The crisis in managing communicable disease will deepen as the NHS reorganisation moves consultants in the specialty into primary care trusts, says Surinder Bakhshi
The management of communicable disease has been in crisis for a long time and the proposed changes to the structure of the health service have brought this crisis to a head.
Infection control was synonymous with public health from the mid-19th to the first quarter of the 20th century. The medical officer of health was held in great affection and respect.
Since the 1974 NHS reorganisation, the Department of Health has made several attempts to give substance and authority to the MoH's successors: first the medical officer of environmental health and then consultants in communicable disease control (CsCDC).
Under the control of their NHS employers, CsCDC have paid less attention to the funding, organisation and management of infection control than to managing individual infections.With the proposed changes in the organisation of health authorities, many CsCDC will move into primary care trusts. But there has been no thought for their role and functions, and there is a danger that they will become absorbed into the clinical system. To survive, CsCDC will have to learn to recombine the two public health roles.
Public health medicine has defined infectious diseases through narrow categorical terms (for example, tuberculosis and HIV).Yet there is a nonmedical side to these diseases.We need to take a wider view, focusing on the population as a whole.
There are some examples of sectoral programmes, which tend to be recent in origin. In Birmingham, work on TB is an example. But the infrastructure is rigidly linked to categorical programmes. This means it is difficult to link electronic health surveillance, multi-level intervention programmes and multi-faceted research designs.
For example, if a laboratory runs tests for TB, Birmingham's 600 GPs will not get this information and consequently they will not know about the distribution of this disease in their patients. The complex interaction between the environment, society and infectious diseases means we have to overcome this categorisation.
Another problem is that notifiable disease no longer reflects the important infectious diseases.
Methicillin-resistant staphylocococcus aureus is an example of a disease that is not notifiable.We need to create a more dynamic system of notification that addresses modern concerns.
A further issue is that the structure of healthcare is changing. Ten years ago, we knew where patients were: in hospital or in the community. Now, there are fewer acute care facilities and the margins of hospital and community care are blurring.
The shift in healthcare provision from hospitals to the community moves healthcare-related infections into the public arena, challenging our traditional surveillance methods for these conditions and increasing risk to the healthy community. An example is scabies - 10 years ago, this was a hospital issue. Now, scabies can shut nursing homes for long periods: it is a major problem in Birmingham, where there are 500 nursing and residential homes.
If we are to prevent infections associated with care delivery in the entire spectrum of healthcare settings, we will need to expand cost-effective infection surveillance. Infection control also requires improved focus on elderly people rather than on children and women, as in the past.
There is little evidence that we are changing to meet these challenges. Emerging infections, including variant CJD, have a low profile in public health medicine. The great danger is that patchedup arrangements for employing CsCDC will be put in place, leaving the larger questions unanswered. It does not matter where CsCDC are located, but they need to be more independent and they need a mandate to organise their own programmes.
There should be a clear separation between the work of clinicians in treating infection and public health, which should be studying epidemiology and preventing infection.We also need systems to take information from hospitals and laboratories and deliver it rapidly to GPs.We have some national monitoring - for example on HIV rates - but that is no use unless it can be broken down to local levels.
Since 1974, there have been many changes to communicable disease control, but it has never been given the strength to deal with the issues the community faces. Now is the time to tackle these issues.