Health protection framework

The coronavirus (COVID-19) pandemic highlighted to all of us the importance of a robust and resilient public health protection system. The refreshed A Healthier Wales actions were published in November 2024. This includes a high-level preventative action:

to build and strengthen the health protection system to prevent, prepare and respond to existing and future health protection hazards, including pandemics, on an "all hazards" basis.

This first Health Protection Framework for Wales comes at an important time as we emerge from the shadow of the COVID-19 pandemic. As we look to the future, we must harness the collaborative partnership approach that was a key feature of our response to Keep Wales Safe during the pandemic and build on the commitment and dedication of health protection professionals across Wales.

I encourage people across the health and care system to embrace this framework and the implementation of our strategic objectives, to protect the people of Wales. I look forward to working with you as we continue to learn lessons and develop the strong, agile and sustainable health protection service we all need for the future.

Diolch,
Cabinet Secretary for Health and Social Care.

The last 5 years have been the most challenging many of us have known, but the dedication and passion of staff and partners has shone through. When COVID-19 hit, we stood up services and functions at rapid pace, delivering for the people of Wales when they needed it. When the emergency phase of the pandemic was over, we began to transition from the extensive infrastructure and COVID-19 specific resource required at the height of a response towards a more sustainable approach for future preparedness. Our experiences and learning before, during and after the pandemic must shape and support our transition towards the health protection system Wales needs for the future. We must improve our shared understanding of the capability within the system and how we can draw upon resources from across the system to scale up responses when required.

I am pleased to share our first Health Protection Framework for Wales. This framework outlines our vision to prevent, assess and mitigate risks and hazards to human health arising from communicable diseases and environmental incidents. It has been produced with partners from across the health protection system in Wales and I extend my sincere thanks to all involved. I know we will all work together to achieve the strategic objectives outlined in this framework and to further strengthen health protection in Wales over the coming years.

Judith Paget.

As a health protection system, our collective response in Wales to the COVID-19 pandemic demonstrated the importance of being agile, resilient and working together in partnership. During the pandemic response, our health protection system had to act at an unprecedented scale across Wales and adapt quickly to be able to respond effectively. In Autumn 2022, as we began to transition from the emergency phase of the pandemic, Professor David Heymann and Dr Sara Hayes undertook an independent review of the health protection system in Wales to assess its’ strengths against an established benchmark of a high performing health protection system.

The review was published in February 2023 and noted:

a gold standard health protection system needs to have the resilience to manage business as usual at all times and especially during emergencies, to constantly improve the health equity of the population, and to be prepared to manage and respond to health security hazards and emergencies when they arise.

Whilst many positives were highlighted by the review, the report concluded:

there needs to be a review of organisational and individual roles and responsibilities so that the health protection system, a network of organisations, is well understood and well prepared for the next emergency or outbreak

and

health protection partners need to co-produce a framework showing how they relate to each other, taking account of the need for clarity over leadership, collaboration and communication, both in the early stages of emerging threats and as incidents progress.

This first iteration of a national Health Protection Framework for Wales has been developed in collaboration with national and local partners across the health protection system in Wales. It is intended to be used to support ongoing partnership working across prevention, preparedness, response and recovery so that partners understand what they may expect from each other. The framework describes our strategic objectives and how the health protection system in Wales will work together for the people of Wales to minimise harm, save lives and promote wellbeing. The framework is intended to complement related strategies and programmes of work, for example the Communicable Disease Outbreak Control Plan for Wales.

The framework will evolve as we build on the strengths in our current system to develop for the future, informed by findings of the COVID-19 Public Inquiry and learning from exercises which will test the system including Exercise Pegasus later in 2025.

There are wider determinants of health which have an ongoing impact on people’s mental and physical health and wellbeing, including housing and environmental public health^{[footnote 1]}, much of which is covered by existing regulatory frameworks. The health protection system in Wales must work with wider partners to address the wider determinants of health and reduce inequalities and inequities wherever possible. The scope of this first iteration of the framework focuses on hazards to human health arising from communicable diseases^{[footnote 2]} and environmental incidents and incorporates relevant aspects of both "all hazards" and One Health^{[footnote 3]} approaches.

This framework adopts an "all hazards" approach, which includes environmental, chemical, biological, radiological, nuclear, technological and natural events. Human health is interconnected with the health of animals through our shared environment making it possible for infectious diseases to adapt and move between species. When rapidly altered, the health and integrity of our ecosystems increases risk and requires a One Health approach to prevention and preparedness to address hazards from infectious diseases, antimicrobial resistance and food safety.

The core organisations in Wales who make up the health protection system that deliver and/or commission health protection preparation, prevention and response as part of their remit are:

• Welsh Government
• NHS Executive
• Public Health Wales
• health boards and primary care
• local authorities

These organisations are supported by specialised provision delivered by:

• Food Standards Agency
• Animal and Plant Health Agency
• Natural Resources Wales
• UK Health Security Agency
• Health and Safety Executive

Annex 1 provides more detail about each of these organisations.

The Health Protection System in Wales works within a UK and international system. Internationally, UK-wide work involves coordination and collaboration with the World Health Organisation (WHO), European Centre for Disease Prevention and Control (ECDC) and EU Member States.

Key elements of the UK approach, which apply to the health protection system in Wales, include the following.

