EHJ September 2003 page 272-275 Nick Warburton interviews Pat Troop, chief executive of the Health Protection Agency

Despite the great strides that have been made in tackling infections and hazards - brought about through modern vaccines and antibiotics, and through wider controls - there are new and emerging problems to contend with, ones that require new solutions and modern systems to identify, monitor and respond to the impacts on human health.

To tackle these growing challenges, a co-ordinated and integrated approach to health protection is vital, which is why a new national and independent body, the Health Protection Agency (HPA), was created earlier this year. Dedicated to protecting people's health and reducing the impact of infectious diseases, poisons, chemicals, biological and radiation hazards, the HPA brings together the expertise of a wide range of key organisations (see page 275).

"One-stop-shop" for public health protection

It was Dr Pat Troop, former deputy chief medical officer at the Department of Health and currently the HPA's chief executive, who came up with the idea behind the HPA, recognising as she did, the need for an organisation that could deliver a wide range of health protection functions with a single line of accountability. Now that organisations like the Public Health Laboratory Service, the National Focus for Chemical Incidents and the Communicable Disease Surveillance Centre have been brought together under the HPA's umbrella, England and Wales has, for the first time, a dedicated "one-stop shop" for public health protection.

Launched on 1 April 2003, the HPA is still very much in its infancy and has a huge task ahead in order to live up to its promise.1 Though widely welcomed, there are some however, who have voiced concern that the agency was established before the roles and responsibilities of those involved in health protection had been properly clarified. Dr Troop acknowledges this concern but says that the HPA has been actively addressing the issue.

"There are different ways of doing that," she says. "First, although we've put out a memorandum of understanding around links with primary care trusts, we've tried to express in our corporate plan that we're not here as just advisers, we're here to support, to work for and to deliver for the National Health Service." As she points out, part of the new agency's role will involve advising and supporting training in the NHS while another part will entail supporting the NHS's work. A lot of it however, will be on behalf of the NHS delivering.

Investing in relationships

Despite its short existence, Dr Troop says that the HPA has invested a great deal of time and effort in trying to build strong relationships at a national, regional and local level. In fact, one of the key roles the agency will play in health protection is in developing closer working relationships between local authorities, government departments, health services and local communities.

"We've been very clear that we're not some new deterrent group sitting down in the corner, coming out with pearls of wisdom," she says. "I've told everyone that they've got to get in there with their sleeves rolled up". At one level, this means each local HPA team sitting down with its local primary care trust (PCT), strategic health authority and local authority to work out how health protection can best be delivered locally.

"I think it's this lovely phrase that came out called 'facilitated wheel invention'," she says. "You can say, 'this is our role, this is your role', but how that actually works has to be worked through locally. The local interface is one of the most crucial parts."

Dr Troop is determined that health services and local government understand the HPA is there to play a supportive role at the local level. "It's a partnership, so although we are a separate organisation, we want to work closely with health services and local government," she explains. This support will be driven by local teams with specialist skills and knowledge backed up by regional and national centres of excellence.

She is also keen to dispel any fears that the HPA will take over their functions. Noting that PCTs ultimately have responsibility for health protection and that local government has responsibility for environmental health, Dr Troop adds, "Hopefully we can bring to the table some expertise and some skills that can contribute to that, and in some cases, co-ordinate and deliver services on their behalf, so that they will feel that the level of expertise and the level of support is better."

At a regional level, the HPA has started to forge close links with the regional directors of public health (RDPH) in PCTs, although she acknowledges that progress in this area has been hampered slightly due to external events. "The RDPH role is being redefined with the changes in the Department of Health, so obviously we can't totally work through that until they've also worked through to the government offices," Dr Troop says. Nevertheless, one of the first steps the HPA has taken has been to appoint one of the RDPHs to sit in on the agency's job interview panels.

Dr Troop has also gone to great lengths to develop strong relationships at a national level, meeting with the other relevant agencies - the Health and Safety Executive, the Food Standards Agency and the Environment Agency, and has been working through the DoH, advising the department on health protection matters. By working together and highlighting the big issues, Dr Troop believes all organisations involved in health protection will ultimately have a much louder voice. "It's a bit like the UK Public Health Association," she says. "How does public health have a voice? It doesn't have it by having 10 voices, it has it by having one strong one."

