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21 08

Strategic Delivery Plan - Protecting

people from infectious disease and environmental

hazards Author: Mark Dickinson, Executive Director of Planning and PerformanceDate: 11 December 2012 Version: 0gPurpose and Summary of Document: The Public Health Wales Board are asked to approve the Strategic Delivery Plan for protecting people from infectious diseases and environmental hazards. Public Health Wales’ Strategy contains seven strategic objectives, which are each underpinned by a Strategic Delivery Plan. The plan looks forward approximately three years and sets out, at a high level, how the objective will be achieved. The Board approved the first set of Strategic Delivery Plans in June 2012 and it was agreed the remaining documents would be submitted once completed. Sponsoring and presenting Executive Director: Mark Dickinson, Executive Director of Planning and PerformanceDocuments attached:

Protecting People from Infectious Diseases and Environmental Hazards Strategic Delivery Plan

Date of Board meeting:

Public Health Wales Strategic Delivery Plan – Infectious Disease and Environmental Hazards

20 December 2012Please state of the paper is for:Decision The Board are asked to approve the Strategic

Delivery Plan

Date: 11/12/12 Version: 0g Page: 2 of 18


Strategic Delivery Plan

Protecting people from infectious

disease and environmental

hazardsLead Authors: Dr Marion Lyons, Director of Health Protection

Dr Mark Hastings, Director of MicrobiologyDate: 11 December 2012 Version: 0gPurpose and Summary of Document: The Public Health Wales Strategy contains seven strategic objectives. Each objective is underpinned by a Strategic Delivery Plan, which sets out, at a high level, how the objective is to be achieved.This Strategic Delivery Plan underpins the strategic objective to protect people from infectious disease and environmental hazardsThis plan looks forward for approximately three years, but will be reviewed at least annually in the light of experience and progress.Each Strategic Delivery Plan is itself underpinned by more detailed work plans.


http://www2.nphs.wales.nhs.uk:8080/CorporateServicesDocuments.nsf/85c50756737f79ac80256f2700534ea3/e31614e41068e3b9802577b60035c323/$FILE/Public%20Health%20Wales%20Strategy%202010%20-%202015%20%20061010%20v1.doc


1 IntroductionThe Public Health Wales Strategy contains seven strategic objectives, each of which is supported by a Strategic Delivery Plan. This document is the Strategic Delivery Plan supporting the objective:

To protect people from infectious disease and environmental hazards

The plan sets out, at a high level, the approach and key actions that Public Health Wales will take in meeting this objective.

This plan does not address the Public Health Wales response to emergencies, which is covered in the Strategic Delivery Plan supporting the objective “to respond effectively to the public health impacts of emergencies.

This plan will be revised at least annually and in line with new or changing priorities as they emerge

2 Context

2.1 The health impact of infectious disease and environmental hazards

Progress in the prevention, control and treatment of infectious diseases has considerably reduced their impact on health in Wales in recent decades. However, infectious diseases continue to evolve and adapt and remain a significant threat to public health:

healthcare associated infections cause considerable morbidity and mortality and are a source of great public concern

antimicrobial resistance in key pathogens both in hospitals and the community is causing increasing difficulty in the reliable delivery of effective therapy for infections

effective immunisation programmes are essential if vaccine preventable diseases are to be prevented within the population

some sexually transmitted infections have lifelong consequences for the individual infected

the potential re-emergence of old threats, such as tuberculosis the threat of new infections emerging, including those with

pandemic potential the World Health Organisation has estimated that 24% of the global

disease burden can be attributed to environmental factors whilst at


http://www2.nphs.wales.nhs.uk:8080/CorporateServicesDocuments.nsf/85c50756737f79ac80256f2700534ea3/e31614e41068e3b9802577b60035c323/$FILE/Public%20Health%20Wales%20Strategy%202010%20-%202015%20%20061010%20v1.doc


the UK level 14% of the burden of disease is thought to be attributable to environmental stressors

injuries are the leading cause of death amongst under 45 year olds and the improved control of communicable diseases has led to an increase in the relative importance of injuries in terms of the overall burden of disease.

