Scottish Government

Health Protection in Scotland - A Consultation Paper

Chapter 2: What is Health Protection?

2. In one sense, health protection means protecting people from hazards, which damage their health, but it is, of course, possible to construct a range of different, more detailed definitions. This chapter defines the main types of hazards, how people come into contact with them and how they affect their health. It goes on to describe the current legislative framework and organisational arrangements for the provision of services which safeguard people's health in Scotland and outlines the scope for change.

3. Hazards, exposures and ill health

4. Health and illness are a reflection of our interaction with the environment, our genetic endowment, and how we relate to each other. Societies have built on their knowledge of these factors to improve health. Among the steps taken are measures to protect people from hazards occurring in the physical and social environment. The broad categories of agents which endanger health (hazards) and how we come into contact with them (exposures) are presented in Table 1.

5. TABLE 1

   HEALTH PROTECTION
   HAZARDS	EXPOSURES
   Biological Chemical Radiation Physical	Person to person Food Water Air Animal Environmental

6. These categories overlap: for example, an outbreak of infection can involve the population being exposed to a micro-organism through two or more routes.
8. The hazards and exposures encompassed by health protection are often termed "involuntary" i.e. a person does not make a conscious decision to expose him or herself or his/her family to them. However, in real life, the boundary between voluntary and involuntary is blurred, can be contentious, and changes with time. In general, most people recognise that it is often beyond their own means to control their actual or likely exposure to "involuntary" hazards such as air pollution. Rather, they see the wider community and its institutions as having the major responsibility for protecting their health. Conversely, in other areas, such as sexual behaviour and injecting drug use, the dividing line between individual and community responsibility is one of continuing debate.
10. It is therefore important to acknowledge that preventing exposures to hazards is, where possible, a key element of health protection. It is often suggested that the supply of clean drinking water and immunisation against infectious diseases represent the two most significant and effective health protection measures of the last two hundred years.
12. However, most people, at some time in their life, will be affected by an exposure to a hazard. More often, they will be concerned about the risks to themselves and their families. At times, some may be anxious. For the media, health protection issues are often synonymous with the word "scare". People need to know what they themselves can do to reduce these types of risks and what to expect from local, national and international agencies, charged with health protection. For them, exposure to hazards is not just a health but also a quality of life issue. Individuals, therefore, need to be involved in health protection, not just as "cases" of ill health but also as citizens with rights and as consumers of the services which protect their health.
14. Although the hazards and exposures vary, they have in common that:

• they are capable of affecting large groups of the population in a relatively short time;
• when a problem arises, it may not be exactly clear what hazard is involved, how people have been exposed to it, and the numbers of individuals actually or potentially exposed;
• speedy action is essential to trace the source of exposure, control its extent and prevent further exposure.

2. Preparedness for the unusual as well as handling uncertainty and risk are therefore key features of health protection.
4. Exposure to hazards can affect the body to varying degrees. If exposure is severe and/or sustained, this will lead to disease, disability and, in the worse instances, death. The causation of ill health is complex, with lifestyle, life circumstances and genetic factors all playing a part singly and in tandem with exposure to hazards. The most common types of health problems associated with exposure to hazards are:

• infections;
• injuries;
• certain cancers;
• certain respiratory diseases;
• some congenital abnormalities.

