Corporate report

UKHSA Advisory Board: preparedness for infectious disease threats

Updated 2 February 2023

Date: Tuesday 24 January 2023

Sponsor: Susan Hopkins, Chief Medical Advisor

Presenter: Susan Hopkins

Purpose of the paper

The purpose of the paper is to outline the current infectious diseases threats, through the dominant routes of transmission and highlight the preparedness work within the organisation.

Recommendation for the Advisory Board

The Advisory Board is asked to:

  • note the activities underway in UK Health Security Agency (UKHSA) to build capacity and capability to prevent, detect, and manage infectious diseases threats
  • comment on the current work and development work underway in UKHSA and identify significant gaps in the approach
  • comment on the key choices that UKHSA and government may need to make to improve preparedness

Background

The aim of this paper is to give an overview of infectious diseases that the UKHSA is managing and preparing for, to highlight dominant routes of transmission and to discuss the preparedness work being done within the organisation.

Burden of infectious diseases

The absolute number of infectious diseases in the population is challenging to quantify. Respiratory tract infections are one of the most common reasons for attending primary care. About 7% of admissions to hospital have a primary infection diagnosis and at least one third of emergency admissions to hospital receive an antimicrobial therapy to treat an infection. Pneumonia and upper respiratory infections are the most common syndromic diagnosis. More than 500,000 admissions have a pathogen identified and coded (pre-pandemic). While the burden of infectious diseases is much lower in high income countries (HICs) compared to low and middle-income countries (LMICs), the impact of emerging and pandemic threats on society is globally significant. An outline of the estimated burden for certain infections under active surveillance and response in England is included in Annexe A.

Routes of transmission

The 5 main routes of transmission are:

  • respiratory (including droplet and aerosol)
  • vector-borne (mosquitoes, ticks, sandflies and more)
  • contact (touch)
  • oral (food and water)
  • sexual or blood (including mother to child transmission)

Some diseases can be transmitted through multiple routes, but they usually have a predominant route of transmission. For example, vector-borne diseases such as Zika and dengue can also be transmitted through blood. Many contact (touch) illnesses will also be transmitted through sexual routes or blood routes for example, mpox (monkeypox) and Ebola. Oral transmission infections can also be transmitted through some sexual practices (such as Shigella, Hepatitis A). Respiratory diseases can also be transmitted through contact with the environment, for example influenza and respiratory syncytial virus (RSV).

Despite the multiple routes of transmission, in practice, when other options such as vaccination or prophylaxis are unavailable, targeting the main route of transmission will be the most effective public health response to reduce infection spread. This, therefore, is where the priority lies for public health guidance. In health emergencies and pandemics, further government interventions may also be required to control infectious diseases.

Current infectious disease under surveillance

It is difficult to provide a specific number of infectious diseases that are currently being monitored globally, as new diseases can emerge at any time. Many surveillance systems are designed to capture recognised and unusual syndromes, and a wide variety of laboratory-identified pathogens. For known specific threats, the level of monitoring and response can vary depending on the specific disease and the resources available to track and monitor the delivery of effective interventions.

There are more than 30 named infectious diseases (some of these contain multiple different pathogens), and more than 70 organisms causing these diseases, that are notifiable to UKHSA via the Health Protection regulations (Annexe B). The list is not exhaustive and may be updated from time to time to include new infectious diseases that are determined to be of public health importance.

Importantly, when new infectious diseases emerge, particularly from the animal-to-human interface, they are detected if they cause significant human disease. Most recently, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2, often referred to as COVID-19) is an example of a new infectious disease that emerged from the animal-to-human interface to cause a global pandemic.

National specialist teams and regional health protection teams (HPTs) will:

  • conduct risk assessments
  • implement control measures to prevent the further spread of the disease
  • develop evidence-based guidance for healthcare providers and professionals, the non-health sector (for example, schools, business), and the public
  • recommend individuals for diagnostic testing and treatment
  • provide training education

UKHSA has established programmes to reduce the impact of common infectious diseases through detecting, analysing, responding, delivering, and engaging with the wider health system.

Specific current concerns for each transmission route:

Respiratory (airborne) transmitted infections

New evidence has developed over the course of the COVID-19 pandemic and with partners, suggesting we need to consider how the built environment can help reduce transmission in conjunction with traditional methods of prevention. Zoonotic infections, particularly related to influenza, require collaboration across human and animal sectors, with the sharing of data and research, and through academic partnerships.

