The first 5 years of Part 2A Orders: the use of powers from court applications to protect public health in England 2010–15

The first 5 years of Part 2A Orders: the use of powers from court applications to protect public... Abstract Background Part 2A Orders are the legal means which allow local authorities (LAs), upon application to court, to exercise powers over persons, things or premises to protect public health. Methods We surveyed lead professionals involved in applications to understand the use and utility of such Orders since their inception in April 2010 to July 2015. Results All applications for Orders were granted; 29 for persons (28 for tuberculosis, 1 for HIV); these were renewed in 18 (18/25, 72%) cases up to seven times; 23 applications related to things (tattoo and piercing equipment); and three applications related to ‘premises’ (Escherichia coli 0137 on farm, faecal contamination). Use of the Orders against things occurred where there was failure of the Health and Safety Executive to transfer powers to LAs. Orders against persons were used as a last resort and renewed until treatment completion in the minority of cases (n = 3). One patient was detained under quarantine powers while assessing infectiousness. Significant difficulties in implementing the Part 2A Orders due to lack of resources, facilities and interagency collaboration were reported. Conclusions Part 2A Orders are used as a last resort but improved facilities for safe and secure isolation would help improve implementation. public health, tuberculosis Introduction Part 2A Orders were introduced in 20101,2 as the new legal mechanism under the Public Health (Control of Disease) Act 19843 to allow local authorities (LAs) to apply to a justice of the peace (JP) for various powers to protect public health. The changes made to the Public Health Act 1984 were part of wider legislative changes to ensure compliance with the Human Rights Act 19984–6 and the new International Health Regulations 2005.7 The powers encompass new and emerging infections and non-infectious threats in an ‘all hazards’ approach and were primarily legislated for in the Health and Social Care Act 20087–9 and then in the Health Protection (Part 2A Orders) Regulations 2010.1 Part 2A Orders can be applied for and used against persons (including coercive detention in hospital or other suitable establishment), things or places where voluntary co-operation and other methods to avert a risk or hazard are not possible. The new secondary legislation includes safeguards for persons subjected to Part 2A Orders, including the need for a JP to hear the application, the right to apply for revocation and a limit of 28 days to each order. One important feature of Part 2A Orders, considering the potential loss of freedom inherent in the Orders, is that each Order must be reported to Public Health England (PHE) (previously, the Health Protection Agency, HPA). We used these reports to identify key professionals involved in the application so as to undertake a web based survey to understand the current usage of the Orders. Methods The PHE register of Part 2A Applications was used to identify key professionals responsible for applications between 1 April 2010 and 31 July 2015. Consultants in Communicable Disease Control (CCDC) at PHE were identified for person-specific Part 2A Orders, and LA environmental health officers (EHOs) for premises-specific and thing-specific Part 2A Orders. A web based survey with questions requiring a combination of tick box and free text answers was developed and sent out via email to all lead professionals. Reminder emails were sent at 2, 4 and 6 weeks from the date of initial survey. Summary statistics were used to assess tick box responses and a thematic approach was used to summarize free text responses.10 The study was undertaken as part of a service evaluation of Part 2A Order use and so did not require formal ethical approval. Results During the study period, 29 person, 3 premises and 23 thing Orders were reported to PHE/HPA. The 53/55 (96%) completed questionnaires were returned. Two questionnaires for person-specific Part 2A Orders made in 2010 were not returned and missing data was included if available in the reports. The number of Part 2A Orders per year can be seen in Fig. 1. The demographics of persons subjected to orders, type of things and locations and disease specifics for premises can be seen in Table 1. Fig. 1 View largeDownload slide Numbers of Part 2A Orders reported to Public Health England (PHE) or Health Protection Agency (HPA) between 1 April 2010 and 31 July 2015. Fig. 1 View largeDownload slide Numbers of Part 2A Orders reported to Public Health England (PHE) or Health Protection Agency (HPA) between 1 April 2010 and 31 July 2015. Table 1 Type of Orders, demographics and circumstances of use. Order type Comment Number (% except where otherwise stated) Orders against persons n = 29*  Sex: male (n = 28) 26 (93)  Median age, years (IQR) (n = 27) 38 (28.5–42.5)  Disease: TB (n = 29) 28 (97)  MDR-TB and XDR-TB (n = 21) 9 (42)  Disease: HIV (n = 29) 1 (3)  Ethnicity (n = 26) White British 11 (42) Indian or Pakistani 4 (16) White other 6 (23) Black African 4 (15)  Extenuating circumstances leading to order (not mutually exclusive, n = 24) Homelessness 13 (54) Mental health issues 4 (17) Drug and alcohol issues 16 (67) Non-compliance with medication 18 (75) Ex-prisoner 1 (4) Chaotic life 1 (4) violence 1 (4) New diagnosis of MDR-TB 1 (4)  Number of orders renewed (n = 27) 18 (67)  Median number of renewals per order (range) (n = 27) 1 (0–7)  Number of orders with seven renewals 3  Powers requested (not mutually exclusive, n = 24) Medical examination 16 (67) Removed to hospital 21 (88) Detained in hospital 22 (92) Kept in isolation 14 (58) Be disinfected 1 (4) Wear protective clothing 5 (21) Provide information 9 (38) Have health monitored 7 (29) Attend training 2 (8) Subject to restrictions 5 (21) Abstain from work 0 Orders against things (n = 23)  Orders for tattoo equipment 22 (96)  Orders for piercing equipment 1 (4)  Number of orders renewed 0 Orders against place (n = 3)  Petting farm with E-coli 0157 1 (33)  Self-contained flat with faecal contamination 1 (33)  Flat with tattoo equipment inside to prevent blood born virus spread 1 (33)  Number of orders renewed 0 Order type Comment Number (% except where otherwise stated) Orders against persons n = 29*  Sex: male (n = 28) 26 (93)  Median age, years (IQR) (n = 27) 38 (28.5–42.5)  Disease: TB (n = 29) 28 (97)  MDR-TB and XDR-TB (n = 21) 9 (42)  Disease: HIV (n = 29) 1 (3)  Ethnicity (n = 26) White British 11 (42) Indian or Pakistani 4 (16) White other 6 (23) Black African 4 (15)  Extenuating circumstances leading to order (not mutually exclusive, n = 24) Homelessness 13 (54) Mental health issues 4 (17) Drug and alcohol issues 16 (67) Non-compliance with medication 18 (75) Ex-prisoner 1 (4) Chaotic life 1 (4) violence 1 (4) New diagnosis of MDR-TB 1 (4)  Number of orders renewed (n = 27) 18 (67)  Median number of renewals per order (range) (n = 27) 1 (0–7)  Number of orders with seven renewals 3  Powers requested (not mutually exclusive, n = 24) Medical examination 16 (67) Removed to hospital 21 (88) Detained in hospital 22 (92) Kept in isolation 14 (58) Be disinfected 1 (4) Wear protective clothing 5 (21) Provide information 9 (38) Have health monitored 7 (29) Attend training 2 (8) Subject to restrictions 5 (21) Abstain from work 0 Orders against things (n = 23)  Orders for tattoo equipment 22 (96)  Orders for piercing equipment 1 (4)  Number of orders renewed 0 Orders against place (n = 3)  Petting farm with E-coli 0157 1 (33)  Self-contained flat with faecal contamination 1 (33)  Flat with tattoo equipment inside to prevent blood born virus spread 1 (33)  Number of orders renewed 0 *Questionnaires on two person orders were not returned so some data only available for 27 people. Where data was available in the redacted application letters the information was used. If data not entered by respondent then the denominator is <27. Table 1 Type of Orders, demographics and circumstances of use. Order type Comment Number (% except where otherwise stated) Orders against persons n = 29*  Sex: male (n = 28) 26 (93)  Median age, years (IQR) (n = 27) 38 (28.5–42.5)  Disease: TB (n = 29) 28 (97)  MDR-TB and XDR-TB (n = 21) 9 (42)  Disease: HIV (n = 29) 1 (3)  Ethnicity (n = 26) White British 11 (42) Indian or Pakistani 4 (16) White other 6 (23) Black African 4 (15)  Extenuating circumstances leading to order (not mutually exclusive, n = 24) Homelessness 13 (54) Mental health issues 4 (17) Drug and alcohol issues 16 (67) Non-compliance with medication 18 (75) Ex-prisoner 1 (4) Chaotic life 1 (4) violence 1 (4) New diagnosis of MDR-TB 1 (4)  Number of orders renewed (n = 27) 18 (67)  Median number of renewals per order (range) (n = 27) 1 (0–7)  Number of orders with seven renewals 3  Powers requested (not mutually exclusive, n = 24) Medical examination 16 (67) Removed to hospital 21 (88) Detained in hospital 22 (92) Kept in isolation 14 (58) Be disinfected 1 (4) Wear protective clothing 5 (21) Provide information 9 (38) Have health monitored 7 (29) Attend training 2 (8) Subject to restrictions 5 (21) Abstain from work 0 Orders against things (n = 23)  Orders for tattoo equipment 22 (96)  Orders for piercing equipment 1 (4)  Number of orders renewed 0 Orders against place (n = 3)  Petting farm with E-coli 0157 1 (33)  Self-contained flat with faecal contamination 1 (33)  Flat with tattoo equipment inside to prevent blood born virus spread 1 (33)  Number of orders renewed 0 Order type Comment Number (% except where otherwise stated) Orders against persons n = 29*  Sex: male (n = 28) 26 (93)  Median age, years (IQR) (n = 27) 38 (28.5–42.5)  Disease: TB (n = 29) 28 (97)  MDR-TB and XDR-TB (n = 21) 9 (42)  Disease: HIV (n = 29) 1 (3)  Ethnicity (n = 26) White British 11 (42) Indian or Pakistani 4 (16) White other 6 (23) Black African 4 (15)  Extenuating circumstances leading to order (not mutually exclusive, n = 24) Homelessness 13 (54) Mental health issues 4 (17) Drug and alcohol issues 16 (67) Non-compliance with medication 18 (75) Ex-prisoner 1 (4) Chaotic life 1 (4) violence 1 (4) New diagnosis of MDR-TB 1 (4)  Number of orders renewed (n = 27) 18 (67)  Median number of renewals per order (range) (n = 27) 1 (0–7)  Number of orders with seven renewals 3  Powers requested (not mutually exclusive, n = 24) Medical examination 16 (67) Removed to hospital 21 (88) Detained in hospital 22 (92) Kept in isolation 14 (58) Be disinfected 1 (4) Wear protective clothing 5 (21) Provide information 9 (38) Have health monitored 7 (29) Attend training 2 (8) Subject to restrictions 5 (21) Abstain from work 0 Orders against things (n = 23)  Orders for tattoo equipment 22 (96)  Orders for piercing equipment 1 (4)  Number of orders renewed 0 Orders against place (n = 3)  Petting farm with E-coli 0157 1 (33)  Self-contained flat with faecal contamination 1 (33)  Flat with tattoo equipment inside to prevent blood born virus spread 1 (33)  Number of orders renewed 0 *Questionnaires on two person orders were not returned so some data only available for 27 people. Where data was available in the redacted application letters the information was used. If data not entered by respondent then the denominator is <27. Orders used against persons The median number of Orders each year was 5 (range: 2–8) (2011–14: full calendar years). Prior to the order Respondents were asked what steps were undertaken prior to the application. Overall, 83% (24/29) answered this question. And, 17 (17/24) commented that home visits were undertaken by outreach workers, TB organizations (e.g. find and treat), the physician or nurse. And, 17 (17/24) arranged a multidisciplinary team meeting (MDT) to discuss management strategies. In 8 (8/24) cases the patient was difficult to locate and was refusing all contact with services. Examples of other options were tried, e.g. directly observed therapy (DOT), cash incentives, ambulatory care. Examples of comments can be seen in Table 2. Table 2 Abstracts from free text comments from respondents. Question from the questionnaire Free text comments What steps were undertaken prior to the order? ‘Numerous attempts from local hospital consultant and his team and TB community nurse service to contact patient and invite him to attend clinic to start treatment once MDR-TB had a laboratory diagnosis. Once all attempts failed, the Consultant (medical) contacted me (PHE Consultant) and we discussed the situation and the plan of action.’ ‘He had gone home on DOT which he’d agreed to take, and had been referred to “Action for change” for help with his alcohol problem. However, since discharge the TB nurse had not been able to make contact with him—he had started drinking heavily again, and was not answering to calls or visits. …. A case conference was held to discuss the case; in which it was agreed that admission was necessary on public health grounds, but a part 2a order would be the final resort. Before this, a referral was to be made to mental health services by his GP; in view that alcohol use and possibly depression were important factors in his non-compliance with TB therapy. Also TB nurse would make further attempts to persuade case to come into hospital voluntarily….’ ‘At least two provision(s) of housing/hostel accommodation, DOT therapy—and numerous occasion trying to find case to observe DOT.’ ‘Incentives: Cash (via the TB Alert fund), Referral to a Polish speaking alcohol worker, Housing….’ Please comment on the difficulties in obtaining the order. ‘Main issue was transfer of PII (patient identifiable information) between agencies in real time—LA (Local authority) had no secure fax or drop box’ ‘co-ordination of relevant reports from medical team and completion of application.’ ‘as he (the patient) was already well known to services most of the services were disinclined to assist with this case-feeling that their priority lay with those that want to take up their services. Note: An amendment was put into the Part 2A re responsibilities for LA, Trust and CCG with regard to Part 2A and provision of services.’ ‘Agreement achieved after a lot of negotiation about the process with all organizations.…… The security staff and Police were concerned about the risk of catching TB. The Trust were very concerned about the financial implications. In court disagreements emerged about the terms of the order and tensions surfaced between different partners.’ Please comment on the difficulties implementing the order Interagency co-ordination ‘Ambulance Service refused to send the ambulance “patient’s life not in danger” and patient took advantage of me (Consultant in communicable disease) being engaged in difficult discussion with ambulance call centre to run away from the house. We then called the police but obviously there was no sign of the patient.’ ‘The patient’s location was identified and police and ambulance contacted to help with enforcing removal to hospital. However, in practice there was difficulty coordinating police and ambulance service when needed. In the end the patient travelled in a private car’ ‘The plan was to have a security guard at the door but this did not happen by the time patient arrived’ Lack of resources ‘(After multiple defaults) the Chief Executive of trust wrote to CCG (care commissioning group) and LA (local authority) saying that they would no longer have a bed for case.’ ‘No negative pressure rooms were available in the hospital where patient was diagnosed. Patient was sent to another hospital within the same Trust, although initially there was significant reluctance and resistance from this hospital.’ ‘unwillingness of hospital to pay for guard, PCT (Primary Care Trust) (finally paid).’ ‘if the patient had refused to comply with the order requiring them to stay in hospital—there was no ability to detain them—due to lack of ability to fund security guard presence—would have been faced with patient leaving, picked up by police, returned to hospital, patient leaving etc.’ Patient specific ‘Order obtained on 20.10… but case was not located until 31.10…. Found by the police’ ‘The patient absconded continually from the ward and we therefore in the end decided to attempt management at home restricting where he could go. That too failed because there was no sanction in law that we could use to enforce the order.’ ‘it was difficult to get the patient to abide by the order as he kept absconding from hospital to access alcohol and smoke. This also increased his risk of MDR-TB as DOTS (directly observed therapy) was compromised.’ ‘The patient was then a security risk for hospital staff being verbally and physically violent.’ ‘The patient was physically and verbally abusive—ASBO (anti-social behaviour order) obtained by LA (local authority).’ ‘On visiting the house of patient his female housemate displayed a more aggressive behaviour, probably due to the effect of intoxicating substances such as alcohol/drugs.’ Please comment on any problems with the service provided by the police ‘the police refused any involvement in this case as their occupational health advised them there would be a risk to them.’ ‘Police received inappropriate advice about PPE—unable to establish where they got this advice’ ‘A lot of discussion in HPZone notes (these are the Public Health England notes) suggesting police were unaware of what they were allowed to do in terms of bringing him back and level of force’ ‘Police involved saying that the part 2A order didn’t give them powers to remove him from the street only from an actual ‘place’. What were your aims in obtaining an order? ‘to keep a chaotic patient safe and support him to maintain medication to avoid the development of MDR-TB, second to prevent onwards transmission of a communicable disease.’ ‘Allowed us to make a proper assessment of the case who appeared to be a high risk TB case with lung cavities. The cases investigations were negative for TB and on reflection his cavity was probably from an old lung infection. The section was allowed to lapse and he was allowed to leave hospital, not before he had absconded on a number of occasions while waiting for the results of test(s).’ ‘to find out if the patient was currently smear positive and or not and how much screening was required for work contacts’. ‘to quarantine the patient until drug treatment for his condition was completed’ (7 re-applications) ‘to ensure 12 months of treatment so that he did not relapse again’ (7 re-applications) If you didn’t achieve your aims please comment further ‘We hoped to protect the public from this man whilst the police were preparing criminal charges. That didn’t happen but he did eventually go to prison. We completely failed to protect (the Public)……This was an unsatisfactory process. The law does not allow us to enforce the order in a meaningful way. 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. That these orders are probably not worth pursuing other than to put a marker in the sand.’ Question from the questionnaire Free text comments What steps were undertaken prior to the order? ‘Numerous attempts from local hospital consultant and his team and TB community nurse service to contact patient and invite him to attend clinic to start treatment once MDR-TB had a laboratory diagnosis. Once all attempts failed, the Consultant (medical) contacted me (PHE Consultant) and we discussed the situation and the plan of action.’ ‘He had gone home on DOT which he’d agreed to take, and had been referred to “Action for change” for help with his alcohol problem. However, since discharge the TB nurse had not been able to make contact with him—he had started drinking heavily again, and was not answering to calls or visits. …. A case conference was held to discuss the case; in which it was agreed that admission was necessary on public health grounds, but a part 2a order would be the final resort. Before this, a referral was to be made to mental health services by his GP; in view that alcohol use and possibly depression were important factors in his non-compliance with TB therapy. Also TB nurse would make further attempts to persuade case to come into hospital voluntarily….’ ‘At least two provision(s) of housing/hostel accommodation, DOT therapy—and numerous occasion trying to find case to observe DOT.’ ‘Incentives: Cash (via the TB Alert fund), Referral to a Polish speaking alcohol worker, Housing….’ Please comment on the difficulties in obtaining the order. ‘Main issue was transfer of PII (patient identifiable information) between agencies in real time—LA (Local authority) had no secure fax or drop box’ ‘co-ordination of relevant reports from medical team and completion of application.’ ‘as he (the patient) was already well known to services most of the services were disinclined to assist with this case-feeling that their priority lay with those that want to take up their services. Note: An amendment was put into the Part 2A re responsibilities for LA, Trust and CCG with regard to Part 2A and provision of services.’ ‘Agreement achieved after a lot of negotiation about the process with all organizations.…… The security staff and Police were concerned about the risk of catching TB. The Trust were very concerned about the financial implications. In court disagreements emerged about the terms of the order and tensions surfaced between different partners.’ Please comment on the difficulties implementing the order Interagency co-ordination ‘Ambulance Service refused to send the ambulance “patient’s life not in danger” and patient took advantage of me (Consultant in communicable disease) being engaged in difficult discussion with ambulance call centre to run away from the house. We then called the police but obviously there was no sign of the patient.’ ‘The patient’s location was identified and police and ambulance contacted to help with enforcing removal to hospital. However, in practice there was difficulty coordinating police and ambulance service when needed. In the end the patient travelled in a private car’ ‘The plan was to have a security guard at the door but this did not happen by the time patient arrived’ Lack of resources ‘(After multiple defaults) the Chief Executive of trust wrote to CCG (care commissioning group) and LA (local authority) saying that they would no longer have a bed for case.’ ‘No negative pressure rooms were available in the hospital where patient was diagnosed. Patient was sent to another hospital within the same Trust, although initially there was significant reluctance and resistance from this hospital.’ ‘unwillingness of hospital to pay for guard, PCT (Primary Care Trust) (finally paid).’ ‘if the patient had refused to comply with the order requiring them to stay in hospital—there was no ability to detain them—due to lack of ability to fund security guard presence—would have been faced with patient leaving, picked up by police, returned to hospital, patient leaving etc.’ Patient specific ‘Order obtained on 20.10… but case was not located until 31.10…. Found by the police’ ‘The patient absconded continually from the ward and we therefore in the end decided to attempt management at home restricting where he could go. That too failed because there was no sanction in law that we could use to enforce the order.’ ‘it was difficult to get the patient to abide by the order as he kept absconding from hospital to access alcohol and smoke. This also increased his risk of MDR-TB as DOTS (directly observed therapy) was compromised.’ ‘The patient was then a security risk for hospital staff being verbally and physically violent.’ ‘The patient was physically and verbally abusive—ASBO (anti-social behaviour order) obtained by LA (local authority).’ ‘On visiting the house of patient his female housemate displayed a more aggressive behaviour, probably due to the effect of intoxicating substances such as alcohol/drugs.’ Please comment on any problems with the service provided by the police ‘the police refused any involvement in this case as their occupational health advised them there would be a risk to them.’ ‘Police received inappropriate advice about PPE—unable to establish where they got this advice’ ‘A lot of discussion in HPZone notes (these are the Public Health England notes) suggesting police were unaware of what they were allowed to do in terms of bringing him back and level of force’ ‘Police involved saying that the part 2A order didn’t give them powers to remove him from the street only from an actual ‘place’. What were your aims in obtaining an order? ‘to keep a chaotic patient safe and support him to maintain medication to avoid the development of MDR-TB, second to prevent onwards transmission of a communicable disease.’ ‘Allowed us to make a proper assessment of the case who appeared to be a high risk TB case with lung cavities. The cases investigations were negative for TB and on reflection his cavity was probably from an old lung infection. The section was allowed to lapse and he was allowed to leave hospital, not before he had absconded on a number of occasions while waiting for the results of test(s).’ ‘to find out if the patient was currently smear positive and or not and how much screening was required for work contacts’. ‘to quarantine the patient until drug treatment for his condition was completed’ (7 re-applications) ‘to ensure 12 months of treatment so that he did not relapse again’ (7 re-applications) If you didn’t achieve your aims please comment further ‘We hoped to protect the public from this man whilst the police were preparing criminal charges. That didn’t happen but he did eventually go to prison. We completely failed to protect (the Public)……This was an unsatisfactory process. The law does not allow us to enforce the order in a meaningful way. 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. That these orders are probably not worth pursuing other than to put a marker in the sand.’ Words in Brackets have been added to aid understanding. Table 2 Abstracts from free text comments from respondents. Question from the questionnaire Free text comments What steps were undertaken prior to the order? ‘Numerous attempts from local hospital consultant and his team and TB community nurse service to contact patient and invite him to attend clinic to start treatment once MDR-TB had a laboratory diagnosis. Once all attempts failed, the Consultant (medical) contacted me (PHE Consultant) and we discussed the situation and the plan of action.’ ‘He had gone home on DOT which he’d agreed to take, and had been referred to “Action for change” for help with his alcohol problem. However, since discharge the TB nurse had not been able to make contact with him—he had started drinking heavily again, and was not answering to calls or visits. …. A case conference was held to discuss the case; in which it was agreed that admission was necessary on public health grounds, but a part 2a order would be the final resort. Before this, a referral was to be made to mental health services by his GP; in view that alcohol use and possibly depression were important factors in his non-compliance with TB therapy. Also TB nurse would make further attempts to persuade case to come into hospital voluntarily….’ ‘At least two provision(s) of housing/hostel accommodation, DOT therapy—and numerous occasion trying to find case to observe DOT.’ ‘Incentives: Cash (via the TB Alert fund), Referral to a Polish speaking alcohol worker, Housing….’ Please comment on the difficulties in obtaining the order. ‘Main issue was transfer of PII (patient identifiable information) between agencies in real time—LA (Local authority) had no secure fax or drop box’ ‘co-ordination of relevant reports from medical team and completion of application.’ ‘as he (the patient) was already well known to services most of the services were disinclined to assist with this case-feeling that their priority lay with those that want to take up their services. Note: An amendment was put into the Part 2A re responsibilities for LA, Trust and CCG with regard to Part 2A and provision of services.’ ‘Agreement achieved after a lot of negotiation about the process with all organizations.…… The security staff and Police were concerned about the risk of catching TB. The Trust were very concerned about the financial implications. In court disagreements emerged about the terms of the order and tensions surfaced between different partners.’ Please comment on the difficulties implementing the order Interagency co-ordination ‘Ambulance Service refused to send the ambulance “patient’s life not in danger” and patient took advantage of me (Consultant in communicable disease) being engaged in difficult discussion with ambulance call centre to run away from the house. We then called the police but obviously there was no sign of the patient.’ ‘The patient’s location was identified and police and ambulance contacted to help with enforcing removal to hospital. However, in practice there was difficulty coordinating police and ambulance service when needed. In the end the patient travelled in a private car’ ‘The plan was to have a security guard at the door but this did not happen by the time patient arrived’ Lack of resources ‘(After multiple defaults) the Chief Executive of trust wrote to CCG (care commissioning group) and LA (local authority) saying that they would no longer have a bed for case.’ ‘No negative pressure rooms were available in the hospital where patient was diagnosed. Patient was sent to another hospital within the same Trust, although initially there was significant reluctance and resistance from this hospital.’ ‘unwillingness of hospital to pay for guard, PCT (Primary Care Trust) (finally paid).’ ‘if the patient had refused to comply with the order requiring them to stay in hospital—there was no ability to detain them—due to lack of ability to fund security guard presence—would have been faced with patient leaving, picked up by police, returned to hospital, patient leaving etc.’ Patient specific ‘Order obtained on 20.10… but case was not located until 31.10…. Found by the police’ ‘The patient absconded continually from the ward and we therefore in the end decided to attempt management at home restricting where he could go. That too failed because there was no sanction in law that we could use to enforce the order.’ ‘it was difficult to get the patient to abide by the order as he kept absconding from hospital to access alcohol and smoke. This also increased his risk of MDR-TB as DOTS (directly observed therapy) was compromised.’ ‘The patient was then a security risk for hospital staff being verbally and physically violent.’ ‘The patient was physically and verbally abusive—ASBO (anti-social behaviour order) obtained by LA (local authority).’ ‘On visiting the house of patient his female housemate displayed a more aggressive behaviour, probably due to the effect of intoxicating substances such as alcohol/drugs.’ Please comment on any problems with the service provided by the police ‘the police refused any involvement in this case as their occupational health advised them there would be a risk to them.’ ‘Police received inappropriate advice about PPE—unable to establish where they got this advice’ ‘A lot of discussion in HPZone notes (these are the Public Health England notes) suggesting police were unaware of what they were allowed to do in terms of bringing him back and level of force’ ‘Police involved saying that the part 2A order didn’t give them powers to remove him from the street only from an actual ‘place’. What were your aims in obtaining an order? ‘to keep a chaotic patient safe and support him to maintain medication to avoid the development of MDR-TB, second to prevent onwards transmission of a communicable disease.’ ‘Allowed us to make a proper assessment of the case who appeared to be a high risk TB case with lung cavities. The cases investigations were negative for TB and on reflection his cavity was probably from an old lung infection. The section was allowed to lapse and he was allowed to leave hospital, not before he had absconded on a number of occasions while waiting for the results of test(s).’ ‘to find out if the patient was currently smear positive and or not and how much screening was required for work contacts’. ‘to quarantine the patient until drug treatment for his condition was completed’ (7 re-applications) ‘to ensure 12 months of treatment so that he did not relapse again’ (7 re-applications) If you didn’t achieve your aims please comment further ‘We hoped to protect the public from this man whilst the police were preparing criminal charges. That didn’t happen but he did eventually go to prison. We completely failed to protect (the Public)……This was an unsatisfactory process. The law does not allow us to enforce the order in a meaningful way. 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. That these orders are probably not worth pursuing other than to put a marker in the sand.’ Question from the questionnaire Free text comments What steps were undertaken prior to the order? ‘Numerous attempts from local hospital consultant and his team and TB community nurse service to contact patient and invite him to attend clinic to start treatment once MDR-TB had a laboratory diagnosis. Once all attempts failed, the Consultant (medical) contacted me (PHE Consultant) and we discussed the situation and the plan of action.’ ‘He had gone home on DOT which he’d agreed to take, and had been referred to “Action for change” for help with his alcohol problem. However, since discharge the TB nurse had not been able to make contact with him—he had started drinking heavily again, and was not answering to calls or visits. …. A case conference was held to discuss the case; in which it was agreed that admission was necessary on public health grounds, but a part 2a order would be the final resort. Before this, a referral was to be made to mental health services by his GP; in view that alcohol use and possibly depression were important factors in his non-compliance with TB therapy. Also TB nurse would make further attempts to persuade case to come into hospital voluntarily….’ ‘At least two provision(s) of housing/hostel accommodation, DOT therapy—and numerous occasion trying to find case to observe DOT.’ ‘Incentives: Cash (via the TB Alert fund), Referral to a Polish speaking alcohol worker, Housing….’ Please comment on the difficulties in obtaining the order. ‘Main issue was transfer of PII (patient identifiable information) between agencies in real time—LA (Local authority) had no secure fax or drop box’ ‘co-ordination of relevant reports from medical team and completion of application.’ ‘as he (the patient) was already well known to services most of the services were disinclined to assist with this case-feeling that their priority lay with those that want to take up their services. Note: An amendment was put into the Part 2A re responsibilities for LA, Trust and CCG with regard to Part 2A and provision of services.’ ‘Agreement achieved after a lot of negotiation about the process with all organizations.…… The security staff and Police were concerned about the risk of catching TB. The Trust were very concerned about the financial implications. In court disagreements emerged about the terms of the order and tensions surfaced between different partners.’ Please comment on the difficulties implementing the order Interagency co-ordination ‘Ambulance Service refused to send the ambulance “patient’s life not in danger” and patient took advantage of me (Consultant in communicable disease) being engaged in difficult discussion with ambulance call centre to run away from the house. We then called the police but obviously there was no sign of the patient.’ ‘The patient’s location was identified and police and ambulance contacted to help with enforcing removal to hospital. However, in practice there was difficulty coordinating police and ambulance service when needed. In the end the patient travelled in a private car’ ‘The plan was to have a security guard at the door but this did not happen by the time patient arrived’ Lack of resources ‘(After multiple defaults) the Chief Executive of trust wrote to CCG (care commissioning group) and LA (local authority) saying that they would no longer have a bed for case.’ ‘No negative pressure rooms were available in the hospital where patient was diagnosed. Patient was sent to another hospital within the same Trust, although initially there was significant reluctance and resistance from this hospital.’ ‘unwillingness of hospital to pay for guard, PCT (Primary Care Trust) (finally paid).’ ‘if the patient had refused to comply with the order requiring them to stay in hospital—there was no ability to detain them—due to lack of ability to fund security guard presence—would have been faced with patient leaving, picked up by police, returned to hospital, patient leaving etc.’ Patient specific ‘Order obtained on 20.10… but case was not located until 31.10…. Found by the police’ ‘The patient absconded continually from the ward and we therefore in the end decided to attempt management at home restricting where he could go. That too failed because there was no sanction in law that we could use to enforce the order.’ ‘it was difficult to get the patient to abide by the order as he kept absconding from hospital to access alcohol and smoke. This also increased his risk of MDR-TB as DOTS (directly observed therapy) was compromised.’ ‘The patient was then a security risk for hospital staff being verbally and physically violent.’ ‘The patient was physically and verbally abusive—ASBO (anti-social behaviour order) obtained by LA (local authority).’ ‘On visiting the house of patient his female housemate displayed a more aggressive behaviour, probably due to the effect of intoxicating substances such as alcohol/drugs.’ Please comment on any problems with the service provided by the police ‘the police refused any involvement in this case as their occupational health advised them there would be a risk to them.’ ‘Police received inappropriate advice about PPE—unable to establish where they got this advice’ ‘A lot of discussion in HPZone notes (these are the Public Health England notes) suggesting police were unaware of what they were allowed to do in terms of bringing him back and level of force’ ‘Police involved saying that the part 2A order didn’t give them powers to remove him from the street only from an actual ‘place’. What were your aims in obtaining an order? ‘to keep a chaotic patient safe and support him to maintain medication to avoid the development of MDR-TB, second to prevent onwards transmission of a communicable disease.’ ‘Allowed us to make a proper assessment of the case who appeared to be a high risk TB case with lung cavities. The cases investigations were negative for TB and on reflection his cavity was probably from an old lung infection. The section was allowed to lapse and he was allowed to leave hospital, not before he had absconded on a number of occasions while waiting for the results of test(s).’ ‘to find out if the patient was currently smear positive and or not and how much screening was required for work contacts’. ‘to quarantine the patient until drug treatment for his condition was completed’ (7 re-applications) ‘to ensure 12 months of treatment so that he did not relapse again’ (7 re-applications) If you didn’t achieve your aims please comment further ‘We hoped to protect the public from this man whilst the police were preparing criminal charges. That didn’t happen but he did eventually go to prison. We completely failed to protect (the Public)……This was an unsatisfactory process. The law does not allow us to enforce the order in a meaningful way. 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. That these orders are probably not worth pursuing other than to put a marker in the sand.’ Words in Brackets have been added to aid understanding. Difficulties in obtaining the orders Respondents were asked to describe any difficulties experienced obtaining the order. The 15 people answered this question. Difficulties were described in four cases (4/15, 27%) and no problems were commented on in 11 (11/15, 73%). The four difficulties described related to interagency co-ordination (transfer of patient identifiable data between agencies, co-ordination of reports) and lack of agreement by the multiple agencies on their individual responsibilities and the terms of the Part 2A Order (Table 2). Implementation of the orders Respondents were asked to describe difficulties encountered implementing the Part 2A Orders. Six (6/24, 25%) documented that there were no problems implementing the order. The 18 (18/24, 75%) respondents documented one or more problem. Interagency co-ordination was again a problem especially between the police, public health officials and ambulance services on the initial pick up of the patient (four respondents) and co-ordinating a bed and a guard at the correct moment (two respondents). Lack of resources were a major issue, including lack of availability of a negative pressure bed (four comments) and the lack of availability of a guard or uncertainty as to who should pay for the guard (nine respondents). There were examples of the guard being paid for by the hospital, the LA and the primary care trust (PCT). Patient behaviour-related difficulties were also a feature. Six respondents commented on the difficulties of locating the patient at the start or after absconding, eight respondents commented on the patient absconding and how to re-find the patient or stop this happening again and three commented on difficulties experienced when the patient or friends were verbally or physically abusive to staff. Police involvement in the implementation of the orders Respondents were asked whether the police were involved and if any problems arose in the process. A total of 25 (25/29) respondents answered this question. And 17 (17/25, 68%) used the police. The majority of comments were very positive about their experiences contacting the police (six comments). Some respondents were frustrated with the lack of occupational (infection control) advice given to the police or the inappropriateness of the advice given (three respondents) and the ignorance on the part of the police about the Part 2A Order, in particular, the degree of force they could use to implement the Part 2A Order. Description of aims and whether aims were achieved Respondents were asked to describe their aims in using the Part 2A Orders and whether these aims were achieved. In total, 23 responded to this question. Overall, 96% (22/23) achieved their aims. The majority of respondents stated that their aim in using the order was to remove an infectious individual and protect the public, as well as establish medical therapy. Many of the aims stated were also broader than protecting the public and were implemented to support the patient through alcohol and adherence counselling, housing support and financial support packages. The Part 2A Orders were also used for patients who were potentially infectious; both for those without a definitive diagnosis of TB (quarantine) who may have been infectious at the time of order (n = 1) (e.g. for a patient with a cavity on a chest radiograph who was refusing to give sputum samples and lived in shared accommodation) and for those who were known to be infected but not currently infectious (n = 3). The latter category included patients who had been established on medical therapy under a Part 2A Order and were considered likely, through poor adherence, to relapse to an infectious state if the order elapsed. In the only HIV Case in which a Part 2A Order was obtained, the aims were not achieved. Frustration was expressed with the Part 2A Orders due to lack of ability to sanction or facilities to enforce the Order. In this example, the patient continually absconded from the ward and was known to have had unprotected sexual intercourse. Orders used against things There was a 100% reply rate and 13 (13/23) orders were initiated by one environmental health department. All orders were initiated to prevent blood-borne virus spread through the seizing of potentially contaminated equipment. All respondents reported that the orders were used due to limited alternative powers and/or lack of owner collaboration. The environmental health officer (EHO) responsible for 13 of the Orders explained on the questionnaire why the alternative powers were limited as follows: ‘Health and Safety Executive are required to transfer powers to LAs for enforcement Orders for work done in the home but these transfers are not happening so alternative powers have been sought’. The only problem in obtaining an Order was the Court’s unfamiliarity with the process. The problems with implementation were multi-agency coordination (requirement for police, locksmith, trading standards officer to be present), change of address for owner, dogs on site and costs. A police officer was involved in all cases. Respondents stated that aims were achieved in all cases, i.e. the removal of equipment. The general comments were all positive along the lines of: ‘Very effective from a public health and enforcement side to remove the risk and allows for more evidence to add to prosecution file. Also good deterrent to others operating illegally as there is a financial loss for the tattooist’. The only negative comment about achieving aims was that the respondent knew of instances where the tattooist had obtained new equipment. Orders used against premises Overall, 100% (3/3) response rate was obtained. Again these orders were used because of limited alternative powers to restrict work carried at home. No difficulties in obtaining Orders were identified and the only difficulty in implementation was lack of co-operation by the tenant. The aims were achieved in all cases. Conclusion Main findings We undertook the first survey of Part 2A Order usage since their introduction. We show that these orders are used mainly against persons with TB and increasingly for tattoo equipment for things. The orders were straightforward to obtain but in relation to persons were sometimes difficult to implement due to the actions of the individuals being detained, interagency co-operation and limited availability of resources especially guards. We also found that extended powers (e.g. quarantine), newly enshrined in 2010 regulations, were being used. What is already known? All Part 2A Orders create a tension between an individual’s liberty (freedom of movement, personal property) and the health of others (the public). However, the orders detaining people pose the most significant threat to the individual’s rights, so monitoring is important. In England, the powers aim to strike a balance between individual liberty and the public, do not include DOT attendance or coercive treatment and are in line with many countries in Europe.11 Some commentators argue that Orders are never necessary because we have limited evidence that detention prevents spread in TB (significant contacts are normally already exposed),12 that TB is a condition of poverty and it is not fair or just to remove liberty from those already with so little, and thirdly that, with proper funding, alternative measures (wrap-around care etc) should never be inadequate.13,14 However, internationally, the use of legal orders against persons is lawful and dependent on compliance with local law, lack of arbitrariness, proportionality, necessity, as well as international legislation,15 Siracusa principles16 World Health Organization (WHO) guidance for TB17,18 and in case law from the European Court of Human Rights (ECHR).19 Only one case of enforced detention has been challenged at the ECHR. The court ruled that the man was unlawfully detained on the grounds that there was no evidence that less severe measures had been considered and found inadequate (i.e. it was not necessary).5 A case that was upheld at a country level in Europe was that