The Public Health Protection and Health Security Framework

Agreed following the UK’s exit from the European Union to strengthen strategic and operational co-operation between the UK Government, the Devolved Governments and public health agencies of the UK. The agreement includes:

• work related to the prevention and control of serious cross border hazards, including surveillance and early alerting
• the sharing of data, information and intelligence to support emergency response, risk assessment and situational reporting
• public campaigns and messaging
• health security expertise pertinent to mitigating new, emerging or future public health hazards, including cybersecurity

Biological Security Strategy

In recognition that biological hazards include a wide range of infectious diseases that pose health and wellbeing risks to the population, the Biological Security Strategy’s vision is that by 2030 the UK is resilient to a spectrum of biological hazards and a world leader in innovation.

One of the workstreams being developed under the BSS is the National Biosurveillance Network, which aims to connect syndromic, epidemiological and promising environmental surveillance capabilities, in order to have more comprehensive monitoring of hazards over time.

The UK National Action Plan for Antimicrobial Resistance (AMR), "Confronting antimicrobial resistance 2024 to 2029"

The plan builds on work undertaken in the previous 5 year plan to reduce the negative impact of AMR in the UK and globally. The plan takes a co-ordinated approach across the four nations and incorporates action across human health, animal health, agriculture and the environment.

AMR has been declared by the WHO as being one of the top ten global public health hazards facing humanity. If AMR continues to spread, some infectious diseases, which in the UK would normally be simple to treat with an antibiotic, may become significant new causes of morbidity and mortality. This will have a major impact on the health and care system.

A new Respiratory Pandemic Plan

The plan, that's being developed by the 4 nations, builds on learning from the COVID-19 pandemic to update and broaden the original Pandemic Influenza Plan to consider any respiratory pathogen. The intention is that similar plans will be developed to consider other modes of transmission.

Disease elimination

All member states of the WHO European Region have a longstanding commitment to eliminate measles and rubella primarily through high uptake of measles, mumps and rubella (MMR) vaccine. The UK Health Security Agency (UKHSA) is responsible for collating and submitting evidence annually to UK and WHO regional verification committees.

Specific diseases such as HIV, viral hepatitis, sexually transmitted infections and TB continue to pose a major public health burden in the European Region, affecting millions of people and causing premature mortality. As a global health partner, Wales is committed to the priority actions set out in the World Health Organization (WHO) Europe Regional Action Plans for these key global disease epidemics.

The Welsh Government has committed to ending HIV transmission in Wales by 2030 and to take a zero-tolerance approach to HIV-related stigma and discrimination. The Welsh Government has also made specific commitments to meet the WHO elimination targets for Hepatitis C, Hepatitis B and Tuberculosis (TB) by 2030.

Environmental hazards to human health

Including GB wide chemicals legislation under the provisional common framework for chemicals and pesticides.

Key elements of the strategic context in Wales include:

The Well-being of Future Generations (Wales) Act

Includes goals to have a prosperous resilient healthier Wales that is more equal, cohesive and globally responsible. Commits public bodies in Wales to think about long term impacts and to work in collaboration to sustainably develop our systems in Wales.

A Healthier Wales

The Welsh Government’s long-term plan for transforming health and social care in Wales. It sets out a long-term future vision of a ‘whole system approach to health and social care’, which is focussed on health and wellbeing, and on prevention.

The Health and Social Care (Quality and Engagement) (Wales) Act

The act came into force in April 2023 and placed an overarching duty of quality regarding health-based functions. Our healthcare system in Wales should ensure the decisions they make are:

• safe
• timely
• effective
• efficient
• equitable
• person-centred

Together for a Safer Future: COVID-19 – Wales long term transition from pandemic to endemic

Published by Welsh Government in March 2022. The plan placed a clear and enduring emphasis on protecting the most vulnerable in our society from serious disease.

The National Immunisation Framework

Published in October 2022, this set out our ambitions for continued vaccination transformation, with a deepening of integration to improve service provision for everyone in Wales. The National Immunisation Framework sits alongside this Health Protection Framework.

HIV Action Plan for Wales 2023 to 2026

Published in March 2023, sets out 30 key actions to deliver our goal of zero new transmissions of HIV in Wales by 2030 and to tackle the stigma experienced by those living with HIV.

Legislation and strategies to protect human health from environmental hazards

This includes:

• the National Air Quality Strategy, which describes how we are addressing air pollution challenges
• the Environment (Air Quality and Soundscapes) (Wales) Act 2024, which seeks to improve the quality of our air environment and soundscape, including reducing the impacts of airborne pollution on human health, nature, the environment and our economy

The health protection system in Wales will prepare, prevent, and respond to existing, emerging and future health protection hazards in order to protect the people of Wales, minimise risk and harm, promote health and save lives. It will also support communities to recover.

Preparation

Preparation at local, regional and national levels will ensure we have the right people, plans, capabilities and countermeasures in place. Through effective preparation, we have assurance that our health protection system is agile and resilient, and promotes consistency of outcome for people across Wales.

Preparedness arrangements should be:

• co-produced by relevant partner organisations so that the health protection system collectively understands and is ready to scale up to respond to hazards
• informed by evidence and insight including embedding lessons learnt and recommendations from exercises and response to a range of hazards
• regularly reviewed, exercised, evaluated and updated
• horizon scan and be adaptable to new and emerging hazards
• linked to wider emergency planning and civil contingencies arrangements

Prevention

Prevention will mitigate the risks of health protection hazards, especially for vulnerable people, and will reduce avoidable morbidity and mortality. Some people are more at risk of a poor clinical outcome from health protection hazards than others and require tailored approaches to ensure appropriate action is taken.