2. Exposure to hazards, although not the principal cause of ill health in Scotland, still gives rise to a considerable burden of disease. As with most health problems, those associated with exposure to hazards often occur disproportionately in people with the lowest incomes. Improving health protection may therefore also help to reduce inequalities in health.
4. The number of people falling ill and dying from infections has dropped in the UK, and some of the reasons why they succumb to these types of diseases have also changed. New means of economic production, different ways of enjoying ourselves, the globalisation of trade and increasing pressure on the environment have led either to new hazards appearing or people being exposed to old ones in different ways. The pattern of injuries due to accidents has also been changing. Over the past 20 years, there has been a decline in deaths due to injuries as a result of accidents, with the rate in 2000 being less than half that in 1980, and the reduction greatest in children. Explanations for this decline include both improved healthcare and increasing restrictions on children's independent mobility outside the home. Over the same period, emergency hospitalisation rates rose steadily, especially for home accidents, largely due to an increase in falls because of the growing number of older people in the population. Health protection services work in this context of change, and must evolve to reflect this.
6. People's understanding and perception of the risks to their health change with time. For most, as quality of life improves, so their expectations rise of the level and types of risk from which they should be protected. New technologies enable us better to identify hazards and measure exposures to them. These, coupled to an insatiable media appetite for "scare" stories, can give the impression that we are living in an era of unprecedented danger when almost all statistical and scientific data point in the opposite direction. At times, e.g. when they are caught up in an outbreak, people can become frightened. The recent BSE Inquiry and MMR controversy have highlighted the need for health protection agencies to pay as much attention to assessing public perceptions about risks and communicating with people about them as they do to investigating hazards and controlling exposures.

7. What is involved in health protection

8. The aims of health protection services are to:

• reduce the risk to the public from exposure to hazards which damage their health;
• limit the extent of exposure to these hazards if this cannot be avoided;
• reduce the incidence of co-morbidity, disability and mortality occurring as a result of exposure to these hazards;
• ensure that there is an effective response when a major exposure has occurred (i.e. a public health emergency ).

2. The key functions involved in achieving these aims, are:

• Surveillance: monitoring the occurrence of hazards, exposures to them and their impact on health;
• Investigation: investigating the characteristics of hazards, the sources of them and their routes of exposure; assessing and measuring their effects on individuals and populations and evaluating the scope for, and effectiveness of, control measures.
• Risk assessment: estimating the probability of the health of a community being damaged from specific exposures;
• Risk management: taking effective measures to reduce the risk of, or limit the extent of, exposure to hazards and controlling their effect on the health of individuals and communities (for example, immunisation programmes).
• Risk communication: informing and educating the public in ways, which aid understanding, allay unnecessary anxiety and facilitate individual and collective action to reduce risk.
• Planning for and managing emergencies: ensuring that measures are taken promptly to prevent further exposure to a hazard, when a major exposure has taken, or may take, place such as in an outbreak of infection or a chemical incident;

2. Effectively delivering these functions requires underpinning by the following:

• suitable professional education and training;
• networks of professionals and agencies, operating locally, regionally and nationally, which co-ordinate policy, procedures and action;
• effective management, clear systems of accountability (including measures to assess the quality and impact of health protection services) and adequate resourcing of health protection services;
• effective links with UK and international bodies.

2. Protecting health is an individual and collective responsibility. The current legislative framework and current organisational arrangements for discharging health protection functions are now described.

3. Current Legislative Framework

4. The current legislative framework for health protection in Scotland dates from the Infectious Disease (Notification) Act 1889 and from the groundbreaking Public Health (Scotland) Act 1897, which, based on the principle of "protection from nuisances", provided a wide range of functions to protect and improve health. Though powers for implementing this legislation rested mainly with local government, over the years, the responsibility for certain elements of health protection have been distributed from local authorities to other institutions. A series of statutes dealing with, for example, health and safety and the environment has helped re-define the statutory framework for health protection. Within the NHS, the National Health Service (Scotland) Act 1978 places a statutory duty on NHS Boards and local authorities to co-operate with one another to control communicable disease and to secure and advance the health of the people of Scotland. Subordinate legislation made under the 1889 Act and the Public Health (Scotland) Act 1945 requires the notification to the Chief Administrative Medical Officer of certain infectious diseases.

