noble Lord, Lord Clement-Jones, about the debates in this House 30 or so years ago— the National Radiological Protection Board, the National Focus for Chemical Incidents, the National Poisons Information Service and regional service provider units which give advice on chemicals.
What has not been mentioned in the debate is that, at local and regional level in England, the HPA will incorporate the activities of consultants in communicable disease control and other health protection staff currently based in primary care trusts and regional health emergency planning advisers currently based in the Department of Health or the NHS. So part of the restructuring is to embrace people currently employed directly in the NHS within the HPA. It is an example of how we are pulling people together within a national strand of work and ensuring national co-ordination. Consequently, local primary health care teams, local authorities and others who undertake public health activities will be supported by specialists who are part of a regional and national agency. They can supply expertise and back-up wherever and whenever they are needed and can run programmes on their behalf.
It is a pity that that particular change has been overlooked. The result of the proposals is a single national agency capable of delivering a coherent and unified specialist health protection service for the benefit of the public. It will strengthen this country's capacity to respond effectively to a chemical, biological or radiological incident. It will enable this country to contribute in an integrated way to a range of international initiatives. I also believe that it will further enhance our current high reputation for health protection expertise in the international community.
I come now to the issue of the transfer of laboratories, a matter referred to by both the noble Earl, Lord Howe, and the noble Lord, Lord Clement-Jones. I fundamentally disagree with their comments. I absolutely and categorically refute the allegation made by the noble Lord, Lord Clement-Jones, that this has been done as a cost-cutting exercise. Nothing could be further from the truth. We want to raise clinical microbiology standards across the NHS which is why we have proposed strengthening the public health contribution of all NHS microbiology services. Consequently, all laboratories will report infections to public health authorities, send relevant specimens to reference laboratories, assist in managing outbreaks and contribute to the development of local public health policies.
1190 The implications of that philosophy—that each NHS diagnostic laboratory has general public health functions—has led to the proposal in the strategy to transfer to NHS trusts those laboratories in the Public Health Laboratory Service that carry out predominantly routine clinical diagnostic microbiology.
Having listened to the noble Lord, Lord Clement-Jones, and the noble Earl, Lord Howe, talking on a number of occasions about the need to transfer back to the NHS as much responsibility as possible, I believe that the transfer of some PHLS laboratories to the NHS should be welcomed. It gives to the NHS what it should do, but it enables the proposed new agency to concentrate on public health rather than on general clinical diagnostic services.
It also follows from the fact that over 50 per cent of current routine clinical diagnostic microbiology is already carried out within the National Heal Service. With regard to the allegation by the noble Lord, Lord Clement-Jones, that the arms or legs are being cut off the new agency, or that there will be professional isolation issues, as suggested by the noble Baroness, Lady Finlay, let me make clear that the PHLS has always worked closely alongside its NHS colleagues, sometimes sharing the same laboratory facilities, and this move will build on that synergy. It will also bring general public health microbiology firmly into the mainstream of NHS activities. That surely is a great advantage when it comes to action to be taken at local level.
§ Lord Clement-Jones
My Lords, if it were only noble Lords putting these points today, I would understand the absolute certainty with which the Minister puts the case. But he is aware that laboratory managers, the PHLS board, Unison and anyone else with intimate understanding of these laboratories disagrees with him. He has not addressed the points made. No doubt he will have read all the documents from groups such as the laboratory managers forum. He does not address the points they make.
§ Lord Hunt of Kings Heath
My Lords, I shall come to the detailed points raised. However, one should not underestimate the innate conservatism of people working in the National Health Service with regard to any change proposed—certainly during my years in the health service.
§ Lord Clement-Jones
My Lords, that includes presumably the noble Lord's colleague on the Labour Back-Benches.
§ Lord Hunt of Kings Heath
My Lords, I do not know to whom the noble Lord refers, but if he refers to the noble Lord, Lord Turnberg, I have had some useful discussions with him. I also know that whatever reservations the PHLS board may have hat it has pledged itself to co-operate as fully as possible with the transfer of those laboratories.
§ Baroness Finlay of Llandaff
My Lords, I am grateful to the noble Lord for giving way, but I must protest.
1191 The evidence from Wales has been that staff have transferred willingly from the NHS laboratories to the PHLS managed network. They have embraced change and the transition has been very smooth with no disruption. The staff themselves have wanted to move into a managed clinical network.
