12 August 2003

The HPA’s role in port healthA national perspective

Dr Graham Bickler

June 2009

Observations and aspirations

“This curious film was hailed by many critics as a masterpiece, while others suspected a leg-pull. It had only three characters of note, but the problem…was to find out how they were inter-related and what the film was about” Leslie Halliwell on Last Year in Marienbad directed by Alain Resnais

“Now I wish I could write you a melody so plain that could hold you dear lady from going insane” Bob Dylan - Tombstone Blues

PORT HEALTH AND MEDICAL INSPECTION

REVIEW FOR ENGLAND

REPORT FROM THE PROJECT TEAM

MARCH 2006

History

DoH, Home Office and HPA agreed a review:• creation of HPA• massive increase in international travel• SARS and pandemic influenza• IHRsThree previous reviews over a decade

DoH chaired Steering Group

HPA chaired Project Group and published review

Recommendations agreed by DoH and HO Ministers

Implementation happening

Challenges remain…………..

And experience of H1N1v

Terms of Reference

To review the functions of medical inspection of persons subject to immigration control, and port health, at English ports, airports, and juxtaposed controls

To make practical recommendations, drawing upon current best practice, for improvements in efficiency and effectiveness within existing overall resources and within the current policy framework, so as to ensure that the policy is delivered through safe and secure services according to consistent national criteria while fitting local needs

Major themes and outcomes

Complex and confusing• simple statement of accountabilities on HO, DH and HPA web-sites

Purpose• to protect the UK population from the…., to support the Immigration

Service and to comply with the IHRs

What is ‘port health’?• Port Health• medical inspection under Immigration Act• health care in ports

Major themes and outcomes 2

Port Health• see as health protection in ports – it’s a setting• difference from non-port environments

- legal basis (The Regulations of 1984 Act) - partners (Immigration Service, Customs and Excise, MCA, Port

Health Authorities, UKBA)- risk of exotics

• Proposals:- No legal or accountability changes - HPA, LAs and PCTs to work together to manage health protection

at ports- HPA to overview arrangements at all ports- strengthen and ensure capacity and capability to respond- mainstream services

Major themes and outcomes 3

Medical Inspection

• Part of Immigration Act and services• Defined by ‘Instructions to Medical Inspectors’• Purpose to protect public health and public purse• Majority of spend on CXRs for TB• Delivered by individual inspectors not any organisation• Proposals

- single financial stream to HPA- HPA, rather than individual inspectors to have the responsibility to

ensure provision - by commissioning or direct provision- mainstream services

Major themes and outcomes 4

Health care• NHS responsible; may need walk in centres at large ports• Immigration Service to organise care for detainees• single point of access

TB screening• review X ray screening at ports• simplify information flows

Skill mix, quality, training, quality• HPA to work with Board of Airline Representatives on information

needs• free of charge accommodation for inspection function• mainstream into normal clinical governance arrangements

Themes from here on…

Medical Inspection: health protection – using gatwick to illustrate

X ray screening for TB

Pandemic Flu and H1N1v

Outbreaks and incidents

Gatwick today

Over 35m passengers per year

270,000 aircraft movements per year

90 airlines

200 destinations

World’s 28th busiest airport

Port Health Unit

Two areas of work:

1. Port Medical Inspector – advice to UKBA on entrants and onward information flow to local offices

2. Port Medical Officer – act under public health legislation and provide public health advice

3. Additional responsibilities in Emergency Planning

Gatwick Health Control Unit

Clinical Staff:Permanent 4 F/T, 9 P/T & locum

Radiology Manager 1

Non-clinical Staff:15 F/T and 2 P/T

All employed by local PCT

Public Health Referral Activity (06/07)

Number of Routine & Random Boardings

Number of Inbound Flights

Number of Inbound Passengers

Total for Gatwick 127,000 17,000,000

Disinsection Enforcement

Sick Passengers

74

10 72

Total Boardings 84 72

Gatwick immigration referrals

Medical Inspections for Immigration

North Terminal

South Terminal Total

Inspections 7,988 7,139 15,127

CXRs 2,873 62 2,935

Referred for further investigation

28 62 90

TB screening- how does it work?

‘Policy’ – to screen new entrants for TB by CXR who:

- come from high prevalence countries and- are subject to immigration control and- plan to stay for more than 6 months.- information passed on by Port Forms to local

CCDCs/PCTs

and

- Home Office sponsored pre-exit screening programme

But, practice not so simple…

concerns about• efficiency• effectiveness • appropriateness• cost-effectiveness• evidence

every way in which public health interventions should be judged……

UK flows

Number of international arrivals from abroad into British Isles (2007)

109.5 m

Number of EEA Nationals and transit passengers 96.1 m

People entering for more than 6 months and subject to immigration control

396,300

Number of people coming from countries with a high risk of TB

270,000

Heathrow and Gatwick flows

Heathrowtotal referrals 175,000

have X ray 71,000

abnormal 173

TB diagnosed 92

Gatwicktotal referrals 8,900

have X ray 2,000

abnormal 18

suspected TB 3

Port 103 Form sent 15

the issues……

limited access to X ray machines –only at Gatwick and Heathrow

EU enlargement excludes some countries

changing travel patterns - E Europe increasing ++

cant send people back if ill or infectious

follow up hopeless• Address data poor – no need for

address to enter UK• Limited capacity for follow up in high

incidence areas

ports unsuitable setting for follow up

maximum 126 TB cases per year –modelling data

proportion of smear positive diagnosed cases not clear

those picked up through system would be picked up anyway

expensive - perhaps £2-3m per year

Politics

NICE recommendations (what not where)

knee jerk analysis

TB is

increasing……

TB is asso

ciated with

migration…..We have to strengthen border

protection…..

Pandemic Flu

Complex policy area – not signed off yet

What can and should happen at ports?• Varies by pandemic phase• Worth intervening early on• But may need to do entry and/or exit screening

HPA roles• Provides advice at all levels• Undertakes contact tracing and surveillance• ? Delivers / ? supports screening

Pandemic Flu 2

HPA responsibilities?

• Advice +• Screening provider - / ?• Partner +• Legal enforcer –UKBA roles

• ??

NHS concerns

• Capacity• Accountability• resourcesLA/PHA issues

• Accountability• resources

H1N1v (Swine Flu)

HPA• met direct flights from Mexico for 3 weeks• wrote leaflet distributed at all ports• did contact tracing on over 60 flights (so far)• developed policies and procedures• advised partners at airports• sorted issues at sea ports• provided public reassurance• enabled government to actAll port health functions – not medical inspection

Staff capacity critical

Support ++ from HPUs

Outbreaks and incidents

Two stories today – Hep E and legionella

Role essentially same as that on land…

Its just a setting

What does this tell us?

On roles:

public health unremarkable

Medical Inspection different and difficult

but persistent uncertainty and concern about accountabilities

Health and Social Care Act has limited implications…..

On specifics:

TB screening challenging

financial and quality risks for HPA

need for national service

resource shift from inspection to health protection

Need to build capacity and capability for big health protection issues

Swine Flu demonstrates value of generic service