5. Current Organisational Arrangements

6. Hazards to health tend not to recognise national boundaries. Globally, under the leadership of WHO but with the support of many countries, there is renewed determination to co-ordinate international efforts to control infections such as the worldwide epidemics of TB, HIV and to combat the threat of bio-terrorism. The European Union's new public health programme reflects continuing concern about infection and the environment and the need for EU-wide programmes on surveillance and rapid response to public health threats. In the UK, there is a set of operational arrangements, described in more detail in the following paragraphs, some of which span the four UK countries and, in some instances, encompass the Republic of Ireland. Some of these are reliant on effective professional networks at national and local level, rather than organisations or managerial relationships.
8. In Scotland, the health protection function draws on a variety of national, and local agencies. The Scottish Executive sets the policy and legislative framework, monitors performance, and heads emergency planning, and of course this requires joint working among the Executive Departments concerned with health protection. At a local level, local authorities, NHS Boards and Trusts are the main players. A number of UK organisations provide relevant resources, for example, as outlined below, the Food Standards Agency has key functions in relation to food-related health protection. There follows a list of the main health protection agencies in Scotland:
10. Organisations with UK-wide responsibilities related to health protection

11. a. Food Standards Agency

    The FSA is a UK-wide non-Ministerial Government department that operates at arms length from Ministers and was set up in 2000 to act primarily as an independent voice within Government to protect the public's health and consumer interest in relation to food. The FSA provides advice and information to the public and Government on food safety from farm to fork, nutrition and diet. It also protects consumers through effective food enforcement and monitoring. Its UK headquarters are in London, and the Agency also has a Scottish office in Aberdeen which advises Scottish Ministers on all policy and legislation relating to food safety and standards as these are devolved matters. The FSA employs about 700 staff (60 in Scotland) and is governed by a Board appointed to act in the public interest. The Board consists of a Chair, Deputy Chair and up to 12 other members, two of whom are directly appointed by Scottish Ministers.

    The Meat Hygiene Service is an Executive Agency of the FSA operating within Great Britain and its functions are to provide a meat inspection service to all licensed meat plants.

    b. National Radiological Protection Board

    The National Radiological Protection Board was created by the Radiological Protection Act 1970. Its functions are to advance the acquisition of knowledge about the protection of mankind from radiation hazards and to provide information and advice to persons (including Government Departments) with responsibilities in the United Kingdom in relation to the protection from radiation hazards either of the community as a whole or of particular sections of the community. It also has a role in environmental monitoring and modelling. The NRPB employs some 300 staff at its centres in Glasgow, Leeds and its Head Office at Chilton, Oxfordshire. The NRPB is a Cross Border Public Authority (CBPA) which means, in simple terms, that the Board has functions exercisable in both reserved and devolved matters. Scottish Ministers have powers along with other Health Ministers to appoint members of the Board, extend its terms of reference and to direct it in the discharge of its functions. The Scottish Executive contributes to the funding of the NRPB.

    c. The National Focus for Chemical Incidents

    The National Focus for Chemical Incidents is jointly funded by the UK Health Departments. It is located at the University of Wales Institute at Cardiff. Its main activities are to improve NHS preparedness with respect to chemical incident management; to facilitate the response to chemical incident management; to advise Government of the potential public health impact of chemical incidents and to undertake public health surveillance of the impact of environmental chemicals.

    d. Health and Safety Commission and Executive

    The Health and Safety Commission (HSC) has overall responsibility for policy on health and safety at work in GB and advice to Ministers on standards and regulations. The Health and Safety Executive (HSE) is the operational arm of HSC. HSE's aim is to ensure that risks to people's health and safety from work activities are properly controlled. Its remit includes people outwith the workplace who may be harmed by the way work is done and, in some situations, the way work affects the environment. HSE enforces health and safety law, inspects workplaces, investigates accidents and cases of ill health, promotes good standards, publishes guidance and carries out research.

    It should be noted that, under the Health and Safety (Enforcing Authority) Regulations, Local Authority Environmental Health services have a similar duty to enforce the law, inspect workplaces and investigate accidents and causes of ill health in prescribed workplaces.

    e. State Veterinary Service

    The State Veterinary Service (SVS) covers England, Wales and Scotland but not Northern Ireland. Its head is the Chief Veterinary Officer for Great Britain. The SVS is the lead agency responsible for animal health matters. It exercises the Scottish Executive's statutory responsibilities for responding to notifiable diseases in animals including those which can be transmitted to humans. The SVS in Scotland is an integral part of the Scottish Executive Environment and Rural Affairs Department.