The system will work together to understand and deliver primary, secondary and tertiary prevention. Primary prevention helps prevent communicable disease cases and outbreaks, and environmental incidents. Secondary prevention prevents onward transmission of communicable disease or secondary impacts to the environment. Tertiary prevention reduces the risk of serious illness. The system will embed these preventative actions in both health and wider policy objectives to effectively protect the population in the long term and achieve the goals of the Well-being of Future Generations Act. The healthier our population is, the better our defence against current, emerging and future hazards.

Prevention should be:

• embedded in guidance, policy and standard operating procedures having been influenced and shaped by relevant organisations
• reviewed following insights from debrief processes
• communicated effectively for people to make informed choices and decisions in relation to the communicable and environmental risks that may affect health

Response

Response to communicable disease and environmental incidents will risk assess and implement required public health action to protect individuals and communities in Wales.

The health protection system will work together collectively, locally and nationally to address both acute and chronic health protection hazards. The system will use understanding from preparedness arrangements to ensure the right level of responses as required. Actions taken as part of a response will consider and address inequities and inequalities, seeking to improve outcomes for all.

Response arrangements should be:

• delivered safely, equitably and in a timely and person-centred way that reduces inequalities and inequity
• underpinned by appropriate information sharing between relevant organisations
• enacted in line with national plans so that partners have a shared understanding of processes, leadership and partnership working

Recovery

Recovery will support workforce wellbeing, community rehabilitation and resilience, longer term impacts on population health and environmental restoration.

Sustaining a response while changing focus to other acute and long-term priorities as an emergency evolves has a recognised impact on our workforce and processes. Standing down a response is a crucial stage as the system transitions to business as usual.

Recovery should:

• encourage partners to support each other in order to both transition to business as usual and to implement recommendations
• be considered and prepared for in advance of standing down response arrangements
• be supported by established debrief processes to help transition from response to business as usual
• recognise any ongoing impacts and support needs for communities, the environment and other organisations in the health protection system

To achieve our vision, we aim to achieve the following strategic outcomes. These strategic outcomes are central to our preparation, prevention, response and recovery, whatever hazard we face.

Governance and accountability

Governance and accountability arrangements are clear and include risk assessment and mitigation, ensuring lessons are learned. The system is organised efficiently in order that lines of communication, and decision-making fora and process are well understood and trusted.

Effective leadership

Effective leadership is provided by all partners in the system to safely and effectively prepare, prevent and respond to existing and emerging hazards.

Partnership working

Partnership working is aided by clear well understood roles and responsibilities. Effective collaboration minimises duplication of effort across Wales and maximises the benefit to the population.

Agile and resilient workforce

An agile and resilient workforce with the right skill mix is available at a national, regional and local level to deliver routine health protection work and emergency response.

Excellent services and functions

Excellent services and functions are delivered safely, equitably and in a timely and person-centred way that reduces inequalities.

Digital capabilities

Digital capabilities are continuously developed and improved to enable effective and efficient case and incident management across health protection and the delivery of vaccination programmes.

International, national and regional surveillance

International, national and regional surveillance for hazards and health outcomes is regularly captured, analysed and shared with partners in a timely way to provide insight that informs planning, policy and interventions.

Communication and public information

Communication and public information is relevant, timely and designed to help people to make informed choices and decisions in relation to the communicable and environmental risks that may affect their and families health.

Research and innovation

Research and innovation inform system development, and the evidence base is strengthened in collaboration with academic partners.

Each organisation in the health protection system has a broad remit and responsibilities as detailed in Annex 1. This section builds on current practice to highlight the arrangements, roles and responsibilities that will help us to achieve our strategic outcomes, working in partnership through a whole system approach.

Whilst it is impossible to anticipate every future hazard to the health of the population of Wales, achieving our strategic outcomes will help to ensure the system is resilient to future challenges and has effective governance and accountability structures. These structures will enable appropriate partner representation from the outset and an efficient transition from preparation to response and recovery.

Governance and accountability arrangements are clear and include risk assessment and mitigation, ensuring lessons are learned. The system is organised efficiently in order that lines of communication, and decision-making fora and process are well understood and trusted.

Regional governance and accountability

Each organisation remains accountable to its own governance and accountability structures. For example, health protection functions in local authorities report into public protection governance structures and are accountable to their elected members. Health protection functions in health boards report to health board governance structures.

However, health boards and local authorities work together using an evidence-based approach to agree regional health protection priorities based on a shared understanding of data and intelligence for their population. Regional priorities will also consider national priorities and horizon scanning. Public Health Wales is expected to provide appropriate and timely data and input to assist in regional planning.

Cross-regionally, health boards and local authorities, together with other national partners like Public Health Wales and Natural Resources Wales, engage with Local Resilience Fora to plan and prepare for incidents and emergencies.

National oversight

The Welsh Government will continue to monitor delivery of health protection functions and any related deliverables from the NHS Planning Framework through regular monitoring meetings with all relevant NHS organisations and regional partners where responsibility and accountability is shared.

The Welsh Government monitors countermeasures stockpiles via its Countermeasures Oversight Board, which has representation from NHS Executive and NHS Wales Shared Services Partnership, who are responsible for the operational management of the stockpiles.

Feedback from monitoring meetings forms part of the Welsh Government’s broader health board accountability arrangements including Joint Executive Team (JET) meetings, and Integrated Quality, Planning & Delivery (IQPD) meetings.

Regional representatives feed into national groups usually via professional representatives. For example, All Wales Expert Panels (communicable diseases, port health, pollution, housing and food safety) are led by local authorities and report into Environmental Health Wales and on to the Directors of Public Protection Board. Senior representatives from organisations across the health protection system in Wales feed into the Health Protection Advisory Group (HPAG), chaired by the Chief Medical Officer (CMO).