2.2 The Public Health Wales organisational response

2.2.1 Introduction

In responding to these threats, Public Health Wales brings together, in a single organisation, a unique combination of services and expertise. Two Divisions have the primary responsibility for action to protect people from infectious disease and environmental hazards:

Health Protection Division - consisting of the Health Protection Team, the Communicable Disease Surveillance Centre (CDSC) and priority programmes

Microbiology Division – consisting of a network of microbiology services, embedded in NHS hospital locations, together with a range of specialist and reference services

2.2.2 Health Protection Division

The Health Protection Division has a multi-disciplinary workforce that includes doctors, nurses, scientists and information staff, all of whom are supported by core business and Informatics teams. The Health Protection Division works collaboratively with the Microbiology Division and other Divisions of Public Health Wales and with partners in Welsh Government, health boards, local authorities and the emergency services.

The Health Protection Division focuses on the entire population at both the individual and community level and:

as a single managed service, promotes a consistent Wales-wide approach to health protection, both within the Division and with partners

provides advice, support and information to health professionals, partner agencies and the general public

is responsible for co-ordinating the management of notifiable diseases, incidents and outbreaks

is responsible for taking forward specific health protection programmes (Healthcare Associated Infection, Antimicrobial Resistance, Vaccine Preventable Disease, Sexually Transmitted Infection and HIV, Blood Borne Virus and Tuberculosis and Respiratory Infections)



is the national surveillance centre for communicable diseases and environmental hazards

acts on information received from our large network of partners, our surveillance systems and from investigation and research to reduce the risk to the people of Wales from communicable disease and environmental hazards and injury

2.2.3 Microbiology Division

The Microbiology Division is an integrated service within the healthcare system in Wales and works closely with other divisions in Public Health Wales and partners in health boards and local authorities. The management of laboratory services as a co-ordinated network provides a significant degree of resilience, and capacity, particularly in response to outbreaks, and ensures standardisation and consistency of service delivery.

Health Board Services

Medical microbiologists at each site are fully integrated with local services and provide a comprehensive infection management service. The microbiology diagnostic services work closely with local clinical and pathology services. Its key functions are:

laboratory diagnostics to hospitals, general practitioners and other healthcare providers

advice to hospital physicians and general practitioners on the investigation , diagnosis, treatment and control of infection

medical microbiology leadership of hospital acquired infection prevention and control services

support for outbreaks and community infection control medical and scientific advice and support for microbiologists across

Wales analysis of food, water and environmental samples with the

provision of official food control support microbiological services to proper officer and port health functions

National Services

In addition to local services, the Microbiology Division supports healthcare services across Wales and the UK through the provision of a range of specialist and reference services. These services provide specialist and reference diagnostics, interpretation and expert clinical advice. They include:

National Anaerobe Reference Unit (England and Wales)



National Cryptosporidium Reference Unit (England and Wales) National Toxoplasma Reference Unit (England and Wales) Welsh Mycobacterial Reference Unit (Wales and South West Region,

England) Welsh Specialist Virology Unit Specialist Antimicrobial Chemotherapy Unit (SACU) Welsh Food Water and Environmental microbiology service Welsh Mycology reference service

The Microbiology Division provides key microbiology and infection expertise to the Public Health Wales programmes, the Welsh Government and NHS Wales.

