To understand the use and utility of Part 2A orders since inception in 2010 to current August 2015 - presentation at Faculty of Public Health annual conference 2016
1. PART 2A SURVEY RESULTS
2015
Presented by Amber Arnold
Infectious Diseases and Microbiology SPR
St George’s Hospital
With thanks to
Daniel Philips
Graham Bickler
2. Survey
• Aim: understand the use and utility of Part 2A orders since
inception in 2010 to current August 2015.
• Objective: undertake a web based survey of public health
consultants (PHCs) and environmental health officers
(EHOs) and review results and discuss need for legislative
change with participants at a half day workshop.
• Method: select survey written. Redacted part 2 A order
requests used to identify PHCs and EHOs who had lead on
order requests.
3. Numbers and types of Applications by
year
0
5
10
15
20
25
2010 2011 2012 2013 2014
Number
Year
Part 2A since introduction
Place
Thing
Person
5. premises
premises Infection risk aim
Petting farm E coli 0157 Close farm
LA self-contained
flat
Faecal
contamination
Move out tenant
for cleaning
house BBV Covert visit for
seizing tattoo
equipment
7. 29 person orders
28 TB, 1 HIV Median age
38 years
IQR 28.5-42.5
Male 93%
Female 7% (n=2)
White British 41%
White other 21%
Black African 14%
Unknown 10%
Pakistani 7%
Indian 7%
TB type*
MDR/XDR 28%
Sensitive 41%
Unknown 31%
* From redacted forms
Renewed
No: 24%
Yes: 62%
(median 1, range 1-7)
Unknown: 14%
12. Person- issues obtaining
Most positive responses were positive without any
difficulties
Difficulties reported were:
• Transfer of patient identifiable data (PID) between parties
(LA, PHE etc)
• Coordination of reports between parties- (LA no secure
fax)
• In court: tensions emerged between parties surrounding
requirements
No one requested extra powers
13. Person - difficulties implementing
• Resources: negative pressure bed, ambulance,
police
• Inter agency coordination: ambulance, police, bed,
PHE physician,
• Accountability and roles: Refusals by Ambulance
/police/hospital chief exec./patient, who funds
bed/guard
• Patient based: missing, fear of violence from,
refusal by,
• Hospital based: Drug and alcohol use and ‘cigarette
breaks’, mental health needs while infectious, role
of guards, retrieval on absconding
14. Person- police involvement
yes
58%
no
21%
unknown
21%
police
involvement
• Most: Excellent support, very helpful
• PPE- wrong information, refusal due to
infection risk, who is responsible for
information, need for CCDC in person
• Police Time- 11 days to locate one person,
repeated absconding, how many times
• Police van- unsure if patient can go in van
• Level of force- unsure what level
• Where the police can pick patient up from
with the order (refused to pick up from
street)
15. Person-what did it hope to achieve
• Quarantine until completed RX (7 renewals)
• Time to organise other services (etoh, home
etc)
• Stabilise chaotic life (3 renewals)
• Tell us about contacts
• Detain while police preparing criminal
charges
• Protect specific contacts
16. Person- outcomes
Achieve aims: 1 no (HIV case)
Protect public health: 2 no (HIV, TB Birmingham)
positive but limited
• by case selection bias
• Participant
Comments quite negative:
‘These orders are only used when everything else has failed and to have an
order with no sanctions is going to achieve very little as we found out.’
‘at best a temporary solution’
‘contentious from human rights perspective’
17. Summary
• Major use is for person infected with TB
• Use for persons stable (decreasing?)
• Implementation difficult
• Questions around enforcement powers
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54 since introduction
24 thing, 29 person, 3 place
Excludes 2015 data
Person constant replacing an old legislation, new for place and premises
Section 38 detention orders controlled by pulmonary tuberculosis notification rate and health authority response rates in England and Wales, 1994–9.
We have full results on 27. partial 29.
Males over represented, age slightly older than the peak in TB report, over represented UK born,
place of birth- UK 28%, India 20%, Pak 12%, somalia 3.7%, Bangladesh 3.3, nepal 2.7%
Highest rates 30-34 years and then 25-29 years
Male 58%
MDR/XDR=8, sensitive =12, unknown= 9, renewed no=7, yes=18, unknown=4
resources, inter agency coordination, accountability / legislative??]Coordinating the ambulance and the police to go to pick up the patient
Difficulties locating the patient, a lot of police time, an 11 day delay between order and locating patient in one case
Difficulties in getting the patient to hospital: who police ambulance, PHE consultant, how to coordinate ambulance and police at same time, use of private car in several cases, police said that the order only allowed them to pick up the case from an address and not the street and so refused to pick up patient and bring him in.
The police not able to encourage the patient to come in
Costs to health service to accommodate patient for long duration, cost of guard outside room
Who would pay for the guard: hospital or PCT
Guiard not obtained in time for the arrival of patient
Bed not available in the hospital patient diagnosed in so he had to go to another hospital with no experience and where they were scared of the infection control implications. Very reluctant to take patient.
Ambulance in theory happy to come and pick up patient planned before but when phoned for the ambulance they refused to come as patients life not in danger.
Security at hospital refused to send a guard to sit outside the room in the hospital
On arrival at patients house by EHOs he ran away and had to be searched for by police the next day.
Drug and alcohol use by patient and friends, aggressive behaviour to EHOs when attempting to admit to hospital
LA agreed to pay for the security guard
Aggression of patient to staff on the ward
Lack of medicine compliance making him a risk of MDR TB on the ward to staff
Easier once the patient was transferred to a rehab ward where the patient was familiar
The patient absconded from the ward so many times that they resorted to home management. But that failed too as no ability to physically keep the patient in one place.
Funding for guard an issue
Abusive patient was issued with an ASBO
Patient absconded and not able to get back
Patient requiring cigarettes outside: guard to accompany
Chief executive of hospital wrote to the LA saying that they would not have a bed for the patient after he absconded a few times.
Patient absconded for 3 days before they had a 24 security guard in place
As we were not able to enforce that the patient stay it was lucky that he came back from absconding voluntarily
Financial and logistic of hospital bed
Should be to protect others from infection risk but what was written was quite different
Removal of suspected MDR/xdr case to the hosp to start treatment and remove infection risk
To quarantine until completed treatment (7 orders)
To prevent patient disappearing underground and et up alcohol and other services as well as risk free DOT
To prevent patient spreading infection to others
Detain and stabilise chaotic life so that could take treatment x3
Obviously infection but extra points were interesting
Detain a homeless person while home situation sorted
Isolate from the community
Alloed us to assess patient who seemed to be high risk of tb with cavities
Tell us about contacts
Hoped to protect the community from this man while police were compiling evidence for an arrest and prison. We failed to protect young woman he associated with.(diff to know whetehr the aim was to protect from infection or crimes?)
Tb recurrent absconding, attempt at home, no point carrying on, only so many times can get the police
n many ways gaining the Part 2A Order is the easy part. Enlisting help of others to enact the restrictions or requirements may be harder. And gaining the order does not resolve the problems/circumstances which might be hampering compliance, and these will still need to be addressed subsequently. Additionally the attendant sanctions are not really a concern for many of these cases, who do not have money to pay a fine anyway, and/or who are not unduly concerned by the prospect of a prison spell