15 November 2022: Hopkins - A

Dr Susan Hopkins is the Chief Medical Adviser for the UK Health Security Agency (UKHSA); so, references to Covid to explain and illustrate the work of that agency were anticipated. She has a medical degree and an MSC in epidemiology. She is a consultant for infectious diseases and microbiology. Between January 2020 and September 2021, she was seconded as part of the Government’s Covid-19 response. After a period of being involved on an interim basis, she came into her current role in June 2022.

A brief slot of time was given over to reviewing the various bodies historically responsible for monitoring and addressing public health related issues, particularly on threats from viruses, infectious diseases, chemical, radiation, and environmental risks. Some of these operated as UK bodies completely or they coordinated activity across the four nations. Many of the current organisational remits and activities are arrangements still heavily influenced by Covid. Functions of the UKHSA are not all exactly inherited from former incarnations, since associated bodies pick up on these. From March 2021 the role of the UKHSA has included the need to prevent and anticipate threats to public health and build national readiness, to carry out surveillance and monitoring of threats, to ensure testing and tracing systems are in place, and more. Clearly, these have been geared to Covid, but the organisation is there to look at a wide range of threats.

In relation to detection, the first issue is to know if a threat is coming from an external to the UK source or internally. UKHSA staff continue to follow publications, research, and relevant news sources to be aware of situations, so they know if and when to act. For internally discovered threats, it involves using the existing healthcare and research structures who either bring issues to the attention of UKHSA or become part of the response. ProMED (Programme for Monitoring Emerging Diseases) is an international body which notified the world about Coronavirus on 31st December 2021 and which was immediately picked up by UKHSA.

The operational document, “Communicable Disease Outbreak Management” is produced by Public Health England as a tool to coordinate responses to outbreaks, including standards for recognition and declaration of a risk, forming a team to control the outbreak, etc. Some of these responses involve timeframes which are very short (24 hours to three days), or some examples will happen over a much longer period. Their responses include risk assessments (“rapid risk assessments” where required). Some situations can be handled by existing processes while others need a bespoke response. As required, fuller risk assessments are initiated, and these continue to be reviewed.

A newer document “Bloodborne virus-related infection control breaches” is a toolkit for responding to events to be used, for example, in a blood bank or hospital. A newer BBV would apply the principles, but there may also require a more direct role for UKHSA, for example. There is an “Incident Response Plan” for larger threats which identify types of response (from routine to enhanced) and levels of response (from local/regional to global/international). A “Risks and Issues Register” exists to log all issues with a risk attached.

The example of a response was one which came from the US where their partner body, the CDC (Centre for Disease Control), highlighted a particular issue with a brand of powdered baby food. The system kicked in through the established channels. The Chair asked about the time taken to inform all those who had to know, and it was noted that there were lessons learned which would speed up the timescales for the future. Another example related to a cluster outbreak of a rare hospital acquired infection. The rapid response discovered a link to a certain cleaning product, which was subsequently withdrawn from use. A third example illustrated the UKHSA working closely with the four nations. It involved unexplained serious hepatitis infections in children which required a transplant. It was seen to be related to a combination of unusual viruses and a characteristic of the childrens’ own immune systems. Counsel pursued this to clarify how this was coordinated, for example, how information was cascaded. There was a brief exploration of the use of external experts. Many people are signed up to be a reference to the UKHSA on specific areas of health or other potential issues. There are health protection research units which can be called on as required. This was the case for the childhood hepatitis case and the recent monkeypox case.

The UKHSA is a step removed from patients ands their representative bodies, but the UKHSA does have some links to certain bodies, such as the Terence-Higgins Trust as part of the response to the Monkeypox situation. The UKHSA readily publishes their documents to allow for easy access, including to the emerging thinking on various issues. A judgement has to be made in some rapidly changing situations on how to communicate and in what way (e.g. directly to patients or the public, or through clinicians). This may be influenced by factors such as their being the possibility of many unidentified people needing to be picked up quickly as a matter of public health. Again, the Covid situation has heavily influenced these issues in recent times. The notification processes are subject to the Duty of Candour as overseen by the Care Quality Commission. This is related to both the supporting of other organisations, and of lab work on individual samples. The clinicians involved in UKHSA are naturally subject to candour requirements. On the possibility of people being reluctant to apply the duty of candour, the witness did not have any personal examples of people showing reluctance, but said she thought the healthcare world was becoming increasingly aware of the need to deliver on that responsibility.

The matter of “proportionality” was reviewed in relation to deciding the level of notification involved in any particular circumstance. It is a “consensus-based approach” rather than the decision being left to one organisation. The tendency is to notify. The issue of not having a diagnostic test or treatment does provide problems for notification decisions. A reference to “reputational harm” being a factor was raised and the witness spoke personally that it should not be a factor. Similarly, there is the person’s “right to know” (autonomy), and the witness agreed that it should be part of the decision-making process.

The “Precautionary Principle” was also explored. It was summarised as “thinking twice” to make sure the consequences are properly considered, and “whether you should do something at the time, or not” when considering a range of factors and impacts.

“Briefing notes” are used to disseminate information to relevant bodies and experts, including those who teach on their subject. The UKHSA may also speak to specialist societies and professional agencies. They arrange webinars as an example of other approaches taken in awareness-raising. On health inequalities, when data is reviewed the UKHSA do look to identify protected characteristics and trends connected to these.

The witness was asked about what she considered to be the strengths in the work carried out by the UKHSA. These were noted as: the dedicated people in the team; the wide variety of specialists practitioners; the close relationship with academia; and the UKHSA being a learning organisation. The weaknesses were mentioned as: organisational restructuring which results in a loss of institutional memory; the external changes due to pressures not related to infectious diseases or external health threats which may make that aspect seem less important; fragmentation in the public health system with lots of small teams in different parts of government nationally and locally which takes up time and energy to keep on top of and which could be more effectively used. The witness would like to see a level of stability over a period of say, 20 years.

All that remained were questions from core participants, for after the break.

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