3 Strategic approachPublic Health Wales aims to reduce the impact of infectious disease and protect the people of Wales from infectious and environmental hazards by:

building on the unique advantages of having health protection, communicable disease surveillance and microbiology embedded in a public health system, through a coordinated and collaborative approach

developing a transparent mechanism for prioritisation of resources based on burden of disease

providing timely and accurate intelligence to guide health protection action in support of clear objectives

delivering safe, accessible, responsive, effective and resilient services of an assured high quality and which are continually improved

providing training on immunisation to NHS and other providers in an acceptable, effective and efficient manner (e-learning)

improving service efficiency and effectiveness by exploiting new technology (automation) and economies of scale

minimising health impacts from environmental hazard exposures

adopting an explicit policy of zero tolerance to preventable healthcare associated infections

harmonising the infection service model and supporting best practice in infection management across Wales

ensuring appropriate antimicrobial usage by all health professionals in Wales



working from and contributing to the scientific evidence base, including through collaboration in research and development with other public health agencies and academic institutions

ensuring that the workforce is resilient and has the required knowledge, skills and expertise to meet current and future needs

incorporating appropriate scientific and technological development into diagnostic services to improve the identification of infectious disease for the management and control of outbreaks and enhanced epidemiology and surveillance of disease

4 Specific actions

4.1 Co-ordinated and collaborative approach

4.1.1 Current position

The Health Protection Division and Microbiology Services work together to reduce the burden of infection and work closely with partners to achieve results. With the NLIAH Service Improvement Team (including 1000 Lives Plus) joining the organisation in April 2013 there is a real opportunity to capitalise on the organisations assets. Frequently populations that we need to engage with or services that require support and development are also targeted by other divisions within the organisation. A joined up approach in priority areas may result in better outcomes more efficiently achieved (e.g. reduction in health care associated infections and reduction in burden of liver disease caused by blood borne viruses, alcohol and obesity).

Health Protection systems, functions and responsibilities are also changing and evolving in other parts of the UK. There is a need of ongoing collaborative working with the relevant public health agencies.

4.1.2 Further actions necessary

1) Implement The Healthcare Associated Infection Reduction Programme and learn from the experience

2) Achieve organisational sign up to, and implement, a similar approach to combat liver disease in Wales, a public health priority

3) Further develop links with Health Protection England and other UK Health Protection Services

4) Develop specialist and reference unit work plans in line with National (UK) priorities



4.2 Prioritisation


The programmes of work currently undertaken have arisen as a result of many different factors – policy, personal interest, political need etc. As the burden of disease from all infections/environmental hazards has not been explored by the Health Protection Division it is possible that we are neglecting areas where our input may contribute to improved health.

Changes in healthcare priorities, advances in science and technology and the emergence of new diseases continue to provide challenges and the stimulus for refocusing service planning and delivery within Microbiology Services. An ambitious programme of service development and change is beginning now and prioritisation of resources and effort will be necessary to ensure delivery to necessary timescales.


5) The Strategic Lead for Surveillance to develop a programme of inquiry into the burden of disease, the evidence for effective interventions and their relative cost effectiveness, through engagement with the wider resources and expertise of Public Health Wales

6) Where action for health agreed and extra funding required Board support to be sought

7) A service development plan identifying priorities and incorporating resource mapping and appropriate timescales will be developed and agreed

4.3 Timely and accurate intelligence


There are a number of weaknesses in the current surveillance systems. These include both the quality and timeliness of the data provided to Public Health Wales and uncertainty as to the value of all of the information provided to stakeholders by Public Health Wales.


8) Appoint a strategic lead for surveillance9) Complete the development of Information Bureau for Infectious

Diseases and ensure resources are available for comprehensive introduction, implementation and maintenance



10) Agree with NWIS the mechanism for timely access to data from the Primary Care Data System (audit+)

11) Complete the surveillance review, agree recommendations with stakeholders and implement them

12) With partner health protection organisations, contribute to a horizon scanning process to protect from, and anticipate, harm from infections or hazards

13) Complete and maintain the standard operating procedures for infection diagnostics across Wales

4.4 Safe, accessible, responsive, effective and resilient services of an assured high quality


The response to any notifiable disease, incident or outbreak should be consistent across Wales and all Wales policies and procedures have been developed to support this.

For some communicable diseases the burden of disease is considerably greater in some marginalised groups and the Health Protection Division is committed to equal access for all.