12. Non-NHS statutory organisations with Scotland-wide responsibilities related to health protection

13. a. Scottish Environment Protection Agency

    The Scottish Environment Protection Agency (SEPA) is the public body responsible for environmental protection in Scotland. It was established under the Environment Act 1995. SEPA's main aim is to provide an efficient and integrated environmental protection system for Scotland, which will both improve the environment and contribute to the Scottish Ministers' goal of sustainable development. SEPA regulates potential pollution of natural waters and the air and the storage, transportation and disposal of controlled waste as well as the keeping and disposal of radioactive materials. SEPA provides extensive guidance and advice to regulated organisations and works in partnership with others to deliver environmental goals through non-statutory means.

    b. Drinking Water Quality Unit

    Under the Terms of the Water Industry (Scotland) Act 2002, a Drinking Water Quality Regulator for Scotland was appointed in April 2002. He and his staff form the Drinking Water Quality Unit, which has the general functions of monitoring and enforcing drinking water quality standards on the public networks (provided by Scottish Water) and of supervising local authority enforcement of any private water supplies within their remit.

14. NHS Organisations with Scotland-wide health protection responsibilities

15. a. Scottish Centre for Infection and Environmental Health

    The Scottish Centre for Infection and Environmental Health (SCIEH) is a Division of the Common Services Agency for NHSScotland. It is responsible for the national surveillance of communicable diseases and environmental health hazards and the provision of expert operational support on infection and environmental health to NHS Boards and local authorities in Scotland. Its aim is to improve the health of the Scottish population by providing the best possible information and expert support to practitioners, policy-makers and others on infectious and environmental hazards.

    b. Information and Statistics Division

    The Information and Statistics Division (ISD) is a Division of the Common Services Agency for NHSScotland. ISD collects, validates, interprets and disseminates data received from the NHS about healthcare activity, and the diseases dealt with by the service. It provides medical and public health advice to help understand such information. Key health topics on which data are collected are cancers, coronary heart disease, mental health, accidents, immunisation, drug misuse and sexual and reproductive health.

    c. Health Education Board for Scotland

    The Health Education Board for Scotland (HEBS), a Special Health Board within the NHSScotland, was established on 1 April 1991 as the national agency for health education in Scotland. The Board aims to promote good health through the empowerment of individuals, groups and communities. It works to ensure that people have adequate information about health and can acquire the motivation and skills which enable them to safeguard and enhance their own and other people's health. As well as providing programmes of health education at the national level, HEBS facilitates the development and co-ordination of complementary activities more locally throughout Scotland. Plans are being developed to merge and integrate HEBS and the Public Health Institute of Scotland

    d. Public Health Institute of Scotland

    The Public Health Institute of Scotland (PHIS) is a Division of the Common Services Agency for NHSScotland. PHIS was created in 2001 following the recommendations of the "Review of the Public Health Function in Scotland". Its remit is to protect and improve the health of the people of Scotland by working with relevant agencies and organisations to increase understanding of the determinants of health and ill health, help to formulate public health policy, and increase the effectiveness of the public health endeavour.The work of the Institute focuses on three broad themes, namely, creating a new information base for public health; developing and utilising the public health evidence base; and developing the public health human resource.

    e. Scottish Poisons Information Bureau

    The Scottish Poisons Information Bureau (SPIB) provides health care professionals with advice on the features and the clinical management of poisoning via a 24-hour telephone enquiry service and an on-line computer database. The National Services Division, a Division of the Common Services Agency commissions the service for NHSScotland. It is one of six centres throughout the UK, which make up the National Poisons Information Service. SPIB forms part of the UK network of agencies and professionals with responsibilities for providing advice on toxicology.

    f. Scottish National Reference Laboratories

    The National Services Division of the Common Services Agency commissions this network of microbiological laboratories. They are based in NHS Trusts and most provide a service for the confirmation and typing of organisms in order to provide information for the management of individual patients and epidemiological information for public health purposes. Their work is often used in tracing and following outbreaks. There are national reference laboratories for: tuberculosis, E. coli O157, gonorrhoea, legionella, MRSA, meningococci and pneumococci, parasitology, salmonella, trace elements and toxoplasma. In addition, the Public Health Laboratory Service (PHLS) (an ENDPB with responsibilities in England and Wales under the NHS Act 1977) provides cover for other highly specialist reference services not dealt with by the Scottish laboratories.

