key: cord-0067165-v302npvs
authors: LN Chapman, Ann
title: A ‘giant leap’ for UK NHS Infection services?
date: 2021-09-02
journal: Clin Infect Pract
DOI: 10.1016/j.clinpr.2021.100094
sha: 6b68bfb65c6950a7e14d8d705eec5f2bacb7519d
doc_id: 67165
cord_uid: v302npvs

nan

Never before has there been a greater need for infection expertise -the current COVID-19 pandemic has taken centre stage in the media, and in all of our lives, over the past 18 months. Indeed, taking a historical view, pandemics have occurred with startling regularity over time. [1] Even in my own professional life, we have seen the emergence of 'new' pathogens such as HIV, hepatitis C, Middle East respiratory syndrome (MERS) and severe acute respiratory syndrome (SARS). We have had influenza and COVID-19 pandemics, more localised epidemics of ebola, dengue and Zika with global impact, and also a multitude of local outbreaks, of tuberculosis, mumps, hepatitis A, and many more. Although mortality due to communicable diseases is declining globally, they still account for 20% of all deaths, and over 50% in low-income countries.

[2]

Over the past 80 years, our knowledge of the science of infectious diseases has expanded beyond the wildest imaginings of our forebears -there are still people alive who remember life before antibiotics, as a patient reminded me the other day. However, we have struggled to keep up with an advancing army of pathogens -no sooner do we come up with a new antibiotic than an organism develops resistance to counteract it. Now antimicrobial resistance is one of the greatest challenges for modern medicine [3] and we need infection specialists to lead local and global efforts to combat it.

It could be said that historically our clinical infection services were not best-designed to tackle these 'wicked' problems. The traditional divide between laboratory-based infection specialists and those providing direct clinical care to patients hampered our ability to provide a 'bench to bedside' service.

In the past, the two disciplines, of laboratory-based and ward-based specialists, only infrequently encroached on each other's territory and hence could be said to have had limited practical understanding of the other domain (although please excuse the gross overgeneralisation here). [4] There existed a cultural divide between the two that is only recently being broken down through the development of a combined training programme for medical infection specialists. Currently this training programme still produces doctors who have either a ward or a laboratory 'flavour' but gradually the two are being brought closer together. Indeed, some hospital trusts now have combined infection services where medical specialists with either background share the same roles and competencies. However, if we consider non-medical infection specialists, for example laboratory scientists or specialist nurses, the separation of 'bench' and 'bedside' persists.

Given these challenging times, and the changes in training and in the structure of clinical infection services, the publication of these Best Practice Standards for the delivery of NHS infection services in the UK is timely. [5] This document represents a huge piece of work over a number of years involving varied stakeholders from across the Infection specialities and allied organisations; in itself its development has supported closer alignment of laboratory and direct clinical services. Furthermore, the structure of infection services varies widely across the UK, and it has been challenging to ensure that these Best Practice Standards are applicable across all service models, sometimes through partnerships between services. A further challenge is in setting standards, particularly for turnaround times, in an ever changing environment where there may be an urgent need to step up some parts of the service, as we have seen with the current COVID-19 pandemic. However, this document is a first step towards a clearer vision of the future of clinical infection services in acute hospital trusts in the UK. Throughout the Best Practice Standards, existing guidelines and standards are referenced, ensuring that the Best Practice Standards align well with these and act as a single resource for infection teams.

The Best Practice Standards are divided up into seven sections. Section 1 sets out general principles of an infection service, stressing the importance of multi-disciplinary and multi-professional involvement.

Section 2 contains the 'meat' of the document -an outline of the range of services that should be delivered by a specialist infection service, within the laboratory and through direct patient care, but also at a broader level in engaging with other clinical and management teams to apply infection expertise wherever this adds value to patients and services. The document focuses to a major extent on secondary care, and of course there is as much a need for infection expertise within primary care, an area that historically has had more limited input.

Another area that could be said to be under-represented is that of travel medicine: increasingly pretravel advice and vaccination services are being provided through specialist clinics, rather than by practice nurses; most clinical infectious diseases services based in acute hospital trusts run travel clinics, often managing complex travel-related issues, for example travellers with comorbidities or complex itineraries, or provision of infrequently used travel vaccines. Travel medicine remains an important element of the curriculum for specialist infection trainees. [6] Therefore, it would seem appropriate for travel medicine to be included as a core activity of infection services.

Section 3 explores infection prevention and control (IPC) and discusses the importance of collaboration with others, in particular public health teams. It stresses the importance of allocated time for IPC roles and table 3 gives some suggested programmed activity (PA) allocations for IPC and other roles -by necessity these are quite broad: in future updates of this document it may be useful to specify time allocations for specific patient population size or acute bed numbers, or some other appropriate measure, although the evidence base for such recommendations is limited. Sections 4 and 6 discuss issues relating to workforce and to teaching and training. These are difficult areas in which to develop standards, given the variety of training pathways across the wide range of staff involved in delivering infection services, and the document provides some general principles, including the focus on competences/skills rather than traditional professional roles, the growth of nonmedical professions in delivery of infection services, in particular consultant clinical scientists, and the importance of clear and robust training pathways for all staff. Over time, as the various roles become more aligned, it will be easier to set more specific standards in these areas. Finally, standards 5 and 7 cover continuing professional development, governance and research, all important areas for consideration when developing and reviewing infection services.

Infection in Practice, a journal whose aim is to 'provide a forum for the advancement of knowledge and discussion of clinical infection in practice'. The Best Practice Standards document is a practical tool that individual services can use for their ongoing development and benchmarking. Although the Standards have undergone extensive consultation already, they will undoubtedly stimulate further debate: this is to be welcomed as part of further multi-professional discussions about the evolution of UK infection services as we move towards a single integrated model for the future.

The history of the world in 100 pandemics, plagues and epidemics. 2021. Pen & Sword Books Ltd

Clinical Infection services -the UK perspective

Best Practice Standards for the delivery of NHS infection services in the United Kingdom

Joint Royal Colleges of Physicians Training Board / Royal College of Pathologists