of a patient with MDR-TB in Ireland who refused treatment and continued to be infectious. Prolonged detention due to the patient’s infectivity was upheld.20 What this study adds Although the purpose of our survey was not to establish whether individual cases would have been upheld in a legal challenge we were reassured that respondents stated that multiple interventions had taken place prior to the application and that, in many cases, the patient was hard to find and refusing admission both suggesting the Part 2A Order was necessary. Reassuringly, the numbers of Orders used against persons was low at under 0.1% per TB notification (5 Orders per year when TB notifications were in the range of 6000–9000 cases per year21,22) and at similar levels to a previous report, and not supporting suggested onward increase in use.23 A comparison of use of enforced detention for Tuberculosis or other infectious conditions is difficult because little is published internationally and some countries have no powers to detain on public health grounds.11 However, the rate of use in the UK of legal powers is low compared to reports that are available.18,24,25 The 2010 Regulations are procedurally tighter with significant safeguards (28 days duration, representation, right to appeal) for the individual, compared with the previous versions of sections 37 and 38 of the Public Health Act 1984, which they replaced (Table 3). However, the standard for certainty about infectious risk posed by the person has been relaxed in the amended legislation. Before the amended legislation, the JP has to be certain that the ‘Person is suffering from a notifiable disease’ and that ‘serious risk of infection is thereby caused to other persons’. By contrast, the amended legislation states that the JP must be certain that the ‘person is or may (quarantine law introduction) be infected’ and that there is ‘a risk that the person might infect or contaminate others’. We show that there is evidence that the amended legislation is being used as a quarantine law and that renewals of orders are, on occasion, being made several times against patients who are not infectious currently, but who may become so in the event that they fail to complete therapy. It is difficult to establish whether the criteria by which applications were being determined were consistently applied and whether, in each case, these renewals were objectively necessary (to protect public health in the future, through ensuring full treatment compliance). Nevertheless, our view is that this study shows that the orders are not being abused and we know well that non-compliance with a full course of treatment can result in re-infectiousness. Table 3 Differences between the sections 37 and 38 of the Public Health Act 1984 and the Health Protection Regulations 2010 (Part 2A orders) (2, 27, 28) Sections 37 and 38 of the Public Health Act 1984 Part 2A Orders: Heath and Social Care Act 2008/2010 Regulations Application made by Local authority Local authority Application to Justice of the peace (Magistrate) Justice of the peace (Magistrate) Acceptable in absentia Yes, if the JP deems it necessary Yes, if a risk of patient absconding Grounds that must be met Person is suffering from a notifiable disease Persons circumstances are such that proper precautions to prevent the spread of infection cannot be taken That serious risk of infection is thereby caused to other persons The person is or may be infected/ contaminated The infection or contamination presents or could present significant harm to human health There is a risk that the person might infect or contaminate others; It is necessary to make the order to remove or reduce the risk Compulsory measures that can requested Removal to hospital Detention in hospital Medical examination Removal to hospital Detention in hospital/isolation Disinfection/decontamination Wearing of protective clothing Answering questions re health and contacts Health monitoring and results reporting Attendance of training/ advice on reducing risk of infection Restrictions on movement Abstention from work Duration None defined 28 Days, can be re-applied for Right of Appeal No Yes Written notification of legal orders to person No Yes Monitoring of law No Yes: all applications for orders must reported to Public Health England (previously the Health Protection Agency) Fine if the patient does not comply with the order Level one on standard scale Fine may not exceed £20 000 Sections 37 and 38 of the Public Health Act 1984 Part 2A Orders: Heath and Social Care Act 2008/2010 Regulations Application made by Local authority Local authority Application to Justice of the peace (Magistrate) Justice of the peace (Magistrate) Acceptable in absentia Yes, if the JP deems it necessary Yes, if a risk of patient absconding Grounds that must be met Person is suffering from a notifiable disease Persons circumstances are such that proper precautions to prevent the spread of infection cannot be taken That serious risk of infection is thereby caused to other persons The person is or may be infected/ contaminated The infection or contamination presents or could present significant harm to human health There is a risk that the person might infect or contaminate others; It is necessary to make the order to remove or reduce the risk Compulsory measures that can requested Removal to hospital Detention in hospital Medical examination Removal to hospital Detention in hospital/isolation Disinfection/decontamination Wearing of protective clothing Answering questions re health and contacts Health monitoring and results reporting Attendance of training/ advice on reducing risk of infection Restrictions on movement Abstention from work Duration None defined 28 Days, can be re-applied for Right of Appeal No Yes Written notification of legal orders to person No Yes Monitoring of law No Yes: all applications for orders must reported to Public Health England (previously the Health Protection Agency) Fine if the patient does not comply with the order Level one on standard scale Fine may not exceed £20 000 Table 3 Differences between the sections 37 and 38 of the Public Health Act 1984 and the Health Protection Regulations 2010 (Part 2A orders) (2, 27, 28) Sections 37 and 38 of the Public Health Act 1984 Part 2A Orders: Heath and Social Care Act 2008/2010 Regulations Application made by Local authority Local authority Application to Justice of the peace (Magistrate) Justice of the peace (Magistrate) Acceptable in absentia Yes, if the JP deems it necessary Yes, if a risk of patient absconding Grounds that must be met Person is suffering from a notifiable disease Persons circumstances are such that proper precautions to prevent the spread of infection cannot be taken That serious risk of infection is thereby caused to other persons The person is or may be infected/ contaminated The infection or contamination presents or could present significant harm to human health There is a risk that the person might infect or contaminate others; It is necessary to make the order to remove or reduce the risk Compulsory measures that can requested Removal to hospital Detention in hospital Medical examination Removal to hospital Detention in hospital/isolation Disinfection/decontamination Wearing of protective clothing Answering questions re health and contacts Health monitoring and results reporting Attendance of training/ advice on reducing risk of infection Restrictions on movement Abstention from work Duration None defined 28 Days, can be re-applied for Right of Appeal No Yes Written notification of legal orders to person No Yes Monitoring of law No Yes: all applications for orders must reported to Public Health England (previously the Health Protection Agency) Fine if the patient does not comply with the order Level one on standard scale Fine may not exceed £20 000 Sections 37 and 38 of the Public Health Act 1984 Part 2A Orders: Heath and Social Care Act 2008/2010 Regulations Application made by Local authority Local authority Application to Justice of the peace (Magistrate) Justice of the peace (Magistrate) Acceptable in absentia Yes, if the JP deems it necessary Yes, if a risk of patient absconding Grounds that must be met Person is suffering from a notifiable disease Persons circumstances are such that proper precautions to prevent the spread of infection cannot be taken That serious risk of infection is thereby caused to other persons The person is or may be infected/ contaminated The infection or contamination presents or could present significant harm to human health There is a risk that the person might infect or contaminate others; It is necessary to make the order to remove or reduce the risk Compulsory measures that can requested Removal to hospital Detention in hospital Medical examination Removal to hospital Detention in hospital/isolation Disinfection/decontamination Wearing of protective clothing Answering questions re health and contacts Health monitoring and results reporting Attendance of training/ advice on reducing risk of infection Restrictions on movement Abstention from work Duration None defined 28 Days, can be re-applied for Right of Appeal No Yes Written notification of legal orders to person No Yes Monitoring of law No Yes: all applications for orders must reported to Public Health England (previously the Health Protection Agency) Fine if the patient does not comply with the order Level one on standard scale Fine may not exceed £20 000 Much of the evidence from this study suggests that the facilities for detention are not appropriate and are limiting effective public health action. The difficulties described—securing beds, guards and the number of patients who default—show that we do not have the facilities to provide care safely in locked rooms with permanent guards. Although the UK is not alone,26 the current situation where patients are detained in small acute hospital side rooms with limited access to the outside, occupational assistance or financial compensation for lost earnings it is not surprising that patients default. Moral theories of reciprocity as a justification for public health action would suggest that if we were to provide improved community 24-h care with access to the outside and wrap-around support to those who are deprived of their liberty to protect the public, that society would reap the benefit of better outcomes and adherence.27 The main limitations The main limitation of our study is that it does not include all the Part 2A Orders that were considered but not applied for and the reasons for these choices. Another issue is around efficacy of the orders due to the circularity of asking those who defined the aims of use to comment on outcomes. If we had surveyed physicians or patients, we are likely to have had different responses. Furthermore, although the aims were reported as achieved in most cases, there were multiple reports of patients absconding from the wards where it is possible transmission may have occurred. Finally, we are aware that there are concerns about whether Part 2A Orders can be implemented rapidly should this be needed. This issue did not appear in this study, presumably because TB is a chronic disease with longer time scales. We conclude that Part 2A Orders are currently being used as a last resort but improved facilities for safe and secure isolation would help improve implementation of Orders against people. Funding There was no funding for this study except that AA was employed as a teaching fellow at St George’s Healthcare NHS Trust and GB was an employee of Public Health England. Ethics The work was undertaken as a service evaluation of the Part 2A order process and no patient identifiable information was collected in line with Caldicott Principles. Conflicts of interest None declared. References 1 Health Protection (Part 2A Orders) Regulations 2010 (SI 2010/658). 2 Health and Social Care Act 2008 (c. 14. 2008). 3 Public Health (Control of Disease) Act 1984 (c. 22. 1984). 4 Coker RJ . The law, human rights, and the detention of individuals with tuberculosis in England and Wales . J Public Health Med 2000 ; 22 ( 3 ): 263 – 7 . Google Scholar CrossRef Search ADS PubMed 5 Martin R . The exercise of public health powers in cases of infectious disease: human rights implications . Med Law Rev 2006 ; 14 ( 1 ): 132 – 43 . Google Scholar CrossRef Search ADS PubMed 6 Harris A , Martin R . The exercise of public health powers in an era of human rights: the particular problems of tuberculosis . Public Health 2004 ; 118 ( 5 ): 313 – 22 . Google Scholar CrossRef Search ADS PubMed 7 World Health Assembly . International Health Regulations ( 2005 ). World Health Assembly, 2005. 8 Department of Health . Review of Parts 2, 5 and 6 of the Public Health (Control of Disease) Act 1984: A Consultation . London : Department of Health , 2007 . 9 Department of Health . Review of Parts 2, 5 and 6 of the Public Heath (control of Disease) Act 1984: Report on Consultation . London : Department of Health , 2007 . 10 Green J , Thorogood N . Qualitative Methods for Health Research . Los Angeles, USA : Sage , 2009 . 11 Coker RJ , Mounier-Jack S , Martin R . Public health law and tuberculosis control in Europe . Public Health 2007 ; 121 ( 4 ): 266 – 73 . Google Scholar CrossRef Search ADS PubMed 12 Coker RJ . Public health impact of detention of individuals with tuberculosis: systematic literature review . Public Health 2003 ; 117 ( 4 ): 281 – 7 . Google Scholar CrossRef Search ADS PubMed 13 Todrys KW , Howe E , Amon JJ . Failing Siracusa: governments’ obligations to find the least restrictive options for tuberculosis control . Public Health Action 2013 ; 3 ( 1 ): 7 – 10 . Google Scholar CrossRef Search ADS PubMed 14 Selgelid MJ . Ethics, tuberculosis and gloablization . Public Health Ethics 2008 ; 1 ( 1 ): 10 – 20 . Google Scholar CrossRef Search ADS 15 United Nations . International Covenant on Civil and Political Rights . New York : United Nations , 1966 . 16 The Siracusa Principles on the Limitation and Derogation Provisions in the International Covenant on Civil and Political Rights. United Nations Commission on Human Rights: New York, 1984 . 17 World Health Organization . Guidance on Ethics of Tuberculosis Prevention, Care and Control . Geneva, Switzerland : World Health Institution , 2010 . 18 World Health Organization . Tuberculosis, Ethics and Human Rights. Report of a Regional Workshop 2013 . Copenhagen, Denmark : World Health Organization , 2013 . 19 Enhorn v. Sweden (Application no. 56529/00). 41 EHRR 633, 19 BHRC 222, Judgement, European Court of Human Rights, Strasbourg, 2005 . 20 Donnelly M . Public Health and Patient Rights: S v HSE [2009] IEHC 106 . Medico-Legal J Ireland 2009 ; 15 ( 2 ): MLJI 66 . 21 Tuberculosis in England : 2015 report version 1.1. 2015 . Public Health England: London. 22 Tuberculosis in the UK . Annual Report on Tuberculosis Surveillance in the UK . London : Health Protection Agency , 2012 . 23 Coker RJ . National survey of detention and TB . Thorax 2001 ; 56 ( 10 ): 818 . Google Scholar CrossRef Search ADS PubMed 24 Pursnani S , Srivastava S , Ali S et al. . Risk factors for and outcomes of detention of patients with TB in New York City: an update: 2002–2009 . Chest 2014 ; 145 ( 1 ): 95 – 100 . Google Scholar CrossRef Search ADS PubMed 25 Lerner BH . Catching patients: tuberculosis and detention in the 1990s . Chest 1999 ; 115 ( 1 ): 236 – 41 . Google Scholar CrossRef Search ADS PubMed 26 Conaty S . Detention to prevent transmission of tuberculosis: a proportionate public health response? N S W Public Health Bull 2012 ; 23 ( 5–6 ): 120 – 1 . Google Scholar CrossRef Search ADS PubMed 27 Viens AM , Bensimon CM , Upshur REG . Your liberty or your life: reciprocity in the use of restrictive measures in contexts of contagion . Bioeth Inq 2009 ; 6 : 207 – 17 . Google Scholar CrossRef Search ADS © The Author(s) 2018. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Public Health Oxford University Press

