Personal View: Sleep walking to another Stanley Royd?
Authors: Brian Keeble
Journal: BMJ (2006)

In August 1984 an outbreak of salmonella food poisoning at Stanley Royd Hospital, a large psychogeriatric hospital in Wakefield, Yorkshire, claimed the lives of 19 patients. Just over six months later, in April 1985, an outbreak of legionnaires' disease at Stafford District General Hospital caused the deaths of 28 people.

Public inquiries into these outbreaks were established by the then Department of Health and Social Security, and their findings were published in 1986. The inquiries, in highlighting concerns about the decline in available medical expertise in environmental health and in the investigation and control of infectious diseases, called for a review of the responsibilities and authority of medical officers of environmental health—the local public health doctors who at the time were responsible for investigating outbreaks of communicable diseases in the community.


Primary care trusts may even have to recreate the post of local consultants in communicable disease control


The then secretary of state, Norman Fowler, asked the chief medical officer, Donald Acheson, to undertake a “fundamental examination of the role of public health doctors, including how such a role could best be fulfilled.” The result was Public Health in England, published in January 1988, which emphasised the need for properly staffed local public health departments, led by a director of public health and including a consultant in communicable disease control working alongside other public health consultants.

When adequately staffed, these new departments worked well, and their teams of public health doctors assumed 24 hour responsibility for control of communicable diseases, under the clinical leadership of the consultant in communicable disease control. Indeed, they stood the test of time until their fragmentation in April 2002, with the demise of health authorities and the creation of smaller primary care trusts.

In January 2002, when concerns about terrorist attacks with infectious disease agents were high after September 11, the current chief medical officer, Liam Donaldson, produced Getting Ahead of the Curve, a new strategy for combating infectious diseases in England. This resulted in the creation of the Health Protection Authority (HPA) as a standalone government organisation outside the NHS. The authority was largely funded by the primary care trusts, and by April 2003 the fragmentation of the “old” public health departments was completed, as consultants in communicable disease control and their staff transferred from NHS employment into the HPA.

Since 2003 the separation of primary care trusts' public health doctors and colleagues in the HPA has moved ahead at a pace. Joint bases for trust and HPA doctors, often in old health authority buildings, have become an increasingly rare phenomenon, as the HPA has restructured to become a more regionally focused service—leading to increasingly less day to day dialogue between the NHS and the HPA at the local level. Also, shared on-call rotas, which involved trust and HPA doctors taking joint responsibility for an area, are now threatened, as the HPA seeks to strengthen its own regional out of hours rota.

The effect of all this is increasingly to leave groups of isolated public health doctors in primary care trusts, with atrophying skills in communicable disease control, responsible for carrying out the statutory duties of their trusts with regards to communicable disease. Outside normal working hours, in particular, potentially vital decisions about communicable disease control now rest with these doctors: shades indeed of the run up to Stanley Royd.

The HPA, meanwhile, continues to concentrate resources on preparing for major emergencies such as pandemic flu. This is entirely understandable, given the political and media spotlight that falls on the issue whenever a chicken sneezes, but one that risks less focus on common communicable disease issues.

What can be done about this? Apart, that is, from taking the opportunities created by the latest reorganisation of the NHS in England to reintegrate the HPA's communicable disease consultants with the public health staff in the new larger primary care trusts? Regrettably, this does not seem to be an option, so directors of public health and chief executives in these new organisations will need to be clear about just what is expected of them with regard to communicable disease control and then ensure that they have either the necessary staff or the money to contract someone else to do it for them.

They will need to leave on one side the fact that the entire financial resource that used to fund their local team of consultants in communicable disease control now sits with the HPA and dig deep to find the money again. They may even have to recreate the post of local consultants in communicable disease control employed by the NHS as part and parcel of their deliberations, as failure to take action soon may well leave them sleep walking to the next Stanley Royd.