Getting environmental health on board

In her drive to build strong relationships, Dr Troop is particularly keen to establish closer links with the Chartered Institute of Environmental Health, which she recognises as a vital component in the health protection framework. "I think the opportunity for partnership is extremely strong," she says. "I've been talking to the chief executive of the CIEH and he was asking me if we might take some students on placement, which we're very keen to do."

The HPA also hopes to bring more environmental health professionals on board, for example, through secondments. "As you know, we're multi-professional as health protection people, and we're very keen to bring a range of skills and backgrounds into the teams," she adds.

A staunch supporter of the profession, Dr Troop is well aware of the decline in local authority environmental health officers. Acknowledging the growing shortage of environmental health graduates, which was cited as a key concern in the House of Lords Select Committee's Fighting infection report, published in July, she believes the HPA does have a role in helping to reverse the trend, albeit indirectly, by working through its partnerships. "We are all concerned about how we promote the environmental health aspects of local government," she says. "I think that it comes back to highlighting the big issues. What the four agencies - the FSA, the HSE, the EA and ourselves - have talked about is how we can collectively major on some of the issues. I think that's very powerful."

Taking food safety as an example, Dr Troop continues, "If the FSA and ourselves and the CIEH all talk about food safety issues, I think we'll have a much louder voice. I think as well, it helps the more we raise the issues, not just what the issues are but what needs to be done about them."

Dr Troop also sees the HPA being able to exert its influence through the RDPHs. "We work closely with the RDPHs - and we can obviously give them sufficient background to enable them to do that role. That's a potentially powerful role that we could well exploit."

Gaining the public trust

While the HPA has a wide remit (see HPA facts box), its formation around the time of the SARS outbreak has arguably coloured the public's view of what the agency is and why it is there. Dr Troop does not deny that this perception of the agency may exist, but is quick to point out that it is working at all levels to ensure people understand its wider role. Getting the message across at the local level is again a vital part of the process.

"If we are going to build up people's confidence in us an authoritative group of people, local people like to trust local people," she says. "Therefore if we can have a strong presence locally and through local teams, we can be really proactive with the local community on programmes of prevention, health care and fighting infection". As with the NHS, Dr Troop says people tend to trust their own patch which is why focusing on the local community is so important.

It's with working with communities that Dr Troop believes the HPA can play a vital role in fighting infection. Here she sees a direct link with reducing health inequalities. "If you look at infectious diseases, and look at the history books and how we tackled tuberculosis, for example, it was through tackling inequalities," she argues. "So, I've been encouraging people not to say the handling of TB starts with surveillance, actually it starts with how you work with local communities."

By using its wealth of expertise and knowledge, Dr Troop believes that the HPA can help local people and local partnerships gain a better understanding of the particular patterns of disease, the particular groups and their particular risk factors and vulnerabilities. As well as encouraging and raising the profile of these key issues, she also says the agency can provide local partnerships with "really good information to help them when they work in those communities, so that they can address the issues in the most effective way."

When the agency was launched almost six months ago, part of its remit was to provide impartial and authoritative information and advice to both professionals and the public. Like the other key agencies, the HPA intends to publish regular reports and other documents, which Dr Troop hopes will "get into public thinking". It also has plans to revamp its website, providing an interactive service with local organisations as well as offering supportive and user-friendly information.

A two-way process

Dr Troop wants this to be a two-way process. "We are going to do some work about understanding what people will expect from us," she says, focusing specifically on the values and outcomes the public wants from the agency. "It's one of those things that you have to build up over a period of time," adds Dr Troop. "We want to build it up as being solid rather than flash."

Given the trend for re-organisation and restructuring of public health bodies in the UK, Dr Troop admits to having done little to change the agency's interim structure since her arrival. As she explains, "We are putting far more emphasis on the ways of working and the benefits of working together than we are on the interim structures." Any development that does happen will be organic and evolutionary rather than revolutionary.

Even so, she adds, people are finding change without moving. For instance, until now, local and regional teams have never had direct links to the national ones. This is one of the many encouraging developments that have emerged over the last five months. And what about the challenges facing the agency over the next 12 months? "It's about keeping people on board," she says. "It's keeping all that enthusiasm and keeping people moving forward, and for me that means a lot of my time is out there talking and listening to people. I came here at the beginning of March and my enthusiasm has still not be dented."

References

1. Fighting infection, House of Lords Select Committee on Science and Technology, published 18 July 2003. To download a copy, visit: www.parliament.uk/hlscience/