HPAG aims to secure wide integration and effective implementation of health protection policies, maintain an overview of the work of health protection and drive forward the health protection agenda. It seeks assurance that health protection risks are being managed effectively by the relevant statutory organisations. Key groups report to HPAG to ensure the visibility of a wide spectrum of activity related to health protection. This includes:

• communicable disease
• environmental public health
• one health
• screening and vaccination

At an operational level, regional leads, Environmental Health Wales, Welsh Government and Public Health Wales come together at the Health Protection Operational Readiness Group (HPORG) to discuss any operational risks, issues and opportunities.

Effective leadership is provided by all partners in the system to safely and effectively prepare, prevent and respond to existing and emerging hazards

Leadership

All partners contribute to system leadership and partnership working through membership of relevant groups as noted above, such as HPAG.

Welsh Government determines national policy and national strategic priorities, leading to the production of legislation, advice, plans or instruction to the wider system as required. Welsh Government allocates resources in line with those strategic priorities and monitors delivery, progress and outcomes.

The Welsh Government takes a leadership role in UK wide health protection policy and strategy, working closely with UK Government and the UK Health Security Agency as well as with colleagues from other devolved nations.

Public Health Wales provides a leadership role at a UK and global level as Wales’ national public health agency. It provides input to UK incidents or contingency planning groups through attending incident management teams, strategic groups and subgroups as relevant. and onwards communication of relevant information to Welsh partners.

The Chief Medical Officer (CMO) works within Welsh Government to provide advice to ministers and officials on public health matters and provide clinical leadership to the profession in Wales.

The Public Health Directors Leadership Group is an opportunity for the CMO and Deputy CMO to meet regularly with senior leaders across the health protection system. These meetings allow for the sharing of ideas and challenges at a strategic level, and for discussion and feedback about policy as it develops. Directors of Public Health in health boards and Directors of Public Protection in local authorities play a pivotal role in leading the health protection agenda in their organisations. Public Health Wales has a key national leadership role in ensuring organisations have relevant data, as well as national guidance for local action to be taken.

Incidents and outbreaks

For acute challenges, where a hazard has been identified for which the system needs to prepare at pace, a national Incident Management Team (IMT) structure should be stood up in accordance with the relevant response plan. This structure should be stood up to enable multi-agency information sharing, preparation and response.

For rising tide incidents, Welsh Government, in line with the arrangements set out in the Communicable Disease Outbreak Control plan, will convene a Health Policy Oversight Cell which brings together relevant leads to consider required actions. Public Health Wales will establish a parallel group to consider operational readiness.

Longer term or chronic challenges should be addressed within the current HPAG structure and its subgroups. HPAG can choose to convene a bespoke task and finish group, if needed.

Partnership working is aided by clear well understood roles and responsibilities

Partnership working

Partner organisations work together and collaborate to minimise duplication of effort and maximise the benefit to the population. Depending on the context, collaboration can be on an informal basis, via existing partnership groups and structures, or exceptionally by creating new groups or structures as required.

Where local incidents or cases require additional support and/or an ongoing response, local and regional partners and Public Health Wales work together to enhance the local response. Welsh Government funds a National Surge Team, based at Cardiff Council, which works closely with Public Health Wales.

In emergency planning, resilience and response (EPRR), local authority emergency planners engage with Welsh Government, Public Health Wales, health boards and other partners through local resilience fora (LRFs) to horizon scan and coordinate activities. In response to an emergency where there is an impact on public health, EPRR teams attend and establish multi-agency partnerships in line with civil contingencies arrangements.

Response plans

All organisations in the health protection system have up-to-date and tested preparedness plans in place to scale up in the event of a future hazard, including a future pandemic scenario. The NHS Executive seeks assurance that health boards and Public Health Wales have relevant plans such as emergency response plans, major incident plans, and countermeasures deployment plans, exercising arrangements together with adequately trained staff.

All partners respond to outbreaks and incidents using the agreed process outlined in the "Communicable disease outbreak control plan for Wales" and the "Managing public health risks from environmental incidents: guidance for Wales". These plans set out in detail how the system works together to respond to health protection incidents in Wales and were updated in partnership in 2023.

Health boards and local authorities, together with Public Health Wales and Natural Resources Wales are Category 1 responders under the Civil Contingencies Act (2004). Responders are obligated to assess the risk posed by emergencies and major incidents, put in place emergency plans, communicate with, warn and advise the public, and share information and cooperate with other responders. Plans should be sound and proportionate to risk.

Exercises

Partners work together to regularly exercise and update preparedness and response plans at local, regional and national level, linked to wider emergency planning and civil contingencies arrangements. All relevant partners contribute to multi-agency plans, exercises and incident debriefs to inform preparedness and future practice.

Welsh Government provides strategic leadership setting direction for national exercises, including co-ordinating the Welsh input into 4 Nations exercises to test preparedness and emergency plans and arrangements.

Public Health Wales co-ordinates and contributes to national exercises with partners to test preparedness and emergency plans and arrangements for communicable disease hazards.

Members of the Environmental Public Health (EPH) HPAG sub-group, which includes representation from NRW and Water Health Partnership, co-ordinate and contribute collaboratively to national exercises to test preparedness for managing the public health risks from environmental incidents.

An agile and resilient workforce with the right skill mix is available at a national and local level to deliver routine health protection work and emergency response

Funding

Welsh Government provides core funding for health boards and Public Health Wales to support national and local health protection, and the delivery of the actions outlined in "A healthier Wales".

Regional decisions are taken to delegate some of this funding to local authorities where this best supports local and regional health protection structures.

