Public Health Wales / Executive Director of Public Health Services Report – December 2012
Report of the Executive Director of Public Health Services
December 2012
Author:Public Health Services
Date:11 December 2012 / Version:1
Distribution:
  • Public Health Wales Board

Purpose and Summary of Document:
The purpose of this paper is to provide the Public Health Wales Board with an update on the performance of the Health Protection, Microbiology and Screening Divisions. It contains briefings from the Divisional Directors together with informationon professional and corporate matters that are the responsibility of the Executive Director.
Date of Board meeting:
20 December 2012
This paper is for:
Discussion / x
Decision
Information / x
Date: 11 December 2012 / Version: 1 / Page: 1 of 24
Public Health Wales / Executive Director of Public Health Services Report – December 2012

1Purpose

  • This report contains briefings from the three Divisional Directors (Health Protection, Microbiology Services and Screening) and reports current performance, together with informationon professional and corporate matters that are the responsibility of the Executive Director.

2Medical Director/Responsible Officer

2.1Revalidation

  • Revalidation for licensed doctors became a legal requirement on Monday 3 December. In preparation for this the Responsible Officer has undertaken the following:
  • confirmed the list of doctors with a prescribed connection to Public Health Wales (n=86) with the GMC
  • confirmed with the GMC the schedule for their revalidation dates starting in the first quarter of 2013-14 ie between April and the end of June 2013;
  • written to all doctors with a prescribed connection to Public Health Wales to advise them of their revalidation date.
  • On 3 December 2012 the GMC wrote to every licensed doctor who has a revalidation submission date in:
  • year zero (December 2012 to end of March 2013)
  • quarter one of year one (April 2013 to end of June 2013)
  • and quarter two of year one (July and August 2013 only)
  • Doctors with submission dates in year zero and quarter one of year one will receive a letter from the GMC with their date plus their formal revalidation notice.
  • Doctors with submission dates in July and August 2013 (in quarter two of year one) will receive a letter with their date but they won’t receive their formal revalidation notice until four months before their submission is due (the GMC is using four months as their standard notification process).
  • In January 2013 the GMC will write to licensed doctors with a revalidation date from the start of September 2013 onwards, and so the process will continue with the revalidation cycle repeating every five years.

2.2Medical staff appraisal

  • In November 2012 Jenny Brick demitted office as Lead Appraiser. Brendan Mason has agreed to take on this role with immediate effect.
  • Arrangements are being made for the current pool of appraisers, as well as doctors due to be revalidated in year one, to undergo Deanery appraiser training – this will ensure appraiser/appraisal consistency and give non-appraisers insight to the process.
  • The plan is for trained appraisers to cascade their learning and grow the appraiser pool over time.

2.3Medical Appraisal and Revalidation System (MARS)

  • MARS is a web-based system that has been agreed between the Deanery, Welsh Government and BMA Cymru as the platform for managing medical appraisal and revalidation in Wales. Public Health Wales has asked to be included as a responsible body and has arranged training in its use for appraisers and year one doctors. A ‘go live’ date is planned for late January (date tbc) when doctors in Public Health Wales will be encouraged to register and start loading their supporting information on the system.

2.4Responsible Officer (RO)

  • Dr Quentin Sandifer, as designated RO, has now completed the training requirements for this role, which included:
  • Module 1: Revalidation overview and RO regulations and guidance
  • Module 2: Organisational governance and appraisal systems
  • Module 3: Responding to concerns about performance, conduct and health
  • The RO is supported in his responsibilities by a team including Deborah St John as Appraisal Co-ordinator and Senior Administrative and Resource Officer, Brendan Mason as Lead Appraiser, Ruth Davies as Director of Workforce and OD, Claire Barley as Head of Professional and Organisational Development, and Gillian Jones as Human Resources Officer.

3Health Protection

3.1Vaccination and Immunisation July – September 2012

3.1.1Uptake Figures

Figure 1.Percentage uptake of childhood immunisations in Wales, quarter 1 1997 to quarter 3 2012. Data are for children reaching 1 year of age each quarter for diphtheria, pertussis, Hib, MenC and pneumococcal conjugate vaccine (PCV2), children reaching 2 years of age for MMR1 (first dose) and the HibMenC booster, and 5 years of age for MMR2 (second dose).

Figure 2.Summary of uptake rates for selected immunisations in resident children reaching their 1st, 2nd, 5th and 16th birthday between 01/07/12 and 30/09/12 and resident on 30/09/12.

