Section 2: The approach to outbreak management at local and national levels in Scotland
The Strategic Framework, supports established public health approaches to communicable disease outbreak control, involving tried and tested, internationally recommended approaches. These approaches described in the Scottish guidance on the Management of Public Health Incidents (MPHI).
During each stage of the national response to the COVID-19 pandemic we need collectively to be able to react to incidents involving individual cases, clusters and outbreaks of infection to limit further spread and protect public health, especially of the most vulnerable groups.
The standard approach to communicable disease control in any situation, including COVID-19, involves some basic elements, as set out in this workbook.
How are local public health incidents classified?
Five levels of incident are outlined with increasing severity and magnitude from:
- Level 1 - minimal response due to limited local level impact;
- Level 2 - more severe local level impacts requiring the co-ordinated efforts of local partner organisations to manage effectively;
- Level 3 - regional level, significantly wider impacts requiring cross boundary but still mainly local agency working;
- Level 4 - more severe local or wider regional impact requiring activation of a local resilience partnership for a high level of multi-agency coordinated response; and
- Level 5 - national level incident requiring local and central government co-ordination with population-wide national scale interventions.
Note: These should not be confused with the COVID-19 local protection levels.
At publication the COVID-19 pandemic response was being managed in Scotland as a Level 5 incident, with local and national resilience functions co-ordinating a Scotland-wide, nationally coordinated response. Within this national level response framework, however, the response to local incidents must still be managed by the local NHS Board Directors of Public Health, their HPTs and their partners; they may need to react to multiple Level 1 and 2 incidents, and may also be involved in co-ordinating local responses and contributions to more widespread (Level 3 and 4) incidents.
What is Public Health Incident Management?
Public Health incidents are identified though surveillance (either via early warning intelligence of impending risks or via COVID-19 case identification) by the NHS Board HPTs. The NHS Board Director of Public Health has overall responsibility for this function but normally delegates this to the NHS Board HPT. The team undertake rapid information gathering and risk assessment to determine if other partner organisations need to be asked to contribute to an investigation. This initial assessment may be undertaken by a Problem Assessment Group (PAG).
Problem Assessment Group (PAG) - is usually an internal, preparatory meeting. If necessary, wider agency involvement will be sought
A simple incident may be dealt with by a single PAG meeting. If an incident has wider implications or is likely to require an ongoing response, the next step is formation of a formal group - an Incident Management Team (IMT) - to discuss the situation in more detail, to assess the situation and to coordinate action to control the incident.
Incident Management Team (IMT) - is a multi-agency group chaired by a Consultant in Public Health. Relevant partner organisations whose input is essential to manage the incident are invited to participate as members. This group undertakes a structured investigation and will meet multiple times until the incident is brought under control.
An IMT is formed in response to a specific incident and is not a pre-formed group. Partner organisations who are relevant to the incident under investigation will be invited to join the IMT. Partner organisations act within their own area of expertise and under their own legislative frameworks, to undertake investigation and enact interventions on behalf of the IMT. The potential membership of an IMT is detailed in Appendix 2. IMTs are usually chaired by a Consultant in Public Health (Medicine), delegated by the DPH on behalf of the NHS Board Chief Executive and the NHS Board.
The IMT will undertake an established process of investigation to establish the "who", "what", "why", "when", "where" and "how" of the incident. This includes:
- an epidemiological investigation (the "who", "where", and "when" of the incident);
- identification and investigation of the hazard, or laboratory investigation (the "what");
- investigation of the method of exposure to the hazard, or environmental investigation for the source of the hazard (the "how" and "why");
- risk assessment - if the hazard is still putting people at risk and the impact of the hazard;
- risk management - interventions or control measures to minimise the risk to the population; and
- risk communication - between and within agencies and with the public.
Effective communication about the incident will play an important role and an NHS Board communications officer will usually be a member of the IMT.
An IMT operates in confidence to enable the sort of open discussion needed to establish the facts, discuss hypotheses on the cause of a problem, consider options for action and make decisions on appropriate action. One of the primary responsibilities of the IMT is to act quickly in order to protect public health.
A full IMT response may not be appropriate or necessary for all incidents, especially if there is local experience of managing similar incidents or the incident has minimum local impact. The HPT in conjunction with the Director of Public Health will assess this on a case by case basis by using a risk assessment process.
At this stage of the COVID-19 pandemic response the potential for health protection teams having to manage multiple incidents (COVID-19 as well as non-COVID-19 situations) will increase. Good communications among local and national partners aimed at rapid learning of lessons and sharing of practical experience (shared learning) and intelligence gained, with local and, potentially, regional or national health protection and formal resilience structures will be necessary instead.