Workforce planning

All organisations sustain capacity to provide multi-disciplinary skills and expertise to fulfil their legal and mandated roles and responsibilities, recognising that there will be peaks of activity through the year according to national and regional demand.

To be able to respond to future hazards, organisations have clear plans in place to be able to both deploy and scale up the workforce required across the health protection system. This may include mutual aid arrangements, redeployment plans and/or reservist models. Plans recognise how any required training, processes and structures will be delivered so that capacity can be in place in a short timeframe.

Training and skills

All organisations provide access to training so that staff can maintain professional competency and, subsequently, each organisation can continue to fulfil their legal and mandated roles and responsibilities.

In addition, cross-organisational training strengthens the knowledge and understanding of how the health protection system works together to respond to a breadth of health protection hazards. For communicable disease, Public Health Wales provides bespoke training to internal and external partners on health protection principles and skills to ensure capability and competence in the public health and public protection workforce, including requirements to maintain professional registration.

Capacity and capability are kept under review and will be shaped by emerging evidence and best practice, for example the forthcoming output of the 4 Nations Health Protection Oversight Group workforce planning workstream.

Wider partners in health protection

Welsh Government, Public Health Wales, health boards and local authorities work with other organisations to support public health protection where appropriate. For example:

• with the Food Standards Agency Wales (FSA) in the investigation of food borne outbreaks, where FSA will provide advice and/or scientific risk assessments to ensure that any remedial action takes account of food safety issues
• with the Animal and Plant Health Agency where there is a link to animal or plant health
• with Natural Resources Wales (NRW) on environmental public health or pollution incidents, where NRW is accountable for controlling environmental pollution through issuing permits and enforcing compliance
• with the UK Health Security Agency (UKHSA) on chemical, radiation and nuclear risk assessment and public health management
• with the Health and Safety Executive (HSE) where there are health and safety considerations including at major hazard sites and factories
• with Care Inspectorate Wales to help drive improvement in social care services, and Healthcare Inspectorate Wales to help drive improvement in health services

Excellent services and functions are delivered safely, equitably and in a timely and person-centred way that reduces inequalities

Inequity and inequality

All partners understand the importance of addressing equity of access and opportunity and work together locally and nationally to support and deliver actions towards this aim. Many of the wider determinants of health have an impact on a person’s risk of morbidity and mortality from communicable disease and environmental hazards. All organisations consider these factors when addressing inequalities and inequities.

Local authorities are key partners in providing local intelligence and insight on community enablers and barriers to enable effective response and to prevent disease transmission in a person-centred way that reduces inequalities.

Health boards ensure a high take up of vaccination across programmes, including by ensuring equitable access to and opportunity for vaccination in accordance with The National Immunisation Framework for Wales and Welsh Health Circulars.

Approaches to prevention of health protection hazards and exposures, and resulting ill health, should be informed by models such as the Prevention-based Health and Care Framework. This model aims to drive policy into practice to achieve a tangible shift towards prevention in health and care. In turn, this focus will contribute to delivering services and functions in a person-centred way that reduced inequalities and inequities.

Acute response service

Public Health Wales provides an acute response service 24 hours a day, 365 days per year for both communicable disease and environmental incidents. This service includes providing expert risk assessment to ascertain and undertake appropriate public health actions required. This also includes supporting and advising partners (such as Environmental Health Officers and healthcare professionals) to interpret, manage, and communicate risk.

Sampling and testing

Health boards provide timely and effective access to diagnostic, treatment and care services, to their populations including to inclusion health groups and to those seeking sanctuary (including infectious disease screening and catch-up vaccination). Where testing of patients in healthcare settings is required, Health boards and/or GP services undertake sampling for the purpose of diagnosis of communicable disease.

Local authorities, Natural Resources Wales, the Food Standards Agency and the Drinking Water Inspectorate undertake Food, Water, Air and Environmental Sampling as appropriate in environmental incidents. Local authorities also undertake community sampling and manage cases of gastrointestinal infections and food poisoning.

Where community sampling is required for other pathogens, either for case or incident management, sampling is agreed by discussion between health boards and Public Health Wales on a case-by-case basis and arrangements are made to transport samples in a timely way to appropriate testing facilities.

Appropriate testing facilities include Public Health Wales infection services laboratories, accredited health board laboratories and reference laboratories. Clinical samples are processed for the purposes of diagnosis of suspected acute communicable disease. Public Health Wales infection services provide advice to the wider infectious disease and health protection community on differential diagnoses, sample types, and treatment.

There is a clear desire for the system to work together to standardise responsibility across Wales for the different types of sampling in the future. Public Health Wales will lead on developing alongside partners multi-agency standard operating procedures to clarify processes. Once agreed, these will be agreed and signed off by HPAG. Public Health Wales will keep this advice and guidance up to date working with the wider system in Wales.

Wider local authority services and functions

Local authorities provide a range of services and functions that play an essential role in health protection. Some of these functions relevant to the scope of this framework include:

• air quality management, contaminated land identification and remediation, and permitting of defined industrial processes
• infection prevention and control in nurseries, schools and care homes
• regulation including risk assessment and sampling of private water supplies
• regulation of tattooists (including semi-permanent make-up), acupuncture, electrolysis and body piercing providers to prevent blood borne viruses and bacterial infection
• inspection and management of zoonoses at petting zoos, farm parks and visitor attractions

Port health

Local Authorities are required to appoint ‘Proper’ Officers from the Health Authority (Public Health Wales) for the purposes of Public Health (Control of Disease) Act and Regulations made under the 1984 Act.