The Microbiology Division provides routine and specialist microbiology services through a managed laboratory network, delivered from eight sites across Wales. The service has CPA accreditation as a network and UKAS accreditation for its Public Health Microbiology Service (Food, Water and Environmental laboratories). Microbiology Services are accessible at all sites 24 hours a day, seven days a week, through a combination of routine and out of hours service (including on-call), which ensures an emergency response.

Changes in clinical service configuration across Wales, improved standards for patient care and the need to respond to new and emerging diseases requires development of expanded service delivery models (weekends/bank holidays) that can deliver effective and sustainable response at all times.


14) Deliver a rolling audit programme on the management of notifiable diseases

15) Audit outbreak and incident responses and ensure lessons learnt are implemented

16) Build a process for evaluating the impact of interventions into all work plans and share with stakeholders



17) Reduce the impact of inequalities on access to prevention initiatives and testing for and treatment of infections. Each programme to address known areas of inequality and develop actions for improvement

18) Develop proposals for Public Health Wales to undertake awareness raising campaigns - for example seasonal influenza vaccination

19) Develop a performance management framework to provide assurance on safety and quality of microbiology services, including Standards for Health Services, Risk Register and performance reports to the Board and Executive Team.

20) Develop harmonised service specifications (including turn-around times) for all microbiology services, including emergency and out of hours working

21) Develop plans and implement service change to enable delivery of enhanced microbiology services (weekend/evenings) necessary for standardised service specification

22) Build resilience in capacity to provide expert advice and expertise for development of diagnostic capability in response to emerging (novel) pathogens

4.5 Training on immunisation


The Vaccine Preventable Disease Programme provides learning resources to support immunisation training throughout Wales. These are accessible through the intranet in the form of documents, presentations and videos. Scoping the needs of health boards has identified the potential for offering e-learning to complement current local approaches.


23) Work with NWIS and NHS Learning England to scope potential e-learning resources for Wales, and develop a costed proposal

24) Develop and introduce online knowledge assessment tools as an exit test for immunisation training modules

25) Collaborate with and support health board Immunisation Coordinators to integrate future e-learning with existing local provision, including mentorship and monitoring use



4.6 Improving service efficiency and effectiveness


The Carter report 2008 set out principles and guidance on modernisation of pathology services in England and Wales. Significant changes in a number of areas in England have been seen, largely as a consequence of commercial pressure.

In Wales, the National Pathology Framework defined standards and provided guidance, while the Future Delivery of Pathology Services in Wales 2008 gave recommendations for design and delivery of laboratory services. While much progress has been made in Wales and the Microbiology Division have led the way, the challenge of introducing significant service re-design is still to be faced.

Public Health Wales already delivers around seventy percent of microbiology services in Wales and with the incorporation of Withybush and Wrexham microbiology services into the network (April 2013) this will be nearer eighty percent. In addition specialist and reference services are delivered for the whole of Wales and to the UK.

Following service review consolidation of the laboratories in North Wales and South West Wales, it has been identified as the only way to ensure that services can continue to be delivered safely and effectively and be able to meet the needs of the changing healthcare system.


26) Develop and deliver plan for implementation of North Wales Microbiology Service Review

27) Develop and deliver plan for implementation of AMBU Microbiology Services Review

28) Develop and deliver implementation plan for incorporation of Hywel Dda Microbiology Service (Withybush) into Public Health Wales Microbiology Network

29) Contribute to South East Wales Microbiology Review and support project to develop options for future service delivery

30) Review management arrangements and develop structures aligned with service re-configuration

31) Implement harmonised on call arrangements and develop delivery plans for all out of hours working

32) Develop common workload measure and standardised pricing model

33) Lead standardisation and harmonisation of laboratory methods and clinical practice in Wales



34) Explore commercial partnerships, where appropriate, to develop opportunities for introducing new technologies