§ Lord Hunt of Kings Heath
My Lords, I am delighted to hear that. I take the point raised by the noble Baroness. I am keen to ensure that in terms of arrangements and co-ordination there is no fragmentation between England, Scotland, Wales and Northern Ireland. I agree with her on that.
Let me pick up some specific points. On the issue of speed, my long experience of structural change in the National Health Service demonstrates that time and again we have had great problems because change has taken place too slowly. Decisions become blighted. People become uncertain about what is to happen to them. I am convinced that the key to organisational change is that once you have decided what to do, you do it decisively, of course with due regard to the interest and concerns of the staff involved and ensuring that you maintain a stable service.
I come back to the point that the noble Earl raised about risk assessment. Surely it is right that a risk assessment should be undertaken. I do not think that there is any disagreement about that. I would expect any risk assessment to be undertaken seriously and for the relevant organisation to be as confident as it could be that it had quantified all the risks so far as possible. I believe that that has happened. I welcome the work of the HPA steering group that received the report to which the noble Earl referred. It agreed the key risks but it also agreed the action to be taken to address them. It agreed especially that interim directors would be appointed to the HPA to provide clear continuity of leadership during the transitional period. That is necessary to ensure that the identified risks are kept to a minimum.
I turn to the question of whether the effective managed network of laboratories will be undermined, or, indeed, destroyed, as some noble Lords allege. That is the last thing that we would wish. We want to encourage the existing network to be maintained in the NHS environment and, indeed, to act as a catalyst for the growth of wider NHS pathology networks. The PHLS experience gained in overseeing networks activities such as standardising operating procedures and procuring media and other supplies will now become widely available to NHS trusts. The idea that the NHS is not able to run networks runs counter to the whole direction and trend in which the NHS is going, in which increasingly care is delivered across networks.
The proposed Health Protection Agency will have a public health laboratory in every public health region. The public health and training outputs will be strengthened with the introduction of the funded public health microbiology posts at local and regional levels as well as by the inspector of microbiology who will oversee standards in service and security.
1192 On the question of funding, we are taking steps to ensure that all the laboratories transferred to NHS trusts are appropriately resourced and motivated to meet their public health responsibilities. We have already said that the public health funding for existing laboratories will be protected for that purpose for at least the first two years.
As regards whether public health will figure as part of future NHS priorities, we are confident that the locally based public health microbiologists, together with the new regional public health microbiologists, and the national microbiology inspector will combine to make sure that the NHS keeps an appropriate focus on public health. I have met directors of public health in primary care trusts who are as concerned as everyone else to ensure that the new arrangements work effectively. We have ensured that directors of public health will be executive directors of primary care trusts. They will be in an excellent position to ensure that future resources will be adequate to meet the challenge that is faced.
Noble Lords mentioned the supply of media for these laboratories being endangered. That is a vitally important matter. Media will continue to be procured in the existing four PHLS media production centres. Of course, some staff have concerns. We have been involved in discussions about the HPA with them for some months. But they know that they will have a future career either in the HPA, where they can have a better career path in specialist public health services, or in the NHS where they can have a better career path in pathology networks. The PHLS management is currently in the process of discussing with individual staff the implications as they affect them.
I have spoken for considerably longer than the time I am allotted to reply to the debate, for which I apologise. However, it is important that I emphasise that I have listened to noble Lords' concerns and I understand their anxieties and motivation. We all wish there to be effective arrangements in future to enhance public protection. I am confident that what the Chief Medical Officer has proposed and the implementation programme will ensure enhanced public protection. I am absolutely confident, when a decision has been made in the National Health Service, that everyone involved will do everything that they can to minimise the risks and ensure that changes are made as swiftly as possible.
§ Lord Clement-Jones
My Lords, I do not want to delay the Minister unduly, but will he comment on the legal authority for these changes?
§ Lord Hunt of Kings Heath
My Lords, we intend that the agency will be established from 1st April 2003. We can establish it now as a special health authority, to be called the Health Protection Agency, which we will do. It will be responsible for functions under the NHS legislation which are to be given to the new agency.
Our eventual aim is that the agency will be fully established as a non-departmental public body from 1st April 2004. That will be subject to legislative time being available. At that stage, it would take responsibility 1193 for functions currently performed by the National Radiological Protection Board. During the period when the HPA is a special health authority, we would expect the HPA and the NRPB to work closely together to prepare the merger. As for the transfer of laboratories from the PHLS to the NHS, I am reliably informed that no legislative power is needed to do that. It has been done before.