How does the IMT interact with COVID-19 response mechanisms?
Local public health incident management sits within the local, regional and national frameworks coordinating the response to COVID-19. HPTs are a finite resource that have to manage all the public health/health protection aspects of the local level COVID-19 response and incident management, in addition to investigating non-COVID-19 incidents.
An IMT may implement local control measures to bring an incident under control, but these need to be implemented in an environment of wider COVID-19 public health interventions. The interplay of local control measures and national interventions will be considered by the IMT. Local incidents of sufficient scale and significance will be managed either on a local basis or draw on other specialist resources (for example, PHS), as required. Any significant developments will be shared with national agencies and Scottish Government.
For more information about the organisational roles and responsibilities please see Annex B of MPHI guidance.
For Level 1 incidents, the IMT membership will be local partner organisations and control measures implemented will affect a small proportion of the population. For these incidents, it is likely that decisions on managing the incident will remain entirely within the IMT, with responsibility lying with the DPH.
For Level 2, 3 and 4 incidents the IMT membership will be more broadly based and the control measures implemented may have a significant interaction with the standing COVID-19 resilience structures. While the IMT will recommend specific control measures in response to the incident, wider discussion with command groups within resilience structures may be needed to establish any interplay. In such situations, the DPH remains responsible for the implementation of control measures for the incident response and for discussing and agreeing actions in any wider groups as required.
For such incidents, there is a likelihood that there will be close interaction between the IMT and local or regional resilience partnerships, including health and social care partnerships (as appropriate), who are key to managing the wider consequences of outbreaks.
Reporting of local public health incidents
Local public health incidents are routinely reported by local health protection teams to Public Health Scotland and the Scottish Government Health Protection Team via established routes.
Confirmed COVID-19 cases as well as outbreaks are currently and continue to be reported to Public Health Scotland. Laboratory reports of confirmed cases tested via NHS Scotland laboratories as well as via the UK Government sponsored testing services are monitored. The numbers of cases are recorded using existing computed database systems used by local health protection teams to track cases and to manage incidents and outbreaks. This data is collated daily by Health Protection Scotland and shared with the Scottish Government and with UK partners, as part of the national and UK surveillance system for COVID-19.
The national collation of data will continue to inform the response to the pandemic and this will continue into the next phase of the pandemic response and recovery period. As indicated earlier, Scottish Government and Public Health Scotland will continue to publishing regular updates. These data will also inform analysis of specific sectors, such as the analysis of infections in school pupils by Public Health Scotland.
Whenever there is an emergency in Scotland, a number of different organisations immediately start working together to tackle it.
Depending on the nature of the incident, this might include Public Health Scotland, Police Scotland, the Scottish Fire and Rescue Service, Scottish Ambulance Service, health boards, local authorities, Integrated Joint Boards, the Scottish Environment Protection Agency or the Maritime and Coastguard Agency.
Working together, these organisations form a 'resilience partnership', which helps them to coordinate, collaborate and share information. Partnerships may also include organisations involved in the energy, telecoms, transport, and water sectors, as well as local or national volunteer groups.
Standing regional and local resilience partnerships meet year-round across Scotland to plan for emergencies and to take part in exercises to test those plans. The Scottish Government supports them with guidance and practical help through embedded teams of Resilience Partnership coordinators from Government.
Scottish Government resources have been committed to develop thinking about the systems and processes which support local incident management teams and Directors of Public Health, and to ensure essential, national strategic cross-Governmental inputs are achieved without interfering with necessary, local management actions or intruding on local clinical decision making.
A National Incident Management Team (NIMT) has been established to take a national public health overview of incidents and outbreaks across Scotland, and to provide clinical response and recommendations to the Chief Medical Officer. The NIMT is chaired by Public Health Scotland and includes representatives from territorial NHS Board public health, National Contact Tracing Centre, Chief Medical Officer, NHS24, COSLA, and Scottish Government officials.
Strong local and national partnerships are already long established to ensure effective and coordinated public health incident management. This is based on many years of experience in dealing with a very wide range of public health incidents ranging from routine outbreaks of food poisoning, legionella, meningitis, measles and many other endemic infections, to complex problems such as HIV and Hepatitis C infection, as well as outbreaks of rarer diseases in recent years such as Anthrax and Ebola.
Information on legislation relating to COVID-19 is found at Appendix 4.