3.1.2Key Points

  • Uptake of all scheduled immunisations in children less than one year of age exceeded the 95% uptake target this quarter. Nineteen Local Authority (LA) areas exceeded the 95% uptake target for the 5 in 1, with 17 achieving 95% uptake for all routine immunisations in one year olds.
  • Uptake of the first dose of MMR vaccine in two year old children was 94% and ranged by LA from 92% to 97%. Eight LA areas and one Health Board achieved the target of 95% uptake.
  • Uptake of the second MMR dose by five years of age remained stable at 89% this quarter, ranging by LA from 86% to 94%.
  • Uptake of 4 in 1 pre-school booster in five year old children was 91%, ranging by LA from 88% to 95%.
  • Uptake of first dose of Human Papilloma Virus (HPV) vaccine in girls in the 2011-12School Year 8 was 89%, uptake of the second dose was 87% and uptake of the third and final dose is currently 81%.
  • Coverage of one dose of MMR vaccine in 16 year olds this quarter was 91% and coverage of a completed two dose course was 83%.

3.1.3Seasonal Influenza Immunisation Uptake

Figure 7.Clinical consultation rate per 100,000 practice population inWelsh sentinel practices (as of 05/12/12)*Reporting through Audit+ commenced during 2010 week 40.
Figures 8 and 9.Uptake of influenza immunisation in patients aged 65 years and older, and six months to 64 years at clinical risk (as at 04/12/2012)

Influenza vaccine uptakeupdate

3.1.4Key Points

  • Based on data from 95% of Welsh practices, reported through Audit+, as at 04/12/2012:
  • 63.1% of patients aged 65 years and over have been vaccinated against influenza (Health Board (HB) range 60.3% to 65.5%)
  • 44.4% of patients aged under 65 years in at-risk groups have been vaccinated against influenza (HB range 40.3% to 46.2%)
  • 34.4% of pregnant women have been vaccinated against influenza (HB range 24.3% to 45.0%)
  • The 75% target was achieved by 8.9% of practices in those 65 years and over, and 0.2% of practices in those under 65 years at risk.
  • 27.8% of NHS staff have been vaccinated against influenza (HB range 22.8% to 33.1%) based on data provided by Occupational Health Departments up to the end of October 2012.
  • The CMO Wales has expressed concern about uptake, especially among healthcare workers, and is meeting regularly with Health Board Directors of Public Health. Public Health Wales is supporting the CMO and Health Boards to encourage improved uptake.

Other vaccines

  • At the start of October 2012 Wales, together with other home countries, launched a campaign to encourage Pertussis immunisation in pregnant women between 28 and 38 weeks of pregnancy in response to a high level of confirmed Pertussis cases this year and the susceptibility of the newborn to this disease.
  • Wales published its first data on uptake on 30 November 2012 –uptake in the target population to that date was 28.8%

3.2Diagnoses of Sexual Transmitted Infections

3.2.1Key Points

  • With the exception of Herpes Simplex Virus infections, sexually transmitted infections are falling in Wales.
  • From January 2012, a PCR test for Gonococcus detection was introduced in all sexual health services in Wales. This is a much more sensitive test than the culture tests previously available. Access to the PCR test in community settings has increased the number of tests undertaken and this together with increased test sensitivity will inevitably lead to an increase in the cases of gonorrhoea detected in 2012. (A similar effect was seen with Chlamydia in 2008 when a PCR test for Chlamydia was introduced).
  • The Health Protection Division in collaboration with sexual health services and Cardiff Microbiology Services is undertaking enhanced surveillance of all gonorrhoeal infections to better understand the epidemiology of the disease.

3.3People presenting at late stage with HIV

Since January 2012, the Health Protection Division has commenced collection of CD4 cell counts on all new diagnoses of HIV infection. CD4 cells are T-lymphocyte (immune cells) which have CD4 receptors. The HIV virus adheres itself to CD4 cells, ultimately destroying the cell. This depletion in CD4 cells results in individuals being susceptible to infection. The CD4 cell count is depleted over a number of years, so the count can be used to estimate how long an individual has been infected with the HIV virus. An individual with a CD4 count of 500+ has most probably acquired the HIV virus very recently and another with a CD4 count of 0-100 has most probably had the virus for many years.

Figure 14. CD4 count at diagnosis in patients diagnosed with HIV in Wales, January to June2012

3.3.1Key Points

  • From the information available to date, approximately one third of individuals with newly diagnosed infection in Wales have acquired the HIV virus recently.
  • To encourage those at risk to be tested for HIV and appropriately treated, a national HIV awareness campaign will be launched on World AIDs Day 2012.
  • In 2013, the Health Protection Team will be offering point of care testing to high risk groups in community settings.