16. NHS Organisations with responsibilities within Scotland for health protection

17. a. NHS Boards

    There are 15 NHS Boards in Scotland. They have very broad responsibilities for improving and protecting the health of their local population. Recent guidance has reiterated that health protection is one of the key functions they must deliver in the push to improve Scotland's health.

    The control of communicable diseases is a prime responsibility of NHS Boards. This entails the surveillance of communicable diseases, immunisation co-ordination, the management of programmes to prevent bloodborne virus infections, outbreak and incident management, the development and co-ordination of infection control policy and education related to health protection. A multi-disciplinary team, led by a Consultant in Public Health Medicine, usually carries out these functions. The Consultant normally carries the powers of Designated Medical Officer to the local authority in the event that legal powers are required to control the spread of communicable disease or other hazards. (In practice, of course, this responsibility rests with Directors of Public Health, working with a number of CPHMs on an on-call rota).

    NHS Boards also monitor and manage the impact on health of exposure to chemical and other toxic agents and lead the local NHS emergency planning function.

    b. NHS Trusts

    NHS Trusts provide a range of clinical and diagnostic services to treat people exposed to hazards. However, they also play a key role in their prevention. All clinical services are important in the early recognition of illnesses due to exposure to hazards. Microbiology services are essential for the diagnosis and management of infections, the surveillance of biological hazards, the investigation of outbreaks and the control of infection in healthcare settings. Infection Control Teams are fundamental to combating healthcare associated infection. Specialists in infectious diseases and genito-urinary medicine, paediatricians and general practitioners have a key role in the early recognition and subsequent control of communicable diseases.

18. Non-NHS statutory organisations with responsibilities within Scotland related to health protection

19. a. Local authorities

    Local authorities play a pivotal role in protecting the health of their communities through three key approaches: planning, regulation and service provision. In the first, the development of local plans, the preparation of emergency plans, the promotion of sustainable development and the granting of permission to planning applications all influence the degree of health protection offered to local communities. This will be reinforced by the Local Government Bill, which, if enacted, will provide a statutory basis for community planning, and place on local authorities a duty to initiate and facilitate the process (working with other public bodies such as the Police and other emergency services, and NHS Boards). As such, local authorities also have a pivotal role in the context of planning and implementing action to respond to emergency situations.

    Local authorities also monitor and enforce a series of national and local statutes related to health protection. These include licensing services and establishments, controlling air quality, trading standards, food safety, health and safety at work, contaminated land, public health nuisance, pest control, consumer protection, building control, road and community safety. Education, housing and cleansing are among the key services provided by authorities, which help prevent exposures to hazards.

    Local authorities share the statutory responsibility for controlling communicable diseases with NHS Boards. On a day-to-day basis, Environmental Health Officers working in Environmental Services or other departments, constitute the prime local authority resource in this area of health protection. They also have the principal local responsibility for reducing the risks from many environmental hazards. They liaise closely with their NHS colleagues in the investigation and control of outbreaks of infections, being the enforcement arm of the teams set up to manage these incidents.

    b. Public Analyst and other laboratories

    Public Analysts provide chemical and biological testing of environmental, food, water and other types of samples at four laboratories in Scotland. They work to ensure the best scientific expertise is available to local authorities for their law enforcement role.

    Food microbiological laboratories are an important part of the health protection function. Commissioned by local authorities, food laboratories are geared to detect human pathogens likely to be found in clinical material from human specimens.

