1. HPA local and regional capacity and resilience Presentation to Scottish Health Protection Stocktake Working Group 15 November 2010 - Edinburgh Dr Sue Ibbotson Regional Director, HPA West Midlands

2. HPA local and regional capacity and resilience Structures Responsibilities and roles Governance arrangements Operating arrangements Testing the system – pandemic flu Issues for the future

3. Current structure HPA Board Chief Executive Local and regional services Centre for Emergency Preparedness and Response Centre for Infections Regional Microbiology Network Centre for Radiation, Chemical & Environmental Hazards (CRCE) National Institute for Biological Standards and Control New Health Protection Services Microbiology Services

4. LaRS - structure Nine coterminous regions – covering 2.5m to 7.6m population, with 26 coterminous Health Protection Units National Emergency Response Department LaRS Divisional director As well as HPUs each region also has: Regional Epidemiology Unit Regional Health Emergency Planning team Regional Director and business/governance support LaRS operations are supported by: CRCE “field teams” (Birmingham, Chilton, London, Nottingham) Regional Communications Manager/press officer Regional Microbiologist and HPA regional laboratory HR business partner and case worker (shared) Finance manager (shared) and, national specialists as requested.

5. Regional Director/HPU Director roles RD - manage LaRS resources in the region - overall responsible for HPA delivery in the region - regional HP strategy with and on behalf of RDPH - LaRS lead for specified national programme(s) HPU D (c0.5 wte + CCDC work) - manage HPU resources - responsible for HPU operational delivery - direct regional programmes

6. Workforce HPUs – multidisciplinary – CCDCs, HP nurses, practitioners, information support and admin An “average” HPU: - covers 2m population - has >1 CCDC per 500,000 population - total 18.5 wte staff REUs – c2 Consultant Epidemiologists, scientists and admin

7. LaRS Functions Prepare, Respond, Prevent Preparing for incidents, outbreaks and emergencies Responding to incidents, outbreaks and emergencies Working strategically to prevent ill health Operational and strategic management Enabling individuals and teams (clinical governance)

8. HPA Local and Regional Services - roles 1.Surveillance of infectious diseases, and tracking of health protection incidents, exposures and health impacts, to inform local and regional action 2.Alerting of partners to emerging infectious and environmental threats to health 3.24/7 specialist provision to investigate and manage incidents, outbreaks, emergencies and clusters of disease 4.Provision of evidence-based risk assessment and health protection advice for action by partners across the full range of hazards 5.Provision of plans, tools, training and exercising for partners to prepare for incidents and emergencies 6.Designing and providing training for partners to ensure high quality health protection delivery and train the next generation of specialists 7.Strengthening the science base for health protection. 8.Leadership and specialist support to local and regional strategic partnerships on health protection prevention and control programmes 9.Provision of health protection information, tools and advice to NHS commissioners, performance managers and providers in support of NHS priorities 10.Provision of named medical consultants to provide expert advice to and agreed proper officers for the relevant sections of the Public Health Regulations for each Local Authority.

9. Governance arrangements - internal Line management – LaRS team via Regional Director to LaRS Division/CEO. Local and regional business plans. Corporate financial and HR frameworks and scrutiny. Health protection “programmes” – cross-divisional, LaRS nationwide and regionwide networked leads (developing HPA strategy and supporting “policy into practice”) Development of guidance, structured nationwide briefings, operating procedures and associated standards Emphasis on competence through PDPs; networked learning and training opportunities HPZone – case management tool plus LaRS-wide clinical governance strategy and standards plus development support; governance and quality structures at local, regional and corporate level Integrated governance arrangements, through Regional Executive Groups and LaRS Senior Management Team to corporate group Assurance processes – linked to HCC/CQC and CCA requirements – coordinated corporately

10. Governance arrangements – with DsPH and LAs Framework Agreement 2008 with the NHS Front line PH delivery eg mass immunisation/prophylaxis; TB contact tracing is responsibility of PCT (provision and commissioning) Local Health Protection Partnership Boards proposed – variably embedded and formalised RD HPA works closely with Regional Director of Public Health