3.4Under 18 Conception

Figure15. Three monthly moving average of under 18 conceptions by Health Board in Wales

3.4.1Key Points

  • From 2009-2011 there has been a large decrease in under 18 conceptions in Wales. The data is not yet complete for 2011 but it is expected to show a 25% reduction from 2009 - 2011
  • The decrease is not uniform across Wales. Teenage conceptions have decreased by more than 50% in Aneurin Bevan Health Board while in others the decrease is more modest.

Figure 16. Under 18 conceptions in Wales 2001-2011

3.5Healthcare Associated Infections

3.5.1All Wales rate of C.difficile in inpatients aged over 65 by financial year Apr 09 to Mar 12

Financial year / Number of C.difficile / Number of admissions / C.difficile rate/1000 admissions / 95% confidence intervals
Apr 09 to Mar 10 / 2638 / 174537 / 15.1 / 14.5 – 15.7
Apr 10 to Mar 11 / 1917 / 177479 / 10.8 / 10.3 – 11.3
Apr 11 to Mar 12 / 1295 / 180307 / 7.2 / 6.8 – 7.6

3.5.2All Wales rate of S.aureus in by financial year Apr 09 to Mar 12

Financial year / Number of S.aureus / Number of bed days / S.aureus rate/100000
Bed days / 95% confidence intervals
Apr 09 to Mar 10 / 958 / 3721800 / 26 / 24.1 – 27.4
Apr 10 to Mar 11 / 877 / 3681358 / 24 / 22.3 – 25.5
Apr 11 to Mar 12 / 850 / 3672869 / 23 / 21.6 – 24.8

3.5.3Key Points

  • The rate of infections of Clostridium difficilein inpatients aged over 65 per 1000 admissions in Wales continues to fall
  • The rate of bacteraemias caused by Staph aureushas not changed significantly for the last two years.

Date: 11 December 2012 / Version: 1 / Page: 1 of 24
Public Health Wales / Executive Director of Public Health Services Report – December 2012

4Microbiology Services

PERIOD COVERED / October 2012 - December 2012
The purpose of this report is to provide the Board with an update on progress for the key service reconfiguration and change management projects being undertaken.
Summary
Reference / Task/Milestone / Standard / Due Date / This Quarter / Comments/Risks
Due Date in Past or Ongoing / Due Date in Future
CPA Accreditation
CPA Accreditation / Address non conformances and re-establish full CPA accreditation / 01/02/2013 / On schedule / Outstanding non conformance issues being addressed. Virology clinical leadership arrangements in Swansea to be confirmed within next two weeks. If not agreed, specialist service will be consolidated in Cardiff.
North Wales Microbiology Services Review
North Wales Microbiology Services Review / Review completed and report presented to Public Health Wales and BCUHB / 01/11/2012 / Delivered on schedule / to standard / Report finalised and presented to respective Boards. Recommendations supported to proceed to project initiation phase.
North Wales Microbiology Services Review / Implementation project to be established / 01/12/2012 / On schedule / Project initiation meeting took place on 23 November 2012. Project plan being developed and will commence in December 2012.
North Wales Microbiology Services Review / Wrexham Microbiology Services to transfer to Public Health Wales management / 01/04/2013 / On schedule / Service transfer request received from BCUHB on 23 November 2012. Initial HR discussions commenced. Staff consultation (90 days) anticipated to begin early 2013
Hywel Dda Microbiology Service Expansion
Hywel Dda Microbiology Service Expansion / Clinical Microbiology Service Withybush to be delivered by Public Health Wales / 01/10/2012 / Delivered on schedule / to standard / Financial transfer agreed. Locum consultant being recruited as interim measure pending substantive appointment
Hywel Dda Microbiology Service Expansion / Diagnostic laboratory service to transfer to Public Health Wales / 01/04/2013 / On schedule / Informal staff meeting completed. Formal HR and financial process to be initiated by Hywel Dda
ABMU Microbiology Services Review
ABMU Microbiology Services Review / Review to be undertaken and report produced / 01/08/2012 / Delivered on schedule / to standard / On schedule / Report finalised. Microbiology Services Management to agree recommendations
ABMU Microbiology Services Review / Implementation project to be established / 01/04/2013 / On schedule / Project to be initiated early 2013
On-call and out of hours service change
On-call and out of hours service change / Harmonised on-call arrangements to be implemented / 01/07/2012 / Delivered on schedule / to standard / Risk to service continuity when pay protection ends in June 2013 to be assessed. Partnership group arranged for 30 November 2012 to undertake work. Requirement for contractual commitment to be considered.
On-call and out of hours service change / Out of hours service to be enhanced (7 day working) / 01/07/2013 / On schedule / Local partnership working has developed local service plans on most sites. Service development plans being finalised. Resource requirements to be confirmed
Service Improvement /Technological Developments
Service Improvement /Technological Developments / Enhancement of TB Reference Unit for Wales - facilities refurbishment and service expansion / 01/04/2013 / Behind schedule / Work on refurbishment of laboratory suite delayed due to contractors. Financial risk with one of the health boards and limited service risk with Public Health Wales.
Service Improvement /Technological Developments / Replacement of automated AST and ID equipment (Phoenix) / 01/04/2013 / On schedule / Tender process with anticipated selection in December. Implementation to take place in first quarter 2013
Service Improvement /Technological Developments / Replacement of serology equipment / TBC 2013/14 / On schedule / Core information collated, initial scoping of options complete, replacement project to be developed during early 2013
LIMS Implementation
LIMS Implementation / Implementation in Public Health Wales laboratories to agreed schedule / 01/12/2013 / Behind schedule / Carmarthen and Aberystwyth implemented but performance issues hashalted further implementations across Wales. Revised schedule to be agreed.