    Scottish Water has a number of laboratories, which test for the presence of chemical and biological agents in the public water supply, as a matter of routine and in emergency situations, and established arrangements for reporting to public health authorities. The Scottish Agricultural College provides laboratory services to the SVS, including testing for the presence of zoonotic pathogens and levels of anti-microbial resistance.

    c. Emergency Services

    The Police and Fire Services, often in liaison with NHS Boards and local authorities, provide essential services in protecting the public from exposure to hazards in chemical incidents and other public health emergencies and in ensuring that safety measures, which help prevent accidental injury, are in place and being observed.

    d. Procurators Fiscal

    Procurators Fiscal are responsible for criminal investigations and any consequent court proceedings as a result of infractions of legislation related to health protection

    The scope for new organisational arrangements for health protection

20. Hazards do not respect frontiers. As described earlier, health protection agencies must, and do, link together in combating them. Global travel and trade arrangements mean that the Scottish response to certain incidents will form part of a wider UK and international response. The need for close co-operation among Scottish, other UK, European and international health protection agencies has never been greater. New organisational arrangements should seek to strengthen these ties.
22. Certain hazards are uncommon and expertise in dealing with them is limited and can only be made available at a UK or European level. Because of this, most formal scientific advice on health protection issues comes from expert committees organised on a UK-wide basis. The move in England to establish the proposed Health Protection Agency is not expected to alter the arrangements for obtaining formal expert scientific advice. This will continue to be provided on a UK-wide basis and the Scottish Executive will continue to liaise closely with its UK partners in this area. Of particular importance will be the new National Panel on Emerging Infectious Diseases, in terms of horizon scanning.
24. However, the day-to-day business of health protection work mainly involves more locally based tasks such as dealing with food poisoning, bloodborne virus and health care associated infections. The need for strong local partnerships is nowhere clearer than in these areas. Health protection measures to control these problems need to be integrated with other health improvement functions such as health promotion. At times, relationships and organisational arrangements can be severely tested, particularly in the management of emergencies that potentially, or actually, threaten public health. Here a quick and effective response is essential. Professional networks and direct contact with individuals and communities who are affected or feel threatened by hazards are essential to the overall effectiveness of the function.
26. Health protection agencies operate in what, at times, is a highly adversarial climate, where blame is often used as a method of attack. Recent events have focused attention on how best to obtain the public's trust in risk management measures. Securing this requires developing a "listening, learning and engaging" mode of operation. To engage in this, health protection professionals and agencies should be clear about the objectives they are seeking to achieve. Local accountability is a key factor in ensuring that this occurs.
28. Organisational arrangements, therefore, have to balance local action with international co-operation. The establishment of the proposed HPA has a number of implications for local health protection services in Scotland. Firstly, it is proposed that the HPA will assume those functions currently undertaken for the UK Government and the National Assembly for Wales by the National Radiological Protection Board. As such an alternative arrangement for providing radiological protection functions in Scotland may need to be considered. Secondly, it is proposed that certain specialist laboratory and epidemiological units which provide UK-wide services and essential back-up to Scottish services, should either form part of the HPA or be commissioned by it. This may have implications for the Scottish National Reference Laboratories and SCIEH. Thirdly, the arrangements for providing advice on chemical toxicology issues relating to clinical poisoning and chemical incidents affected by the proposed establishment of the HPA require us to consider how the services provided by SPIB and the NFCI should best be arranged. Lastly, it is proposed that the HPA will develop new standards for information collection and public health practice in health protection, which may directly influence how we carry these out in Scotland.
30. It seems clear that because of these factors, it may not be possible to maintain the status quo for our organisational arrangements for health protection in Scotland. But the need to consider such change also provides an opportunity to review the range of problems to be dealt with in any alternative structure for health protection in Scotland.
32. The 2001 Review of the Public Health Function in Scotland included the following definitions:

• public health: the activity associated with "the science and art of preventing disease, prolonging life, and promoting health through the organised efforts of society".
• the public health function: a robust, adequately resourced endeavour that can secure and sustain the public health, addressing health policy issues at a population level, and leading a co-ordinated effort to tackle the underlying causes of poor health and disease. The Public Health Function is the pursuit of population health improvement by a whole range of bodies.
• health protection: activities that protect health and prevent ill health. These include communicable disease control; control of environmental hazards to health; management of public health emergencies; and population immunisation and screening programmes.