35) Implementation of all Wales LIMS in line with agreed roll out schedule

36) Replacement of automated AST /ID equipment (Phoenix) to deliver further improvement in standardisation and detection of antibiotic resistance

37) Implement agreed expansion of TB laboratory (Llandough) to ensure specialist services for Wales can deliver enhanced diagnostics necessary for reducing the effect of Tuberculosis in Wales

4.7 Minimising health impacts from environmental hazard exposures


An Environmental Public Health Strategic Framework and work plan for 2012-2015 has been jointly developed with the Health Protection Agency CRCE-Wales. This framework has four key aims: to reduce ill-health associated with environmental hazard exposures, reduce rates of injuries and associated environmental hazard exposures, reduce health impacts from environmental incidents and monitor trends and patterns in environmental public health exposures and concerns. Each aim applies to key areas of work that cover emergency planning and preparedness, environmental hazards (air, land, water, nuisance, radiation, housing), environmental permitting/planning, risk communications, the wider environment, children’s environmental health, training and education, research and development and audit and governance. Service delivery and development are further supported by detailed annual programmes of work.


38) Vision for environmental public health surveillance in Wales to be developed, to support and inform the ongoing review of organisational surveillance functions

39) Audit of previous environmental incidents to determine extent to which ‘lessons to be learned’ have been acted upon

40) Development of performance standards (in conjunction with HPA-CRCE Wales) to support future audits

41) Development of an Environmental Health Protection Network to improve communication between central consultants and local public health teams



42) Develop processes to support a more coherent and coordinated (national and local) response in relation to Health Impact Assessment

43) Conduct of a review of where responsibility for implementation of evidence based injury prevention interventions lies and, where possible, the extent to which these agencies/authorities are undertaking this work

44) Development of an education programme to support the reduction of poisonings amongst 0 to 4 year olds

4.8 Zero tolerance to preventable health care associated infections


The Health Protection Division through its Welsh Healthcare Associated Infection Programme (WHAIP) supports the health boards in reducing the burden of HCAIs. Considerable reductions in C.difficile and MRSA have been achieved by health boards in Wales but we recognise that there is still room for improvement. E coli bacteraemias have doubled in the last 5 years and currently account for approximately 40% of all bacteraemias. The 2011 Point Prevalence Survey in hospitals in Wales showed that Surgical Site Infections accounted for 20% of all HCAIs.


45) Public Health Wales to consider the reduction of HCAIs a priority and commit resources from across the organisation to support the HCAI agenda

46) Develop a Healthcare Associated Reduction Programme bringing together expertise from all divisions, so that an integrated service model is achieved and the Health Protection Division can be supported in the implementation of good practice and the evaluation of its effectiveness

47) Discuss with stakeholders at the surveillance review meeting the role of Public Health Wales as a critical friend

48) Undertake a systematic and scientific root cause analysis into the increase in E coli bacteraemia in Wales over the last 10 years

49) Develop a comprehensive action plan to tackle Surgical Site Infections and measure impact



4.9 Harmonising the infection service model


Infection management services are delivered to hospitals across Wales by Consultant Microbiologists based at all laboratory sites With the creation of the new health board structure in Wales, acute hospitals, primary care and community healthcare have been brought together with the same remit to reduce infection and the burden of disease in Wales.

This has led to an increased expectation and demand on Public Health Wales to provide leadership and expert advice and support in a number of key areas:

appropriate use of antibiotics infection prevention and control doctor functions development of infection management algorithms

To meet these demands clinical microbiologists will need to build on collaborations with health board Infection Control Teams, ensure co-ordination with other infection management resources (WHAIP/HPT) and may have to adopt a different approach to delivery of clinical microbiology services.


50) A baseline for clinical services (infection management) delivered through Service Level Agreements to be developed with health boards

51) Clinical microbiology services to be developed to reflect new ways of working (links to workforce development)

52) Contribute to all Wales approach to infection management linked to antibiotic stewardship

53) Support clinical teams and specialist networks in developing infection management pathways

4.10 Ensuring appropriate antimicrobial usage


Work started with All Wales prescribing group to develop an antibiotic formulary for Wales, anticipated completion August 2013.