Local Authorities (LA) or Port Health Authority (PHA) at the port of landing/berthing for arriving vessels or aircraft (into the UK) discharge public health management responsibilities. This includes screening of the master’s/captain’s pre arrival medical declaration of health notifications. The LA/PHA will refer relevant communicable disease information on to Public Health Wales (PHW) where public health concerns exist. PHW will strategically assess the information and engage with appropriate NHS boards, trusts and other relevant public authorities, proportionately, to the identified risk. Restrictions on disembarking passenger and crew or redirecting the vessel/aircraft can be implemented.

Where no concern exists the LA/ PHA Authorised Officer may notify free pratique to the vessel.

Where such a medical declaration of health (MDH) is received the LA/PHA shall inspect the arriving vessel.

International sea going vessels must hold a valid Ship Sanitation Certificate, which must be renewed every 6 months. LA/PHA’s may upon request conduct a Public Health inspection in line with the IHR requirements and issue a Ship Sanitation (Exemption, Control or Extension) certificate. This function includes sampling of water or food onboard. Local authority staff or Proper Officers are referred to as Authorised Officers.

Additional duties of medical evaluation of crew or passengers based on suspicion of communicable illness may be requested by the Vessels Master or Captain and undertaken by a Medical Officer. This is now taken to mean an intervention by a NHS board or trust, or other medical practitioner under the guidance of PHW.

Notification and international obligations

Local authorities appoint ‘Proper Officers’ in accordance with the current Health Protection (Notification) Regulations, taking notifications of infectious disease. Public Health Wales undertake the Proper Officer role and function on behalf of the local authorities.

Under the International Health Regulations (IHR) (2005), Public Health Wales liaises with the UK Health Security Agency as the UK IHR focal point to report any significant, unexpected cases of disease, and request other member states undertake public health action for cases/contacts no longer in Wales.

Medicines for health protection purposes

The people of Wales have quick access to necessary treatment and intervention when they require medicines for public health purposes (including chemoprophylaxis, immunoglobulin, antivirals and vaccination).

Public Health Wales produces clinical guidance and will ensure processes to access health protection medicines are clear and up to date, with multi-agency deployment plans, including agreed pathways for prescribing and distribution.

Health boards ensure staff are trained and know how to access relevant health protection medicines when required.

Welsh Government determines which stockpiles of medicines and equipment should be maintained for emergency use, planning with UK Government and the other devolved nations. NHS Wales Shared Services Partnership monitors and maintains the stockpiles at the required levels.

Infection Prevention and Control (IPC) and Personal Protective Equipment (PPE)

All services and functions are delivered in line with relevant infection prevention and control guidance to protect staff and other patients from communicable diseases.

Public Health Wales provides relevant Infection Prevention and Control (IPC) guidance. Health boards, primary care services and other clinical services ensure staff are trained how to use appropriate PPE in line with guidance.

Welsh Government determines the level of PPE stockpile that should be maintained for pandemic/emergencies. NHS Wales Shared Services Partnership monitors and maintains stockpiles at the required levels and distributes to agreed local storage and distribution centres.

Digital capabilities are continuously developed and improved to enable effective and efficient case and incident management across health protection and the delivery of vaccination programmes

Digital infrastructure

Digital infrastructure facilitates data and information sharing across partner organisations.

Welsh Government funds digital infrastructure and will consider and where appropriate fund developments in digital case recording and vaccination systems. Public Health Wales is leading development of options for a new case and incident management system for health protection which will have the capability to appropriately manage routine cases and incidents and be scaled up to an enhanced response, a large outbreak or a pandemic.

Data and information sharing

All organisations are committed to good information governance practices. Data sharing agreements are in place to enable cross-organisational working within Wales and where appropriate with other organisations across the 4 nations.

International, national and regional surveillance for hazards and burden of disease is regularly undertaken and all relevant data is captured, analysed and shared in a timely way to provide insight to inform planning, policy and interventions

Surveillance

World class research, evidence, scientific advice and horizon scanning aids policy and operational decisions. Communicable diseases and other hazards do not respect borders, so we work with other nations of the UK and internationally to inform and learn from UK-wide and international surveillance.

An effective combined surveillance system provides timely information to aid risk assessment and risk management decisions and is critical to facilitating an effective response. Public Health Wales undertakes surveillance of all aspects of health protection including primary surveillance, sentinel surveillance, vaccination uptake, and genomics. This includes epidemiological expertise and supporting and initiating mass event surveillance. Regular situational awareness reports are provided to Welsh Government, partners across the health protection system in Wales and other UK public health agencies.

Public Health Wales distributes test kits to notified cases of measles, mumps and rubella for surveillance purposes. UK Health Security Agency also sends test kits for measles in order to comply with elimination plans.

Regionally, health boards and local authorities have a key role in intelligence sharing, reviewing surveillance data and horizon scanning.

Partner organisations including the Food Standards Agency in Wales and Natural Resources Wales undertake their own surveillance and horizon scanning, sharing relevant information with partners across the health protection system as appropriate.

Genomics

Pathogen genomics provides an unambiguous mechanism to identify and describe the scope of an outbreak, and to track/map transmission at a range of scales. Genomic data is used to support the process of identifying and managing outbreaks. The Public Health Wales genomics service provides a key tool for quality assurance and development of diagnostic tests.

Genomics are also required in some patient populations to ensure that the treatment patients are receiving is matched to drug resistances in the pathogen that is infecting them. PHW provides genomics data to clinicians to help inform treatment.

Disease elimination

Public Health Wales provides system leadership and subject matter support on disease elimination plans across Wales which consist of a range of preventative interventions and wider health and social care service developments. This includes proactively sharing intelligence, surveillance, best practice and evidence-based approaches across the system.

