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Part 2A survey results 2015
- 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
- 4. Thing- • 23 orders (13 Blackpool, 3 Yorkshire, 7 other) 1 Piercing equipment 22 Tattoo equipment 0 re-applications
- 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
- 6. Section 38 detention orders controlled by pulmonary tuberculosis notification rate and health authority response rates in England and Wales, 1994–9. R J COKER Thorax 2001;56:818 Copyright © BMJ Publishing Group Ltd & British Thoracic Society. All rights reserved.
- 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%
- 8. person 0 2 4 6 8 10 12 14 16 18 20 Homeless Mental health Drug/Alcohol Non-compliance Agression Prison Chaotic life Number Reason Reason for Application More than one allowed per application
- 9. person 0 5 10 15 20 25 Number Powers Powers requested More than one allowed per application N=25
- 10. person 0 2 4 6 8 10 12 PHE clinician PHE+clincian PHE and EHO PHE, EHO, Clinician Order initiated by
- 11. person 0 2 4 6 8 10 12 14 Home visits phone calls MDT LA legal team police psychiatric review no response Prior to application More than one allowed per application
- 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