The first 5 years of Part 2A Orders: the use of powers from court applications to protect public health in England 2010–15

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Abstract

Abstract Background Part 2A Orders are the legal means which allow local authorities (LAs), upon application to court, to exercise powers over persons, things or premises to protect public health. Methods We surveyed lead professionals involved in applications to understand the use and utility of such Orders since their inception in April 2010 to July 2015. Results All applications for Orders were granted; 29 for persons (28 for tuberculosis, 1 for HIV); these were renewed in 18 (18/25, 72%) cases up to seven times; 23 applications related to things (tattoo and piercing equipment); and three applications related to ‘premises’ (Escherichia coli 0137 on farm, faecal contamination). Use of the Orders against things occurred where there was failure of the Health and Safety Executive to transfer powers to LAs. Orders against persons were used as a last resort and renewed until treatment completion in the minority of cases (n = 3). One patient was detained under quarantine powers while assessing infectiousness. Significant difficulties in implementing the Part 2A Orders due to lack of resources, facilities and interagency collaboration were reported. Conclusions Part 2A Orders are used as a last resort but improved facilities for safe and secure isolation would help improve implementation. public health, tuberculosis Introduction Part 2A Orders were introduced in 20101,2 as the new legal mechanism under the Public Health (Control of Disease) Act 19843 to allow local authorities (LAs) to apply to a justice of the peace (JP) for various powers to protect public health. The changes made to the Public Health Act 1984 were part of wider legislative changes to ensure compliance with the Human Rights Act 19984–6 and the new International Health Regulations 2005.7 The powers encompass new and emerging infections and non-infectious threats in an ‘all hazards’ approach and were primarily legislated for in the Health and Social Care Act 20087–9 and then in the Health Protection (Part 2A Orders) Regulations 2010.1 Part 2A Orders can be applied for and used against persons (including coercive detention in hospital or other suitable establishment), things or places where voluntary co-operation and other methods to avert a risk or hazard are not possible. The new secondary legislation includes safeguards for persons subjected to Part 2A Orders, including the need for a JP to hear the application, the right to apply for revocation and a limit of 28 days to each order. One important feature of Part 2A Orders, considering the potential loss of freedom inherent in the Orders, is that each Order must be reported to Public Health England (PHE) (previously, the Health Protection Agency, HPA). We used these reports to identify key professionals involved in the application so as to undertake a web based survey to understand the current usage of the Orders. Methods The PHE register of Part 2A Applications was used to identify key professionals responsible for applications between 1 April 2010 and 31 July 2015. Consultants in Communicable Disease Control (CCDC) at PHE were identified for person-specific Part 2A Orders, and LA environmental health officers (EHOs) for premises-specific and thing-specific Part 2A Orders. A web based survey with questions requiring a combination of tick box and free text answers was developed and sent out via email to all lead professionals. Reminder emails were sent at 2, 4 and 6 weeks from the date of initial survey. Summary statistics were used to assess tick box responses and a thematic approach was used to summarize free text responses.10 The study was undertaken as part of a service evaluation of Part 2A Order use and so did not require formal ethical approval. Results During the study period, 29 person, 3 premises and 23 thing Orders were reported to PHE/HPA. The 53/55 (96%) completed questionnaires were returned. Two questionnaires for person-specific Part 2A Orders made in 2010 were not returned and missing data was included if available in the reports. The number of Part 2A Orders per year can be seen in Fig. 1. The demographics of persons subjected to orders, type of things and locations and disease specifics for premises can be seen in Table 1. Fig. 1 View largeDownload slide Numbers of Part 2A Orders reported to Public Health England (PHE) or Health Protection Agency (HPA) between 1 April 2010 and 31 July 2015. Fig. 1 View largeDownload slide Numbers of Part 2A Orders reported to Public Health England (PHE) or Health Protection Agency (HPA) between 1 April 2010 and 31 July 2015. Table 1 Type of Orders, demographics and circumstances of use. Order type Comment Number (% except where otherwise stated) Orders against persons n = 29*  Sex: male (n = 28) 26 (93)  Median age, years (IQR) (n = 27) 38 (28.5–42.5)  Disease: TB (n = 29) 28 (97)  MDR-TB and XDR-TB (n = 21) 9 (42)  Disease: HIV (n = 29) 1 (3)  Ethnicity (n = 26) White British 11 (42) Indian or Pakistani 4 (16) White other 6 (23) Black African 4 (15)  Extenuating circumstances leading to order (not mutually exclusive, n = 24) Homelessness 13 (54) Mental health issues 4 (17) Drug and alcohol issues 16 (67) Non-compliance with medication 18 (75) Ex-prisoner 1 (4) Chaotic life 1 (4) violence 1 (4) New diagnosis of MDR-TB 1 (4)  Number of orders renewed (n = 27) 18 (67)  Median number of renewals per order (range) (n = 27) 1 (0–7)  Number of orders with seven renewals 3  Powers requested (not mutually exclusive, n = 24) Medical examination 16 (67) Removed to hospital 21 (88) Detained in hospital 22 (92) Kept in isolation 14 (58) Be disinfected 1 (4) Wear protective clothing 5 (21) Provide information 9 (38) Have health monitored 7 (29) Attend training 2 (8) Subject to restrictions 5 (21) Abstain from work 0 Orders against things (n = 23)  Orders for tattoo equipment 22 (96)  Orders for piercing equipment 1 (4)  Number of orders renewed 0 Orders against place (n = 3)  Petting farm with E-coli 0157 1 (33)  Self-contained flat with faecal contamination 1 (33)  Flat with tattoo equipment inside to prevent blood born virus spread 1 (33)  Number of orders renewed 0 Order type Comment Number (% except where otherwise stated) Orders against persons n = 29*  Sex: male (n = 28) 26 (93)  Median age, years (IQR) (n = 27) 38 (28.5–42.5)  Disease: TB (n = 29) 28 (97)  MDR-TB and XDR-TB (n = 21) 9 (42)  Disease: HIV (n = 29) 1 (3)  Ethnicity (n = 26) White British 11 (42) Indian or Pakistani 4 (16) White other 6 (23) Black African 4 (15)  Extenuating circumstances leading to order (not mutually exclusive, n = 24) Homelessness 13 (54) Mental health issues 4 (17) Drug and alcohol issues 16 (67) Non-compliance with medication 18 (75) Ex-prisoner 1 (4) Chaotic life 1 (4) violence 1 (4) New diagnosis of MDR-TB 1 (4)  Number of orders renewed (n = 27) 18 (67)  Median number of renewals per order (range) (n = 27) 1 (0–7)  Number of orders with seven renewals 3  Powers requested (not mutually exclusive, n = 24) Medical examination 16 (67) Removed to hospital 21 (88) Detained in hospital 22 (92) Kept in isolation 14 (58) Be disinfected 1 (4) Wear protective clothing 5 (21) Provide information 9 (38) Have health monitored 7 (29) Attend training 2 (8) Subject to restrictions 5 (21) Abstain from work 0 Orders against things (n = 23)  Orders for tattoo equipment 22 (96)  Orders for piercing equipment 1 (4)  Number of orders renewed 0 Orders against place (n = 3)  Petting farm with E-coli 0157 1 (33)  Self-contained flat with faecal contamination 1 (33)  Flat with tattoo equipment inside to prevent blood born virus spread 1 (33)  Number of orders renewed 0 *Questionnaires on two person orders were not returned so some data only available for 27 people. Where data was available in the redacted application letters the information was used. If data not entered by respondent then the denominator is <27. Table 1 Type of Orders, demographics and circumstances of use. Order type Comment Number (% except where otherwise stated) Orders against persons n = 29*  Sex: male (n = 28) 26 (93)  Median age, years (IQR) (n = 27) 38 (28.5–42.5)  Disease: TB (n = 29) 28 (97)  MDR-TB and XDR-TB (n = 21) 9 (42)  Disease: HIV (n = 29) 1 (3)  Ethnicity (n = 26) White British 11 (42) Indian or Pakistani 4 (16) White other 6 (23) Black African 4 (15)  Extenuating circumstances leading to order (not mutually exclusive, n = 24) Homelessness 13 (54) Mental health issues 4 (17) Drug and alcohol issues 16 (67) Non-compliance with medication 18 (75) Ex-prisoner 1 (4) Chaotic life 1 (4) violence 1 (4) New diagnosis of MDR-TB 1 (4)  Number of orders renewed (n = 27) 18 (67)  Median number of renewals per order (range) (n = 27) 1 (0–7)  Number of orders with seven renewals 3  Powers requested (not mutually exclusive, n = 24) Medical examination 16 (67) Removed to hospital 21 (88) Detained in hospital 22 (92) Kept in isolation 14 (58) Be disinfected 1 (4) Wear protective clothing 5 (21) Provide information 9 (38) Have health monitored 7 (29) Attend training 2 (8) Subject to restrictions 5 (21) Abstain from work 0 Orders against things (n = 23)  Orders for tattoo equipment 22 (96)  Orders for piercing equipment 1 (4)  Number of orders renewed 0 Orders against place (n = 3)  Petting farm with E-coli 0157 1 (33)  Self-contained flat with faecal contamination 1 (33)  Flat with tattoo equipment inside to prevent blood born virus spread 1 (33)  Number of orders renewed 0 Order type Comment Number (% except where otherwise stated) Orders against persons n = 29*  Sex: male (n = 28) 26 (93)  Median age, years (IQR) (n = 27) 38 (28.5–42.5)  Disease: TB (n = 29) 28 (97)  MDR-TB and XDR-TB (n = 21) 9 (42)  Disease: HIV (n = 29) 1 (3)  Ethnicity (n = 26) White British 11 (42) Indian or Pakistani 4 (16) White other 6 (23) Black African 4 (15)  Extenuating circumstances leading to order (not mutually exclusive, n = 24) Homelessness 13 (54) Mental health issues 4 (17) Drug and alcohol issues 16 (67) Non-compliance with medication 18 (75) Ex-prisoner 1 (4) Chaotic life 1 (4) violence 1 (4) New diagnosis of MDR-TB 1 (4)  Number of orders renewed (n = 27) 18 (67)  Median number of renewals per order (range) (n = 27) 1 (0–7)  Number of orders with seven renewals 3  Powers requested (not mutually exclusive, n = 24) Medical examination 16 (67) Removed to hospital 21 (88) Detained in hospital 22 (92) Kept in isolation 14 (58) Be disinfected 1 (4) Wear protective clothing 5 (21) Provide information 9 (38) Have health monitored 7 (29) Attend training 2 (8) Subject to restrictions 5 (21) Abstain from work 0 Orders against things (n = 23)  Orders for tattoo equipment 22 (96)  Orders for piercing equipment 1 (4)  Number of orders renewed 0 Orders against place (n = 3)  Petting farm with E-coli 0157 1 (33)  Self-contained flat with faecal contamination 1 (33)  Flat with tattoo equipment inside to prevent blood born virus spread 1 (33)  Number of orders renewed 0 *Questionnaires on two person orders were not returned so some data only available for 27 people. Where data was available in the redacted application letters the information was used. If data not entered by respondent then the denominator is <27. Orders used against persons The median number of Orders each year was 5 (range: 2–8) (2011–14: full calendar years). Prior to the order Respondents were asked what steps were undertaken prior to the application. Overall, 83% (24/29) answered this question. And, 17 (17/24) commented that home visits were undertaken by outreach workers, TB organizations (e.g. find and treat), the physician or nurse. And, 17 (17/24) arranged a multidisciplinary team meeting (MDT) to discuss management strategies. In 8 (8/24) cases the patient was difficult to locate and was refusing all contact with services. Examples of other options were tried, e.g. directly observed therapy (DOT), cash incentives, ambulatory care. Examples of comments can be seen in Table 2. Table 2 Abstracts from free text comments from respondents. Question from the questionnaire Free text comments What steps were undertaken prior to the order? ‘Numerous attempts from local hospital consultant and his team and TB community nurse service to contact patient and invite him to attend clinic to start treatment once MDR-TB had a laboratory diagnosis. Once all attempts failed, the Consultant (medical) contacted me (PHE Consultant) and we discussed the situation and the plan of action.’ ‘He had gone home on DOT which he’d agreed to take, and had been referred to “Action for change” for help with his alcohol problem. However, since discharge the TB nurse had not been able to make contact with him—he had started drinking heavily again, and was not answering to calls or visits. …. A case conference was held to discuss the case; in which it was agreed that admission was necessary on public health grounds, but a part 2a order would be the final resort. Before this, a referral was to be made to mental health services by his GP; in view that alcohol use and possibly depression were important factors in his non-compliance with TB therapy. Also TB nurse would make further attempts to persuade case to come into hospital voluntarily….’ ‘At least two provision(s) of housing/hostel accommodation, DOT therapy—and numerous occasion trying to find case to observe DOT.’ ‘Incentives: Cash (via the TB Alert fund), Referral to a Polish speaking alcohol worker, Housing….’ Please comment on the difficulties in obtaining the order. ‘Main issue was transfer of PII (patient identifiable information) between agencies in real time—LA (Local authority) had no secure fax or drop box’ ‘co-ordination of relevant reports from medical team and completion of application.’ ‘as he (the patient) was already well known to services most of the services were disinclined to assist with this case-feeling that their priority lay with those that want to take up their services. Note: An amendment was put into the Part 2A re responsibilities for LA, Trust and CCG with regard to Part 2A and provision of services.’ ‘Agreement achieved after a lot of negotiation about the process with all organizations.…… The security staff and Police were concerned about the risk of catching TB. The Trust were very concerned about the financial implications. In court disagreements emerged about the terms of the order and tensions surfaced between different partners.’ Please comment on the difficulties implementing the order Interagency co-ordination ‘Ambulance Service refused to send the ambulance “patient’s life not in danger” and patient took advantage of me (Consultant in communicable disease) being engaged in difficult discussion with ambulance call centre to run away from the house. We then called the police but obviously there was no sign of the patient.’ ‘The patient’s location was identified and police and ambulance contacted to help with enforcing removal to hospital. However, in practice there was difficulty coordinating police and ambulance service when needed. In the end the patient travelled in a private car’ ‘The plan was to have a security guard at the door but this did not happen by the time patient arrived’ Lack of resources ‘(After multiple defaults) the Chief Executive of trust wrote to CCG (care commissioning group) and LA (local authority) saying that they would no longer have a bed for case.’ ‘No negative pressure rooms were available in the hospital where patient was diagnosed. Patient was sent to another hospital within the same Trust, although initially there was significant reluctance and resistance from this hospital.’ ‘unwillingness of hospital to pay for guard, PCT (Primary Care Trust) (finally paid).’ ‘if the patient had refused to comply with the order requiring them to stay in hospital—there was no ability to detain them—due to lack of ability to fund security guard presence—would have been faced with patient leaving, picked up by police, returned to hospital, patient leaving etc.’ Patient specific ‘Order obtained on 20.10… but case was not located until 31.10…. Found by the police’ ‘The patient absconded continually from the ward and we therefore in the end decided to attempt management at home restricting where he could go. That too failed because there was no sanction in law that we could use to enforce the order.’ ‘it was difficult to get the patient to abide by the order as he kept absconding from hospital to access alcohol and smoke. This also increased his risk of MDR-TB as DOTS (directly observed therapy) was compromised.’ ‘The patient was then a security risk for hospital staff being verbally and physically violent.’ ‘The patient was physically and verbally abusive—ASBO (anti-social behaviour order) obtained by LA (local authority).’ ‘On visiting the house of patient his female housemate displayed a more aggressive behaviour, probably due to the effect of intoxicating substances such as alcohol/drugs.’ Please comment on any problems with the service provided by the police ‘the police refused any involvement in this case as their occupational health advised them there would be a risk to them.’ ‘Police received inappropriate advice about PPE—unable to establish where they got this advice’ ‘A lot of discussion in HPZone notes (these are the Public Health England notes) suggesting police were unaware of what they were allowed to do in terms of bringing him back and level of force’ ‘Police involved saying that the part 2A order didn’t give them powers to remove him from the street only from an actual ‘place’. What were your aims in obtaining an order? ‘to keep a chaotic patient safe and support him to maintain medication to avoid the development of MDR-TB, second to prevent onwards transmission of a communicable disease.’ ‘Allowed us to make a proper assessment of the case who appeared to be a high risk TB case with lung cavities. The cases investigations were negative for TB and on reflection his cavity was probably from an old lung infection. The section was allowed to lapse and he was allowed to leave hospital, not before he had absconded on a number of occasions while waiting for the results of test(s).’ ‘to find out if the patient was currently smear positive and or not and how much screening was required for work contacts’. ‘to quarantine the patient until drug treatment for his condition was completed’ (7 re-applications) ‘to ensure 12 months of treatment so that he did not relapse again’ (7 re-applications) If you didn’t achieve your aims please comment further ‘We hoped to protect the public from this man whilst the police were preparing criminal charges. That didn’t happen but he did eventually go to prison. We completely failed to protect (the Public)……This was an unsatisfactory process. The law does not allow us to enforce the order in a meaningful way. 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. That these orders are probably not worth pursuing other than to put a marker in the sand.’ Question from the questionnaire Free text comments What steps were undertaken prior to the order? ‘Numerous attempts from local hospital consultant and his team and TB community nurse service to contact patient and invite him to attend clinic to start treatment once MDR-TB had a laboratory diagnosis. Once all attempts failed, the Consultant (medical) contacted me (PHE Consultant) and we discussed the situation and the plan of action.’ ‘He had gone home on DOT which he’d agreed to take, and had been referred to “Action for change” for help with his alcohol problem. However, since discharge the TB nurse had not been able to make contact with him—he had started drinking heavily again, and was not answering to calls or visits. …. A case conference was held to discuss the case; in which it was agreed that admission was necessary on public health grounds, but a part 2a order would be the final resort. Before this, a referral was to be made to mental health services by his GP; in view that alcohol use and possibly depression were important factors in his non-compliance with TB therapy. Also TB nurse would make further attempts to persuade case to come into hospital voluntarily….’ ‘At least two provision(s) of housing/hostel accommodation, DOT therapy—and numerous occasion trying to find case to observe DOT.’ ‘Incentives: Cash (via the TB Alert fund), Referral to a Polish speaking alcohol worker, Housing….’ Please comment on the difficulties in obtaining the order. ‘Main issue was transfer of PII (patient identifiable information) between agencies in real time—LA (Local authority) had no secure fax or drop box’ ‘co-ordination of relevant reports from medical team and completion of application.’ ‘as he (the patient) was already well known to services most of the services were disinclined to assist with this case-feeling that their priority lay with those that want to take up their services. Note: An amendment was put into the Part 2A re responsibilities for LA, Trust and CCG with regard to Part 2A and provision of services.’ ‘Agreement achieved after a lot of negotiation about the process with all organizations.…… The security staff and Police were concerned about the risk of catching TB. The Trust were very concerned about the financial implications. In court disagreements emerged about the terms of the order and tensions surfaced between different partners.’ Please comment on the difficulties implementing the order Interagency co-ordination ‘Ambulance Service refused to send the ambulance “patient’s life not in danger” and patient took advantage of me (Consultant in communicable disease) being engaged in difficult discussion with ambulance call centre to run away from the house. We then called the police but obviously there was no sign of the patient.’ ‘The patient’s location was identified and police and ambulance contacted to help with enforcing removal to hospital. However, in practice there was difficulty coordinating police and ambulance service when needed. In the end the patient travelled in a private car’ ‘The plan was to have a security guard at the door but this did not happen by the time patient arrived’ Lack of resources ‘(After multiple defaults) the Chief Executive of trust wrote to CCG (care commissioning group) and LA (local authority) saying that they would no longer have a bed for case.’ ‘No negative pressure rooms were available in the hospital where patient was diagnosed. Patient was sent to another hospital within the same Trust, although initially there was significant reluctance and resistance from this hospital.’ ‘unwillingness of hospital to pay for guard, PCT (Primary Care Trust) (finally paid).’ ‘if the patient had refused to comply with the order requiring them to stay in hospital—there was no ability to detain them—due to lack of ability to fund security guard presence—would have been faced with patient leaving, picked up by police, returned to hospital, patient leaving etc.’ Patient specific ‘Order obtained on 20.10… but case was not located until 31.10…. Found by the police’ ‘The patient absconded continually from the ward and we therefore in the end decided to attempt management at home restricting where he could go. That too failed because there was no sanction in law that we could use to enforce the order.’ ‘it was difficult to get the patient to abide by the order as he kept absconding from hospital to access alcohol and smoke. This also increased his risk of MDR-TB as DOTS (directly observed therapy) was compromised.’ ‘The patient was then a security risk for hospital staff being verbally and physically violent.’ ‘The patient was physically and verbally abusive—ASBO (anti-social behaviour order) obtained by LA (local authority).’ ‘On visiting the house of patient his female housemate displayed a more aggressive behaviour, probably due to the effect of intoxicating substances such as alcohol/drugs.’ Please comment on any problems with the service provided by the police ‘the police refused any involvement in this case as their occupational health advised them there would be a risk to them.’ ‘Police received inappropriate advice about PPE—unable to establish where they got this advice’ ‘A lot of discussion in HPZone notes (these are the Public Health England notes) suggesting police were unaware of what they were allowed to do in terms of bringing him back and level of force’ ‘Police involved saying that the part 2A order didn’t give them powers to remove him from the street only from an actual ‘place’. What were your aims in obtaining an order? ‘to keep a chaotic patient safe and support him to maintain medication to avoid the development of MDR-TB, second to prevent onwards transmission of a communicable disease.’ ‘Allowed us to make a proper assessment of the case who appeared to be a high risk TB case with lung cavities. The cases investigations were negative for TB and on reflection his cavity was probably from an old lung infection. The section was allowed to lapse and he was allowed to leave hospital, not before he had absconded on a number of occasions while waiting for the results of test(s).’ ‘to find out if the patient was currently smear positive and or not and how much screening was required for work contacts’. ‘to quarantine the patient until drug treatment for his condition was completed’ (7 re-applications) ‘to ensure 12 months of treatment so that he did not relapse again’ (7 re-applications) If you didn’t achieve your aims please comment further ‘We hoped to protect the public from this man whilst the police were preparing criminal charges. That didn’t happen but he did eventually go to prison. We completely failed to protect (the Public)……This was an unsatisfactory process. The law does not allow us to enforce the order in a meaningful way. 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. That these orders are probably not worth pursuing other than to put a marker in the sand.’ Words in Brackets have been added to aid understanding. Table 2 Abstracts from free text comments from respondents. Question from the questionnaire Free text comments What steps were undertaken prior to the order? ‘Numerous attempts from local hospital consultant and his team and TB community nurse service to contact patient and invite him to attend clinic to start treatment once MDR-TB had a laboratory diagnosis. Once all attempts failed, the Consultant (medical) contacted me (PHE Consultant) and we discussed the situation and the plan of action.’ ‘He had gone home on DOT which he’d agreed to take, and had been referred to “Action for change” for help with his alcohol problem. However, since discharge the TB nurse had not been able to make contact with him—he had started drinking heavily again, and was not answering to calls or visits. …. A case conference was held to discuss the case; in which it was agreed that admission was necessary on public health grounds, but a part 2a order would be the final resort. Before this, a referral was to be made to mental health services by his GP; in view that alcohol use and possibly depression were important factors in his non-compliance with TB therapy. Also TB nurse would make further attempts to persuade case to come into hospital voluntarily….’ ‘At least two provision(s) of housing/hostel accommodation, DOT therapy—and numerous occasion trying to find case to observe DOT.’ ‘Incentives: Cash (via the TB Alert fund), Referral to a Polish speaking alcohol worker, Housing….’ Please comment on the difficulties in obtaining the order. ‘Main issue was transfer of PII (patient identifiable information) between agencies in real time—LA (Local authority) had no secure fax or drop box’ ‘co-ordination of relevant reports from medical team and completion of application.’ ‘as he (the patient) was already well known to services most of the services were disinclined to assist with this case-feeling that their priority lay with those that want to take up their services. Note: An amendment was put into the Part 2A re responsibilities for LA, Trust and CCG with regard to Part 2A and provision of services.’ ‘Agreement achieved after a lot of negotiation about the process with all organizations.…… The security staff and Police were concerned about the risk of catching TB. The Trust were very concerned about the financial implications. In court disagreements emerged about the terms of the order and tensions surfaced between different partners.’ Please comment on the difficulties implementing the order Interagency co-ordination ‘Ambulance Service refused to send the ambulance “patient’s life not in danger” and patient took advantage of me (Consultant in communicable disease) being engaged in difficult discussion with ambulance call centre to run away from the house. We then called the police but obviously there was no sign of the patient.’ ‘The patient’s location was identified and police and ambulance contacted to help with enforcing removal to hospital. However, in practice there was difficulty coordinating police and ambulance service when needed. In the end the patient travelled in a private car’ ‘The plan was to have a security guard at the door but this did not happen by the time patient arrived’ Lack of resources ‘(After multiple defaults) the Chief Executive of trust wrote to CCG (care commissioning group) and LA (local authority) saying that they would no longer have a bed for case.’ ‘No negative pressure rooms were available in the hospital where patient was diagnosed. Patient was sent to another hospital within the same Trust, although initially there was significant reluctance and resistance from this hospital.’ ‘unwillingness of hospital to pay for guard, PCT (Primary Care Trust) (finally paid).’ ‘if the patient had refused to comply with the order requiring them to stay in hospital—there was no ability to detain them—due to lack of ability to fund security guard presence—would have been faced with patient leaving, picked up by police, returned to hospital, patient leaving etc.’ Patient specific ‘Order obtained on 20.10… but case was not located until 31.10…. Found by the police’ ‘The patient absconded continually from the ward and we therefore in the end decided to attempt management at home restricting where he could go. That too failed because there was no sanction in law that we could use to enforce the order.’ ‘it was difficult to get the patient to abide by the order as he kept absconding from hospital to access alcohol and smoke. This also increased his risk of MDR-TB as DOTS (directly observed therapy) was compromised.’ ‘The patient was then a security risk for hospital staff being verbally and physically violent.’ ‘The patient was physically and verbally abusive—ASBO (anti-social behaviour order) obtained by LA (local authority).’ ‘On visiting the house of patient his female housemate displayed a more aggressive behaviour, probably due to the effect of intoxicating substances such as alcohol/drugs.’ Please comment on any problems with the service provided by the police ‘the police refused any involvement in this case as their occupational health advised them there would be a risk to them.’ ‘Police received inappropriate advice about PPE—unable to establish where they got this advice’ ‘A lot of discussion in HPZone notes (these are the Public Health England notes) suggesting police were unaware of what they were allowed to do in terms of bringing him back and level of force’ ‘Police involved saying that the part 2A order didn’t give them powers to remove him from the street only from an actual ‘place’. What were your aims in obtaining an order? ‘to keep a chaotic patient safe and support him to maintain medication to avoid the development of MDR-TB, second to prevent onwards transmission of a communicable disease.’ ‘Allowed us to make a proper assessment of the case who appeared to be a high risk TB case with lung cavities. The cases investigations were negative for TB and on reflection his cavity was probably from an old lung infection. The section was allowed to lapse and he was allowed to leave hospital, not before he had absconded on a number of occasions while waiting for the results of test(s).’ ‘to find out if the patient was currently smear positive and or not and how much screening was required for work contacts’. ‘to quarantine the patient until drug treatment for his condition was completed’ (7 re-applications) ‘to ensure 12 months of treatment so that he did not relapse again’ (7 re-applications) If you didn’t achieve your aims please comment further ‘We hoped to protect the public from this man whilst the police were preparing criminal charges. That didn’t happen but he did eventually go to prison. We completely failed to protect (the Public)……This was an unsatisfactory process. The law does not allow us to enforce the order in a meaningful way. 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. That these orders are probably not worth pursuing other than to put a marker in the sand.’ Question from the questionnaire Free text comments What steps were undertaken prior to the order? ‘Numerous attempts from local hospital consultant and his team and TB community nurse service to contact patient and invite him to attend clinic to start treatment once MDR-TB had a laboratory diagnosis. Once all attempts failed, the Consultant (medical) contacted me (PHE Consultant) and we discussed the situation and the plan of action.’ ‘He had gone home on DOT which he’d agreed to take, and had been referred to “Action for change” for help with his alcohol problem. However, since discharge the TB nurse had not been able to make contact with him—he had started drinking heavily again, and was not answering to calls or visits. …. A case conference was held to discuss the case; in which it was agreed that admission was necessary on public health grounds, but a part 2a order would be the final resort. Before this, a referral was to be made to mental health services by his GP; in view that alcohol use and possibly depression were important factors in his non-compliance with TB therapy. Also TB nurse would make further attempts to persuade case to come into hospital voluntarily….’ ‘At least two provision(s) of housing/hostel accommodation, DOT therapy—and numerous occasion trying to find case to observe DOT.’ ‘Incentives: Cash (via the TB Alert fund), Referral to a Polish speaking alcohol worker, Housing….’ Please comment on the difficulties in obtaining the order. ‘Main issue was transfer of PII (patient identifiable information) between agencies in real time—LA (Local authority) had no secure fax or drop box’ ‘co-ordination of relevant reports from medical team and completion of application.’ ‘as he (the patient) was already well known to services most of the services were disinclined to assist with this case-feeling that their priority lay with those that want to take up their services. Note: An amendment was put into the Part 2A re responsibilities for LA, Trust and CCG with regard to Part 2A and provision of services.’ ‘Agreement achieved after a lot of negotiation about the process with all organizations.…… The security staff and Police were concerned about the risk of catching TB. The Trust were very concerned about the financial implications. In court disagreements emerged about the terms of the order and tensions surfaced between different partners.’ Please comment on the difficulties implementing the order Interagency co-ordination ‘Ambulance Service refused to send the ambulance “patient’s life not in danger” and patient took advantage of me (Consultant in communicable disease) being engaged in difficult discussion with ambulance call centre to run away from the house. We then called the police but obviously there was no sign of the patient.’ ‘The patient’s location was identified and police and ambulance contacted to help with enforcing removal to hospital. However, in practice there was difficulty coordinating police and ambulance service when needed. In the end the patient travelled in a private car’ ‘The plan was to have a security guard at the door but this did not happen by the time patient arrived’ Lack of resources ‘(After multiple defaults) the Chief Executive of trust wrote to CCG (care commissioning group) and LA (local authority) saying that they would no longer have a bed for case.’ ‘No negative pressure rooms were available in the hospital where patient was diagnosed. Patient was sent to another hospital within the same Trust, although initially there was significant reluctance and resistance from this hospital.’ ‘unwillingness of hospital to pay for guard, PCT (Primary Care Trust) (finally paid).’ ‘if the patient had refused to comply with the order requiring them to stay in hospital—there was no ability to detain them—due to lack of ability to fund security guard presence—would have been faced with patient leaving, picked up by police, returned to hospital, patient leaving etc.’ Patient specific ‘Order obtained on 20.10… but case was not located until 31.10…. Found by the police’ ‘The patient absconded continually from the ward and we therefore in the end decided to attempt management at home restricting where he could go. That too failed because there was no sanction in law that we could use to enforce the order.’ ‘it was difficult to get the patient to abide by the order as he kept absconding from hospital to access alcohol and smoke. This also increased his risk of MDR-TB as DOTS (directly observed therapy) was compromised.’ ‘The patient was then a security risk for hospital staff being verbally and physically violent.’ ‘The patient was physically and verbally abusive—ASBO (anti-social behaviour order) obtained by LA (local authority).’ ‘On visiting the house of patient his female housemate displayed a more aggressive behaviour, probably due to the effect of intoxicating substances such as alcohol/drugs.’ Please comment on any problems with the service provided by the police ‘the police refused any involvement in this case as their occupational health advised them there would be a risk to them.’ ‘Police received inappropriate advice about PPE—unable to establish where they got this advice’ ‘A lot of discussion in HPZone notes (these are the Public Health England notes) suggesting police were unaware of what they were allowed to do in terms of bringing him back and level of force’ ‘Police involved saying that the part 2A order didn’t give them powers to remove him from the street only from an actual ‘place’. What were your aims in obtaining an order? ‘to keep a chaotic patient safe and support him to maintain medication to avoid the development of MDR-TB, second to prevent onwards transmission of a communicable disease.’ ‘Allowed us to make a proper assessment of the case who appeared to be a high risk TB case with lung cavities. The cases investigations were negative for TB and on reflection his cavity was probably from an old lung infection. The section was allowed to lapse and he was allowed to leave hospital, not before he had absconded on a number of occasions while waiting for the results of test(s).’ ‘to find out if the patient was currently smear positive and or not and how much screening was required for work contacts’. ‘to quarantine the patient until drug treatment for his condition was completed’ (7 re-applications) ‘to ensure 12 months of treatment so that he did not relapse again’ (7 re-applications) If you didn’t achieve your aims please comment further ‘We hoped to protect the public from this man whilst the police were preparing criminal charges. That didn’t happen but he did eventually go to prison. We completely failed to protect (the Public)……This was an unsatisfactory process. The law does not allow us to enforce the order in a meaningful way. 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. That these orders are probably not worth pursuing other than to put a marker in the sand.’ Words in Brackets have been added to aid understanding. Difficulties in obtaining the orders Respondents were asked to describe any difficulties experienced obtaining the order. The 15 people answered this question. Difficulties were described in four cases (4/15, 27%) and no problems were commented on in 11 (11/15, 73%). The four difficulties described related to interagency co-ordination (transfer of patient identifiable data between agencies, co-ordination of reports) and lack of agreement by the multiple agencies on their individual responsibilities and the terms of the Part 2A Order (Table 2). Implementation of the orders Respondents were asked to describe difficulties encountered implementing the Part 2A Orders. Six (6/24, 25%) documented that there were no problems implementing the order. The 18 (18/24, 75%) respondents documented one or more problem. Interagency co-ordination was again a problem especially between the police, public health officials and ambulance services on the initial pick up of the patient (four respondents) and co-ordinating a bed and a guard at the correct moment (two respondents). Lack of resources were a major issue, including lack of availability of a negative pressure bed (four comments) and the lack of availability of a guard or uncertainty as to who should pay for the guard (nine respondents). There were examples of the guard being paid for by the hospital, the LA and the primary care trust (PCT). Patient behaviour-related difficulties were also a feature. Six respondents commented on the difficulties of locating the patient at the start or after absconding, eight respondents commented on the patient absconding and how to re-find the patient or stop this happening again and three commented on difficulties experienced when the patient or friends were verbally or physically abusive to staff. Police involvement in the implementation of the orders Respondents were asked whether the police were involved and if any problems arose in the process. A total of 25 (25/29) respondents answered this question. And 17 (17/25, 68%) used the police. The majority of comments were very positive about their experiences contacting the police (six comments). Some respondents were frustrated with the lack of occupational (infection control) advice given to the police or the inappropriateness of the advice given (three respondents) and the ignorance on the part of the police about the Part 2A Order, in particular, the degree of force they could use to implement the Part 2A Order. Description of aims and whether aims were achieved Respondents were asked to describe their aims in using the Part 2A Orders and whether these aims were achieved. In total, 23 responded to this question. Overall, 96% (22/23) achieved their aims. The majority of respondents stated that their aim in using the order was to remove an infectious individual and protect the public, as well as establish medical therapy. Many of the aims stated were also broader than protecting the public and were implemented to support the patient through alcohol and adherence counselling, housing support and financial support packages. The Part 2A Orders were also used for patients who were potentially infectious; both for those without a definitive diagnosis of TB (quarantine) who may have been infectious at the time of order (n = 1) (e.g. for a patient with a cavity on a chest radiograph who was refusing to give sputum samples and lived in shared accommodation) and for those who were known to be infected but not currently infectious (n = 3). The latter category included patients who had been established on medical therapy under a Part 2A Order and were considered likely, through poor adherence, to relapse to an infectious state if the order elapsed. In the only HIV Case in which a Part 2A Order was obtained, the aims were not achieved. Frustration was expressed with the Part 2A Orders due to lack of ability to sanction or facilities to enforce the Order. In this example, the patient continually absconded from the ward and was known to have had unprotected sexual intercourse. Orders used against things There was a 100% reply rate and 13 (13/23) orders were initiated by one environmental health department. All orders were initiated to prevent blood-borne virus spread through the seizing of potentially contaminated equipment. All respondents reported that the orders were used due to limited alternative powers and/or lack of owner collaboration. The environmental health officer (EHO) responsible for 13 of the Orders explained on the questionnaire why the alternative powers were limited as follows: ‘Health and Safety Executive are required to transfer powers to LAs for enforcement Orders for work done in the home but these transfers are not happening so alternative powers have been sought’. The only problem in obtaining an Order was the Court’s unfamiliarity with the process. The problems with implementation were multi-agency coordination (requirement for police, locksmith, trading standards officer to be present), change of address for owner, dogs on site and costs. A police officer was involved in all cases. Respondents stated that aims were achieved in all cases, i.e. the removal of equipment. The general comments were all positive along the lines of: ‘Very effective from a public health and enforcement side to remove the risk and allows for more evidence to add to prosecution file. Also good deterrent to others operating illegally as there is a financial loss for the tattooist’. The only negative comment about achieving aims was that the respondent knew of instances where the tattooist had obtained new equipment. Orders used against premises Overall, 100% (3/3) response rate was obtained. Again these orders were used because of limited alternative powers to restrict work carried at home. No difficulties in obtaining Orders were identified and the only difficulty in implementation was lack of co-operation by the tenant. The aims were achieved in all cases. Conclusion Main findings We undertook the first survey of Part 2A Order usage since their introduction. We show that these orders are used mainly against persons with TB and increasingly for tattoo equipment for things. The orders were straightforward to obtain but in relation to persons were sometimes difficult to implement due to the actions of the individuals being detained, interagency co-operation and limited availability of resources especially guards. We also found that extended powers (e.g. quarantine), newly enshrined in 2010 regulations, were being used. What is already known? All Part 2A Orders create a tension between an individual’s liberty (freedom of movement, personal property) and the health of others (the public). However, the orders detaining people pose the most significant threat to the individual’s rights, so monitoring is important. In England, the powers aim to strike a balance between individual liberty and the public, do not include DOT attendance or coercive treatment and are in line with many countries in Europe.11 Some commentators argue that Orders are never necessary because we have limited evidence that detention prevents spread in TB (significant contacts are normally already exposed),12 that TB is a condition of poverty and it is not fair or just to remove liberty from those already with so little, and thirdly that, with proper funding, alternative measures (wrap-around care etc) should never be inadequate.13,14 However, internationally, the use of legal orders against persons is lawful and dependent on compliance with local law, lack of arbitrariness, proportionality, necessity, as well as international legislation,15 Siracusa principles16 World Health Organization (WHO) guidance for TB17,18 and in case law from the European Court of Human Rights (ECHR).19 Only one case of enforced detention has been challenged at the ECHR. The court ruled that the man was unlawfully detained on the grounds that there was no evidence that less severe measures had been considered and found inadequate (i.e. it was not necessary).5 A case that was upheld at a country level in Europe was that of a patient with MDR-TB in Ireland who refused treatment and continued to be