Health boards provide vaccination services to prevent disease and clinical services to treat these diseases and have integrated health protection teams to support awareness raising, prevention, testing and incident and outbreak response.

Local authorities and health boards are jointly signing up to the Paris Declaration to create regional Fast Track collaborations to support the goals in relation to HIV, viral hepatitis, sexually transmitted infections and TB.

The Welsh Government provides direction and monitors progress through disease specific Oversight Groups which report to the Communicable Disease Subgroup of the Chief Medical Officer’s Health Protection Advisory Group.

Healthcare associated infections and antimicrobial resistance

The 2024 to 2029 UK AMR national action plan (NAP) aims to reduce the need for and unintentional exposure to, antimicrobials through a whole systems approach to infection and prevention control, improved diagnostics and treatment. Health boards, primary care services and other clinical settings all work in line with the NAP through their infection prevention and control practices and antimicrobial stewardship. Health boards provide leadership and specialist advice for healthcare services across their region. Welsh Government and Public Health Wales have a policy and strategic role in enacting the national plan.

Public Health Wales Healthcare Acquired Infections, Antimicrobial Resistance and Prescribing Programme (HARP) undertakes surveillance of healthcare associated infections (HCAIs) and antimicrobial usage and resistance producing information for action. It also provides support to stakeholders to improve antimicrobial prescribing and reduce the burden of infection through the Antimicrobial Stewardship and Infection Prevention and Control Guidance and Advice.

Communication and public information is relevant, timely and designed to help people to make informed choices and decisions in relation to the communicable and environmental risks that may affect their health

Communications campaigns

Public Health Wales and Welsh Government communications teams work effectively together to ensure public messaging is coherent, timely and accurate. Effective communication will incorporate evidence-based advice and support across all areas of health protection to both the general public, and to specific settings, on a wide range of interventions aimed at preventing harm to health.

Public Health Wales works with Welsh Government and relevant partners to lead on communication activity and awareness campaigns relating to a range of topics, including, but not limited to:

• specific incident and outbreak communication strategies
• new vaccination programmes and improving public vaccination literacy
• infectious disease awareness (such as TB or Hepatitis C)
• environmental hazards (for example, air pollution, carbon monoxide exposure, lead exposure, extreme weather)

Reactive communication will be drafted in line with standard operating procedures, "Communicable Disease Outbreak Control Plan for Wales" and the "Managing public health risks from environmental incidents: Guidance for Wales", as appropriate.

Behavioural science

A behavioural science lens should be used to maximise the impact of public communication. Messaging will be crafted to meet the communication objectives and, where possible it will be piloted and evaluated.

PHW have a behavioural science unit (BeSci) which provides specialist expertise on behavioural science, and developing the application of it, to improve health and wellbeing in Wales.

Accessibility

Public information, whether this is provided by Welsh Government, Public Health Wales or partners, takes a person-centred approach and considers accessibility to improve equity of outcomes. It should be proactively co-produced with relevant stakeholders, including the public, where possible.

Welsh Government and PHW will proactively engage with at risk groups. For example, by working collaboratively with Older People’s Commissioner, Children’s Commissioner, Disability Wales, neurodiversity networks, BAME networks and underserved populations to understand issues affecting them, ensuring guidance and communications are relevant and accessible to all.

Research and innovation inform system development, and the evidence base is strengthened in collaboration with academic partners

Evidence base

All organisations in the health protection system have a role in contributing to innovation, improvement and the evidence base. The system will take action based on evidence and insight, develop through continuous innovation and improvement, and use lessons learnt to aid post-response recovery.

All partners will have their own research and evaluation interests that should be strengthened through academic and industry partnerships.

Welsh Government has strategic leadership of research programmes that support risk assessment, effective management and horizon scanning for the CMO and policy teams.

Research and evaluation should be shared across the health protection system to relevant partners.

Improvements in technology

Public Health Wales will continue to innovate and improve diagnostic testing, microbiology procedures and genomics.

Welsh Government provides strategic leadership for life sciences in Wales. Partnerships should be strengthened with industry and academia to develop and adopt innovative solutions that benefit health and care outcomes.

This first iteration of the framework aimed to describe our strategic priorities and how the health protection system in Wales will work together for the people of Wales to minimise harm, save lives and promote wellbeing.

The framework will be reviewed on an on-going basis through the HPAG governance arrangements and formally reviewed every three years. Future iterations will take on board further learning from the COVID-19 Public Inquiry, exercises and managing incidents and outbreaks. Future iterations of the framework will aim to include a breadth of One Health elements and a wider scope to include broader Environmental Public Health elements.

To effectively act towards a common strategic direction, it is important to continue to foster a shared understanding of our health protection system, and to build on robust national and local partnerships. The health protection system in Wales includes, but is not limited to, the following organisations. The following describes an overview of their health protection functions within the health protection system in Wales, but it is recognised that each organisation has a broader remit.

Welsh Government (WG)

Acts as the system steward. As health is a devolved matter, Welsh Government determines national policy and strategic priorities, leading to the production of statute and legislation, advice, plans or instruction to the wider system. Welsh Government allocates resources in line with those strategic priorities and monitors delivery, progress and outcomes. The Chief Medical Officer (CMO) works within Welsh Government to provide advice to Ministers and officials on public health matters and provide clinical leadership to the profession in Wales.