Initial work on guidance and model policies for antimicrobial usage in primary and secondary care begun ongoing programme.




54) Ensure high quality antimicrobial susceptibility results are available 55) Develop and implement systems for the effective surveillance of

antimicrobial resistance56) Utilise the data collected to change prescribing behaviour57) Develop systems for the prudent use of antimicrobials in

healthcare, working with 1000 Lives Plus

4.11 Working from and contributing to the scientific evidence base


The Health Protection and Microbiology Divisions have active and increasing programmes of research, although to date maximised the opportunities arising from collaboration with universities and other public health agencies have not been maximised.


58) Develop research approval process in line with overarching Public Health Wales research structure

59) Form alliances with universities with research skills and competencies

60) Continue to win external funding for research projects and ensure that all research undertaken is completed and published

61) Have an annual scientific meeting where research undertaken can be presented and discussed

62) Specialist and Reference units to build partnerships and develop research portfolios

4.12 Ensuring that the workforce is resilient and has the required knowledge, skills and expertise


Traditionally Microbiology and Health Protection services have been delivered largely by highly qualified, knowledgeable and experienced staff groups.

Within Health Protection this requirement remains but it is believed that communicable disease will reduce with improvement in the availability and delivery of health protection interventions such as vaccination and immunisation. It is anticipated that a shift to a pro-active approach will be



needed with research, planning, education and training being a focus and the workforce will need to be developed accordingly.

In Microbiology, technological development, standardisation and a change in ways of working are leading to a requirement for different knowledge and skill sets, which together with the modernising scientific careers agenda, provide the catalyst for a new workforce model.

To ensure that an effective, resilient and sustainable workforce is created and can be maintained, an integrated workforce plan that engages staff and co-ordinates finance, training and education and Human Resources will be required


63) Ensure that the workforce is restructured in line with revised development/career pathways and changes in service delivery models

64) Develop and implement a training and development plan to ensure all staff have the necessary knowledge and skill to deliver and maintain services

65) Contribute to the roll out of Modernising Scientific Careers in Wales

4.13 4.13 Incorporating appropriate scientific and technological development into diagnostic services

4.13.1 Current situation

Molecular (DNA/RNA) based methods for the detection, identification and typing of micro-organisms that cause disease although still new and sometimes costly, have become common place in the larger diagnostic laboratories for the routine diagnosis of common infections. These methods still have a big part to play in the diagnosis of infection and it continues to be important to invest in development and optimisation of these techniques and methods.

However, the ability to determine the whole genome sequence within a bacteria, virus or fungi, an expensive research function only available in large commercial or academic institutions, is increasingly being recognising for its ability to fully characterise an organism and present a totally new approach to investigation of infectious diseases.

This is still very expensive technology but through commercialisation and consequential reduction in costs this is now seen to becoming relatively affordable in the specialist laboratory environment.



The HPA have developed a strategic plan and recently invested heavily in facilities, equipment, supporting informatics and staffing which moves their traditional typing and reference services towards genome based technologies and are developing a bioinformatics infrastructure to support their epidemiology and surveillance functions. Initial discussions indicate that this technology has the potential to totally change the way in which laboratory services function and infectious disease is identified and managed. The technology and supporting infrastructure requires a different workforce, facilities and approach to laboratory, epidemiology and health protection practice.

Public Health Wales needs to asses appropriateness and potential application for this development within Wales and pursue opportunities for collaboration, to gain a better understanding of how it may improve understanding and spread of disease.

4.13.2 Further action necessary

66) Invest and further develop molecular technology for diagnosis and management of infection

67) Maintain and build on links with HPA genome project 68) Develop opportunities for collaboration with academic institutions

to demonstrate/determine benefit of genome technologies in Wales