infectious. Prolonged detention due to the patient’s infectivity was upheld.20 What this study adds Although the purpose of our survey was not to establish whether individual cases would have been upheld in a legal challenge we were reassured that respondents stated that multiple interventions had taken place prior to the application and that, in many cases, the patient was hard to find and refusing admission both suggesting the Part 2A Order was necessary. Reassuringly, the numbers of Orders used against persons was low at under 0.1% per TB notification (5 Orders per year when TB notifications were in the range of 6000–9000 cases per year21,22) and at similar levels to a previous report, and not supporting suggested onward increase in use.23 A comparison of use of enforced detention for Tuberculosis or other infectious conditions is difficult because little is published internationally and some countries have no powers to detain on public health grounds.11 However, the rate of use in the UK of legal powers is low compared to reports that are available.18,24,25 The 2010 Regulations are procedurally tighter with significant safeguards (28 days duration, representation, right to appeal) for the individual, compared with the previous versions of sections 37 and 38 of the Public Health Act 1984, which they replaced (Table 3). However, the standard for certainty about infectious risk posed by the person has been relaxed in the amended legislation. Before the amended legislation, the JP has to be certain that the ‘Person is suffering from a notifiable disease’ and that ‘serious risk of infection is thereby caused to other persons’. By contrast, the amended legislation states that the JP must be certain that the ‘person is or may (quarantine law introduction) be infected’ and that there is ‘a risk that the person might infect or contaminate others’. We show that there is evidence that the amended legislation is being used as a quarantine law and that renewals of orders are, on occasion, being made several times against patients who are not infectious currently, but who may become so in the event that they fail to complete therapy. It is difficult to establish whether the criteria by which applications were being determined were consistently applied and whether, in each case, these renewals were objectively necessary (to protect public health in the future, through ensuring full treatment compliance). Nevertheless, our view is that this study shows that the orders are not being abused and we know well that non-compliance with a full course of treatment can result in re-infectiousness. Table 3 Differences between the sections 37 and 38 of the Public Health Act 1984 and the Health Protection Regulations 2010 (Part 2A orders) (2, 27, 28) Sections 37 and 38 of the Public Health Act 1984 Part 2A Orders: Heath and Social Care Act 2008/2010 Regulations Application made by Local authority Local authority Application to Justice of the peace (Magistrate) Justice of the peace (Magistrate) Acceptable in absentia Yes, if the JP deems it necessary Yes, if a risk of patient absconding Grounds that must be met Person is suffering from a notifiable disease Persons circumstances are such that proper precautions to prevent the spread of infection cannot be taken That serious risk of infection is thereby caused to other persons The person is or may be infected/ contaminated The infection or contamination presents or could present significant harm to human health There is a risk that the person might infect or contaminate others; It is necessary to make the order to remove or reduce the risk Compulsory measures that can requested Removal to hospital Detention in hospital Medical examination Removal to hospital Detention in hospital/isolation Disinfection/decontamination Wearing of protective clothing Answering questions re health and contacts Health monitoring and results reporting Attendance of training/ advice on reducing risk of infection Restrictions on movement Abstention from work Duration None defined 28 Days, can be re-applied for Right of Appeal No Yes Written notification of legal orders to person No Yes Monitoring of law No Yes: all applications for orders must reported to Public Health England (previously the Health Protection Agency) Fine if the patient does not comply with the order Level one on standard scale Fine may not exceed £20 000 Sections 37 and 38 of the Public Health Act 1984 Part 2A Orders: Heath and Social Care Act 2008/2010 Regulations Application made by Local authority Local authority Application to Justice of the peace (Magistrate) Justice of the peace (Magistrate) Acceptable in absentia Yes, if the JP deems it necessary Yes, if a risk of patient absconding Grounds that must be met Person is suffering from a notifiable disease Persons circumstances are such that proper precautions to prevent the spread of infection cannot be taken That serious risk of infection is thereby caused to other persons The person is or may be infected/ contaminated The infection or contamination presents or could present significant harm to human health There is a risk that the person might infect or contaminate others; It is necessary to make the order to remove or reduce the risk Compulsory measures that can requested Removal to hospital Detention in hospital Medical examination Removal to hospital Detention in hospital/isolation Disinfection/decontamination Wearing of protective clothing Answering questions re health and contacts Health monitoring and results reporting Attendance of training/ advice on reducing risk of infection Restrictions on movement Abstention from work Duration None defined 28 Days, can be re-applied for Right of Appeal No Yes Written notification of legal orders to person No Yes Monitoring of law No Yes: all applications for orders must reported to Public Health England (previously the Health Protection Agency) Fine if the patient does not comply with the order Level one on standard scale Fine may not exceed £20 000 Table 3 Differences between the sections 37 and 38 of the Public Health Act 1984 and the Health Protection Regulations 2010 (Part 2A orders) (2, 27, 28) Sections 37 and 38 of the Public Health Act 1984 Part 2A Orders: Heath and Social Care Act 2008/2010 Regulations Application made by Local authority Local authority Application to Justice of the peace (Magistrate) Justice of the peace (Magistrate) Acceptable in absentia Yes, if the JP deems it necessary Yes, if a risk of patient absconding Grounds that must be met Person is suffering from a notifiable disease Persons circumstances are such that proper precautions to prevent the spread of infection cannot be taken That serious risk of infection is thereby caused to other persons The person is or may be infected/ contaminated The infection or contamination presents or could present significant harm to human health There is a risk that the person might infect or contaminate others; It is necessary to make the order to remove or reduce the risk Compulsory measures that can requested Removal to hospital Detention in hospital Medical examination Removal to hospital Detention in hospital/isolation Disinfection/decontamination Wearing of protective clothing Answering questions re health and contacts Health monitoring and results reporting Attendance of training/ advice on reducing risk of infection Restrictions on movement Abstention from work Duration None defined 28 Days, can be re-applied for Right of Appeal No Yes Written notification of legal orders to person No Yes Monitoring of law No Yes: all applications for orders must reported to Public Health England (previously the Health Protection Agency) Fine if the patient does not comply with the order Level one on standard scale Fine may not exceed £20 000 Sections 37 and 38 of the Public Health Act 1984 Part 2A Orders: Heath and Social Care Act 2008/2010 Regulations Application made by Local authority Local authority Application to Justice of the peace (Magistrate) Justice of the peace (Magistrate) Acceptable in absentia Yes, if the JP deems it necessary Yes, if a risk of patient absconding Grounds that must be met Person is suffering from a notifiable disease Persons circumstances are such that proper precautions to prevent the spread of infection cannot be taken That serious risk of infection is thereby caused to other persons The person is or may be infected/ contaminated The infection or contamination presents or could present significant harm to human health There is a risk that the person might infect or contaminate others; It is necessary to make the order to remove or reduce the risk Compulsory measures that can requested Removal to hospital Detention in hospital Medical examination Removal to hospital Detention in hospital/isolation Disinfection/decontamination Wearing of protective clothing Answering questions re health and contacts Health monitoring and results reporting Attendance of training/ advice on reducing risk of infection Restrictions on movement Abstention from work Duration None defined 28 Days, can be re-applied for Right of Appeal No Yes Written notification of legal orders to person No Yes Monitoring of law No Yes: all applications for orders must reported to Public Health England (previously the Health Protection Agency) Fine if the patient does not comply with the order Level one on standard scale Fine may not exceed £20 000 Much of the evidence from this study suggests that the facilities for detention are not appropriate and are limiting effective public health action. The difficulties described—securing beds, guards and the number of patients who default—show that we do not have the facilities to provide care safely in locked rooms with permanent guards. Although the UK is not alone,26 the current situation where patients are detained in small acute hospital side rooms with limited access to the outside, occupational assistance or financial compensation for lost earnings it is not surprising that patients default. Moral theories of reciprocity as a justification for public health action would suggest that if we were to provide improved community 24-h care with access to the outside and wrap-around support to those who are deprived of their liberty to protect the public, that society would reap the benefit of better outcomes and adherence.27 The main limitations The main limitation of our study is that it does not include all the Part 2A Orders that were considered but not applied for and the reasons for these choices. Another issue is around efficacy of the orders due to the circularity of asking those who defined the aims of use to comment on outcomes. If we had surveyed physicians or patients, we are likely to have had different responses. Furthermore, although the aims were reported as achieved in most cases, there were multiple reports of patients absconding from the wards where it is possible transmission may have occurred. Finally, we are aware that there are concerns about whether Part 2A Orders can be implemented rapidly should this be needed. This issue did not appear in this study, presumably because TB is a chronic disease with longer time scales. We conclude that Part 2A Orders are currently being used as a last resort but improved facilities for safe and secure isolation would help improve implementation of Orders against people. Funding There was no funding for this study except that AA was employed as a teaching fellow at St George’s Healthcare NHS Trust and GB was an employee of Public Health England. Ethics The work was undertaken as a service evaluation of the Part 2A order process and no patient identifiable information was collected in line with Caldicott Principles. Conflicts of interest None declared. References 1 Health Protection (Part 2A Orders) Regulations 2010 (SI 2010/658). 2 Health and Social Care Act 2008 (c. 14. 2008). 3 Public Health (Control of Disease) Act 1984 (c. 22. 1984). 4 Coker RJ . The law, human rights, and the detention of individuals with tuberculosis in England and Wales . J Public Health Med 2000 ; 22 ( 3 ): 263 – 7 . Google Scholar CrossRef Search ADS PubMed 5 Martin R . The exercise of public health powers in cases of infectious disease: human rights implications . Med Law Rev 2006 ; 14 ( 1 ): 132 – 43 . Google Scholar CrossRef Search ADS PubMed 6 Harris A , Martin R . The exercise of public health powers in an era of human rights: the particular problems of tuberculosis . Public Health 2004 ; 118 ( 5 ): 313 – 22 . Google Scholar CrossRef Search ADS PubMed 7 World Health Assembly . International Health Regulations ( 2005 ). World Health Assembly, 2005. 8 Department of Health . Review of Parts 2, 5 and 6 of the Public Health (Control of Disease) Act 1984: A Consultation . London : Department of Health , 2007 . 9 Department of Health . Review of Parts 2, 5 and 6 of the Public Heath (control of Disease) Act 1984: Report on Consultation . London : Department of Health , 2007 . 10 Green J , Thorogood N . Qualitative Methods for Health Research . Los Angeles, USA : Sage , 2009 . 11 Coker RJ , Mounier-Jack S , Martin R . Public health law and tuberculosis control in Europe . Public Health 2007 ; 121 ( 4 ): 266 – 73 . Google Scholar CrossRef Search ADS PubMed 12 Coker RJ . Public health impact of detention of individuals with tuberculosis: systematic literature review . Public Health 2003 ; 117 ( 4 ): 281 – 7 . Google Scholar CrossRef Search ADS PubMed 13 Todrys KW , Howe E , Amon JJ . Failing Siracusa: governments’ obligations to find the least restrictive options for tuberculosis control . Public Health Action 2013 ; 3 ( 1 ): 7 – 10 . Google Scholar CrossRef Search ADS PubMed 14 Selgelid MJ . Ethics, tuberculosis and gloablization . Public Health Ethics 2008 ; 1 ( 1 ): 10 – 20 . Google Scholar CrossRef Search ADS 15 United Nations . International Covenant on Civil and Political Rights . New York : United Nations , 1966 . 16 The Siracusa Principles on the Limitation and Derogation Provisions in the International Covenant on Civil and Political Rights. United Nations Commission on Human Rights: New York, 1984 . 17 World Health Organization . Guidance on Ethics of Tuberculosis Prevention, Care and Control . Geneva, Switzerland : World Health Institution , 2010 . 18 World Health Organization . Tuberculosis, Ethics and Human Rights. Report of a Regional Workshop 2013 . Copenhagen, Denmark : World Health Organization , 2013 . 19 Enhorn v. Sweden (Application no. 56529/00). 41 EHRR 633, 19 BHRC 222, Judgement, European Court of Human Rights, Strasbourg, 2005 . 20 Donnelly M . Public Health and Patient Rights: S v HSE [2009] IEHC 106 . Medico-Legal J Ireland 2009 ; 15 ( 2 ): MLJI 66 . 21 Tuberculosis in England : 2015 report version 1.1. 2015 . Public Health England: London. 22 Tuberculosis in the UK . Annual Report on Tuberculosis Surveillance in the UK . London : Health Protection Agency , 2012 . 23 Coker RJ . National survey of detention and TB . Thorax 2001 ; 56 ( 10 ): 818 . Google Scholar CrossRef Search ADS PubMed 24 Pursnani S , Srivastava S , Ali S et al. . Risk factors for and outcomes of detention of patients with TB in New York City: an update: 2002–2009 . Chest 2014 ; 145 ( 1 ): 95 – 100 . Google Scholar CrossRef Search ADS PubMed 25 Lerner BH . Catching patients: tuberculosis and detention in the 1990s . Chest 1999 ; 115 ( 1 ): 236 – 41 . Google Scholar CrossRef Search ADS PubMed 26 Conaty S . Detention to prevent transmission of tuberculosis: a proportionate public health response? N S W Public Health Bull 2012 ; 23 ( 5–6 ): 120 – 1 . Google Scholar CrossRef Search ADS PubMed 27 Viens AM , Bensimon CM , Upshur REG . Your liberty or your life: reciprocity in the use of restrictive measures in contexts of contagion . Bioeth Inq 2009 ; 6 : 207 – 17 . Google Scholar CrossRef Search ADS © The Author(s) 2018. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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Journal of Public HealthOxford University Press

Published: Mar 24, 2018

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