5Screening

5.1Cervical Screening Wales

5.2Second Quarter Performance Summary

5.3Breast Test Wales

5.3.1Second Quarter Performance Summary

5.4Bowel Screening Wales

5.4.1Second Quarter Performance Summary

Date: 11 December 2012 / Version: 1 / Page: 1 of 24
Public Health Wales / Executive Director of Public Health Services Report – December 2012

5.5Implementation of digital mammography: Breast Test Wales (BTW)

Implementation in North Wales is proceeding. Screening is scheduled to restart in Llandudno on 17 December 2012, while the service in Wrexham has resumed without major problems.

The round length continues to be prolonged beyond target in all regions. In addition, numerous technical problems, along with the need to redesign patient pathways have led to slower film-reading and delayed issuing of results. A full evaluation report, along with a recovery plan will be prepared once the installation is complete.

  • The digital mammography project will close following the implementation in North Wales. Project subgroups are preparing closure reports for handover to the BTW All-Wales Management Group.

5.6Independent review of Breast Screening (BTW)

  • The report of the independent review of the evidence underpinning breast screening, commissioned by Prof Sir Mike Richards and Dr Harpal Kumar of Cancer Research UK and chaired by Prof Sir Michael Marmot, was published in November.
  • It concluded that breast screening is effective at reducing mortality from breast cancer, and should continue to be offered, but that there is overdiagnosis of breast cancer as a result i.e. women are diagnosed with breast cancer as a result of screening who would not have been diagnosed had they not attended.
  • Clear communication of these harms and benefits to women will be required, and BTW is working to amend its public information accordingly.

5.7Wales Abdominal Aortic Aneurysm Screening Project (WAAASP)

  • Screener recruitment is complete and the ultrasound equipment and training contracts have been placed.
  • Public Health Wales continues to work with Health Boards throughout Wales to facilitate the development of elective vascular networks. We are awaiting the results of a self-assessment questionnaire, which will be followed by QA visits to networks to ensure readiness for launch. The current Health Board consultations on service reconfiguration impact on this work, and this poses a risk to this element of the project.
  • It is currently unclear how network governance will be delivered following the establishment of WAAASP and Chief Executives have been asked to consider their preferred model.
  • WAAASP has issued update bulletins to stakeholders.
  • Staff from WAAASP are attending GP update sessions to inform GPs of the new programme, and their role in the provision of best medical therapy to men on surveillance.
  • Staff from WAAASP attended a four nations meeting with their colleagues from AAA screening programmes in the other home nations. Among items discussed were the development of a common QA structure and sustainable provision of training post-implementation.

5.8Downs Syndrome Screening: Antenatal Screening Wales (ASW)

  • ASW continues to work with Health Boards to facilitate the introduction of combined screening for Downs Syndrome. The development of Health Board Implementation plans is progressing slowly.
  • The Chief Executive of Public Health Wales has contacted Health Board Chief Executives asking for their help in ensuring the planning tool developed by ASW is used within their organisation, to enable the project team to assess the impact of the introduction of the new test.

5.9Newborn Bloodspot Screening Wales (NBSW)