NHS Executive

The role of the NHS Executive is to work in collaboration with NHS Wales to develop and implement policy and national evidence-based approaches/interventions to improve outcomes, inform Welsh Government on variation and support health boards not meeting performance expectations. The national functions and programmes of NHS Executive link into delivery to support the health protection system in Wales. This includes the Vaccination Programme Wales remit to provide NHS strategic planning, national delivery, assurance, evaluation and learning of all vaccination programmes across Wales, including the implementation of the National Immunisation Framework (NIF) and the assurance on emergency planning preparedness of the NHS within the NHS planning function.

Public Health Wales (PHW)

An NHS trust with statutory functions for both the provision of public health services and in relation to the health service in Wales. It provides national guidance and advice to policy leads, leads public health surveillance and works with partners to lead and co-ordinate the actions necessary to control public health outbreaks and the risks associated with environmental incidents. PHW provides acute services to respond to notifications of both communicable and environmental cases and incidents. PHW receives notifications of a range of communicable diseases (not restricted to the list of notifiable diseases in statute) and situations of public health concern, and undertakes the investigation and management in response, along with local authorities.

PHW provides scientific, technical, epidemiological, specialist health protection, public health and clinical (microbiology and virology) expertise into many partnership meetings and fora. PHW is an active member of a wide range of technical, expert, and UK-wide incident groups, such as HAIRS (Human Animal Interface Risk Surveillance) and UK Public Health Network for Zoonoses. PHW therefore plays a critical system leadership role in communicating emerging and developing risks and issues, as well as good practice, from these groups to Welsh Government and other system partners, so that appropriate system wide learning, improvements and mitigations can be considered and implemented.

Health boards (HBs)

NHS organisations which are responsible for provision of clinical services to meet the health and wellbeing needs of their local populations. Health boards clinically assess and treat patients who have been exposed to communicable and environmental hazards and prevent ill health through the delivery of vaccination and prophylaxis. Health boards work in partnership with PHW and local authorities, to contribute to both national and regional (health board footprint) preparedness, prevention, response and recovery.

GP services

Independent providers responsible for provision of clinical services to meet the health and wellbeing needs of their local populations. GP services clinically assess and treat patients who have been exposed to communicable and environmental hazards and prevent ill health through the delivery of vaccination and prophylaxis.

Local authorities (LAs)

Local authorities investigate, control and manage health hazards, including:

• notifiable infections
• food poisoning
• zoonotic infections and animal health
• environmental incidents
• incidents relating to drinking water

They have statutory responses associated with outbreak and hazard control, including:

• investigation
• control and management
• the prohibition of persons from work or other settings
• seizure, detection and prohibition of equipment and foods
• closure of premises

Local authorities also undertake public protection enforcement activity in a range of premises, including:

• powers of entry
• closing premises
• inspections
• risk assessments
• serving notices
• civil sanctions

Other key partners include:

• UK Health Security Agency (UKHSA): has a remit in Wales in relation to some matters reserved to the UK Government (for example radiation, medicines, national security risk assessment processes, and global health protection). UKHSA also acts as UK expert advisors on chemical, radiation and nuclear risk assessment and public health management.
• Food Standards Agency (FSA): an independent government department that operates in England, Wales and Northern Ireland to protect public health and consumers’ wider interests in relation to food. It is responsible for the systems that regulate food businesses and works closely with local authorities in Wales to help ensure food stays safe and gives guidance to explain the regulations and how they can be applied to food businesses. Responsibilities in the following policy areas have been devolved to Wales:
  • food and feed safety and hygiene
  • food compositional standards and labelling
  • nutrition and health claims, standards and labelling (Welsh Government)
• Animal and Plant Health Agency (APHA): an executive agency partly sponsored by Welsh Government which works to safeguard animal and plant health for the benefit of people, the environment and the economy.
• Natural Resources Wales (NRW): responsible for protecting the environment in Wales, but we also have responsibilities to improve wellbeing. NRW regulates business as well as providing advice and guidance to reduce their impact on people's health. NRW also responds to environmental incidents, for example air pollution, tree disease and flooding.
• Health and Safety Executive (HSE): an enforcing authority responsible for the health and safety at work in Great Britain. HSE regulates health and safety across a range of sectors and industries including major hazard sites. The Health and Safety (Enforcing Authority) Regulations 1998 allocate workplace activities to either HSE or LAs for enforcing health and safety legislation.
• Care Inspectorate Wales (CIW): the independent regulator of social care and childcare in Wales. CIW registers, inspects and takes action to improve the quality and safety of services for the wellbeing of the people of Wales.
• Healthcare Inspectorate Wales (HIW): the independent inspectorate and regulator of healthcare in Wales. HIW inspects NHS services and regulates independent healthcare providers against a range of standards, policies, guidance and regulations to highlight areas requiring improvement.
• NHS Wales Shared Services Partnership (NWSSP): have operational duties storing, distribution and managing stockpiles of personal protective equipment (PPE) and vaccinations.

[1] The working definition of environmental public health used by the Welsh Government and Public Health Wales encompasses all action:

to minimise exposures to, and resulting ill-health from, environmental hazards, and support the creation of healthy, fair and sustainable environments and communities.

[2] A communicable disease is:

an illness due to a specific infectious agent or its toxic products that arises through transmission of that agent or its products from an infected person, animal, or inanimate reservoir to a susceptible host. Transmission may be direct from person to person, or indirect through an intermediate plant or animal host, vector, or the inanimate environment.

Heymann DL, editor. Control of communicable diseases manual. 19th ed. Washington, DC: American Public Health Association; 2008.

[3] The World Health Organisation defines One Health as:

an integrated, unifying approach that aims to sustainably balance and optimize the health of people, animals and ecosystems.