11. How we work Maintaining good working arrangements with DsPH Annual local and regional business plans cover developments HPUs are the “front door to the agency” and manage all local routine business plus “level 1” incidents, outbreaks and emergencies HPUs support a wide range of local NHS and partnership groups Implementing strategy through the commissioning process is a PCT responsibility HPU senior staff have geographical and portfolio responsibilities Regional oversight of incidents and outbreaks, support and escalation as required Shared learning from incidents; development of tools, implementation of new systems, procedures etc through national “programmes” and projects Business continuity plans. Mutual aid within regions and then LaRS-wide if necessary through line management arrangements.

12. LaRS West Midlands 5.4m population – mixed urban and rural 3 HPUs and 3 specialist on-call rotas 17 PCTs; 35 LAs; 24 NHS Trusts REU plus national Real Time Syndromic Surveillance c70 wte staff c700 significant incidents/outbreaks per annum

13. LaRS West Midlands – case study HCAI in a hospital 1.outbreak of C difficile 2.HPU advice not being implemented. 3.recommendations not taken forward; a second outbreak; monthly regional surveillance demonstrates outlier status 1.HPU engaged – proactive advice 2.peer review of hospital IPC and surveillance arrangements by Regional Microbiologist, Regional Epidemiologist and CCDC. SHA and PCT engaged. 3.RD engaged, additional REU input, support from national specialists What happened? What did we do?

14. LaRS West Midlands – case study Tyre fire 1.Fire service alerts regional CRCE team 2.CRCE alerts HPU 3.Large fire, potential health effects – likely to burn for days. HPU alerts RD 1.Initial risk assessment – potential extent of toxicological hazard to health – immediate advice 2.HPU engaged, lead CCDC undertakes public health risk assessment with CRCE and assesses need for a structured public health response. Discusses with multiagency police lead and RD. 3.RD asks for a Science and Technical Advice Committee to multiagency “silver” response – established by Health Emergency Planning Adviser working with lead CCDC and CRCE. CRCE engages Environment Agency air quality monitoring team. Air Quality Cell established. Daily syndromic surveillance “switched on”. What happened? What did we do?

15. Testing the system – pandemic flu West Midlands

16. Confirmed cases of pandemic (H1N1) 2009 in the West Midlands during the containment phase by date of illness onset and route of transmission (n=1967)

17. Early distribution of ‘flu A/H1N1 (2009) cases in the West Midlands (to 8 June 2009)

18. Pandemic flu HPA “containment” response May-July 2009 - West Midlands >3000 laboratory confirmed cases; 60 hospitalised 344 schools risk assessed and advice given Contact tracing for 2000 cases >10,000 tests – Regional Microbiology Network laboratories and other staff from HPA centres supported the HPA Birmingham laboratory Briefings and epi reports “up the line”; descriptive epi studies National syndromic surveillance outputs Advice to the NHS commands Engagement with Birmingham City Council Overview and Scrutiny c300 media bids; 70 interviews HPA established a Flu Response Centre - 8 increasing to 60 desks and deployed c150 wte staff daily – from all over the country BADGER Ltd undertook all operations in respect of symptomatic patients in Birmingham PCTs undertook prophylaxis in schools

19. National Emergency Coordination Centre (HPA) DHCCC West Midlands REOC (HPA) ERMA 2 LA(s) RRT West Midlands FRC FRC-HPU Cells FRC-HPU Cell SHA HPU BADGER & PCT Ops EpidemiologyReal Time Surveillance National Primary Care Surveillance Comms HPA Laboratory Community Engagement Media Handling Advice H1N1v West Midlands HPA Integrated Response Coordination Diagram Key Control: Coordination: SHA, PCT and/or LA resource: School cell

20. Capacity and resilience Issues for the future Roles and relationship between the national Public Health Service and DsPH in LAs “Independence” The “intermediate tier” Strengthening the nationwide and national epidemiological approach whilst delivering locally responsive services Increasing expectations; reducing resources Being “local enough” whilst preserving critical mass Workforce development