2. Because these definitions do not wholly coincide with those which underpin the HPA, we need to consider the issue further. One question is whether the remit of health protection agencies in Scotland should include other health problems wholly or partly related to exposures to hazards such as injuries and cancers, and how that might impact on our established commitment to working within a UK and increasingly international context.
4. Microbiological services form a key part of the health protection function. They:

• identify the presence of microbes in samples taken from humans, animals, food, water and the environment and interpret the relevance of the results for health;
• advise clinicians about the significance of results and liaise with them in managing infected patients;
• lead infection controls teams in reducing the risk of healthcare associated infections;
• notify public health services about the presence of microbes, participate in other aspects of surveillance and help investigate and manage outbreaks and incidents;
• investigate the characteristics of biological hazards and the scope for controlling them.

2. They carry out these functions as part of local, national, UK and international networks. Because of this, Scottish services cannot be isolated from the impact of the reforms flowing from Getting Ahead of the Curve. That said, the Scottish Executive takes the view that there is no reason related to health protection for reorganising NHS microbiology services in Scotland - with one exception, the Scottish National Reference Laboratories. We wish to explore the scope for more fully integrating these laboratories with other health protection services. However, based on Getting Ahead of the Curve, the Department of Health in England produced a discussion paper on the contribution of microbiology services to health protection, and we wish to obtain views about which of its recommendations might pertain to Scotland. These are discussed further in Chapter 5.
4. Except for the functions discharged by the NRPB and the NFCI, other UK-wide agencies with a specific health protection remit are not envisaged for inclusion in the proposed HPA. Subject to comments in the consultation process, it is proposed therefore to exclude these other bodies from any specific re-organisation in Scotland. Moreover, SEPA, HEBS, PHIS, NHS Trusts, the Drinking Water Quality Unit, the Emergency Services and Procurators Fiscal have a wider remit than health protection. Again, therefore, the intention is to exclude them from any re-organisation.
6. As earlier described, local authorities have a key role in health protection across the range of their functions. EHOs, in particular, have a crucial contribution to make. Arguments could be adduced for embracing many of the functions EHOs discharge in any reorganisation of health protection in Scotland. Conversely, there are good reasons for not disturbing the present arrangements. For example, EHOs have close links with other agencies, including the Food Standards Agency and SEPA, which are not envisaged as part of any organisational change. It would be helpful to have views on this point and on how the contribution of local authorities and EHOs in particular to health protection can be enhanced. Similarly, it would be helpful to have views on whether this logic can be applied to other posts or functions.
8. It is therefore proposed that the scope for alternative organisational arrangements in Scotland should be limited to the functions discharged by the following bodies:

• National Radiological Protection Board;
• National Focus for Chemical Incidents;
• Scottish Centre for Infection and Environmental Health;
• Information and Statistics Division (the health surveillance elements);
• Scottish Poisons Information Bureau;
• Scottish National Reference Laboratories;
• NHS Boards (health protection functions especially those delivered by communicable disease and environmental health teams).

2. The scope and shape of re-organisation in Scotland should mainly be determined by the major health problems caused by exposure to hazards in Scotland and how well alternative arrangements will help protect the public from them. The next chapters provide further details on these.

3. Conclusion

4. Health protection has a long history in Scotland. It has adapted over the years to an evolving physical and social environment and has made an important contribution to improvements in people's quality of life and wellbeing. At the start of the 21 ^st century, we have an opportunity to modernise services to face the new challenges presented in an ever-changing world.

Key Questions

It would be helpful to have views on:

• the scope of health protection in Scotland and how that might support our established commitment to working within a UK and increasingly international context
• how the contribution of local authorities and EHOs in particular to health protection might be enhanced.

Do consultees agree:

• that consideration of change should focus on the bodies listed in paragraph 48?
• that EHOs should not be considered for inclusion in any new organisational arrangements for health protection?