Orally (food and water) transmitted infections

These require robust management of food and water quality; reducing sewage contaminating water and the environment; and food safety, which are dependent on other organisations. The detection of identified pathogens in clinical cases depend on NHS laboratories and the sharing of isolates for genome sequencing with UKHSA.

Cross-organisational working is required for the regulatory response to remove identified contaminated items from the food chain. Clean water and reductions of sewage overflows into the environment require other government agencies. The recent detection of vaccine derived poliovirus in London sewage, and the subsequent response, demonstrates the multi-agency collaboration on an orally-transmitted infection.

Contact (touch) infections

These require high levels of hand hygiene and cleaning. Current health system pressures and high occupancy rates mean that infections – for example, Methicillin-Resistant Staphylococcus aureus (MRSA) – which have seen a reduction in prevalence over the last 20 years, are at higher risk for outbreaks. Monitoring of recognised healthcare-associated infections (HCAI) continues, and identification of new threats; with the use of genomic surveillance to assess transmission and mechanism of antibiotic resistance; will be important.

Sexually-transmitted infections

Sexually-transmitted infections (STIs) are increasing in England. Changes in commissioning of services have occurred, coupled with reductions in funding over the last 10 years. Significant progress has been made on reducing the impact of blood-borne viruses (BBV) (for example, HIV, HBV, HCV) within the population. However, it is important to target resources on populations who are harder to reach with specific equality programmes with partner organisations.

Population groups of African-Caribbean descent have higher rates of some STIs; men who have sex with men (MSM) population groups, who do not identify as gay or bisexual, require specific interventions and outreach particularly related to pre-exposure prophylaxis (PrEP) for HIV; injecting drug-users and homeless individuals need resources for needle exchange, substitute programmes and access to treatments.

Vector-borne infections

A small number are already endemic (for example, Lyme, tick-borne encephalitis virus, and Usutu) to the UK. Other vector-borne infections are predominantly imported (for example, dengue and chikungunya).

Climate and environmental change mean that we need to enhance current surveillance of vectors and their pathogens; improve the awareness of clinicians in their diagnosis in patients with infectious diseases, without travel abroad; and build capacity to deliver contingency planning to manage emerging vector-borne health threats. Predecessor organisations developed a vector surveillance programme with partner organisations, and this is in the process of being enhanced to improve detection and develop interventions to reduce vector incursion and spread in the UK.

Risk assessment

In the UK, infectious disease threats are included in the national security risk assessment (NSRA) with 3 main threats for humans identified:

  • emerging infectious diseases (EID) (up to 2,000 cases, aiming for containment); this also includes pathogens with the likelihood of limited transmission but with high mortality (for example, greater than 10 to 20%)
  • pandemic infectious diseases (may arise as an EID but with pandemic pathogen factors that lead to up to 50% of the population having symptomatic disease, moving from containment to management)
  • antimicrobial resistance (in any pathogen), leading to a resurgence in previously treatable infectious diseases with resulting morbidity (illness) and mortality (death)

The development of these threat assessments involved UKHSA expert input to a Cabinet Office standardised framework throughout 2021 to 2022.

In addition, the UKHSA All Hazards Intelligence division (AHI) is developing a health security threat assessment which will compare a range of current public health threats that the UK faces and examine how these may evolve over the next 5 to 10 years. It is likely that this will focus on some key areas of emerging or major threats but will need to recognise the continued work to deliver stabilisation, reduction, or elimination targets already in place.

Global and national horizon scanning, and risk assessment is a key function of the organisation that requires further development, global cooperation and information exchange, as well as the use of genomics and high-quality data science to identify new and emerging threats.

Key emerging infectious diseases currently identified

  • a novel respiratory-transmitted infection that emerges zoonotically in another country. Many of these pathogens acquire some degree of human-to-human transmission, but ultimately do not possess the characteristics that predispose pandemic potential (for example, some coronaviruses such as MERS and Nipah virus)
  • viral haemorrhagic fever (for example, Ebola and Marburg virus)
  • vector-borne disease (for example, dengue fever or Zika) or the establishment of an infection in a vector population that is already established in the UK (for example, West Nile virus or tick-borne encephalitis virus)
  • zoonotic infection where the emerging infection arises from an animal reservoir. The most recent example of a potential emerging infectious disease is mpox which disseminated rapidly, globally, through sexual networks
  • food-borne infection, including a novel food-borne infection or new type or variant, which is difficult to detect through existing diagnostic assays (for example, E. coli O154)

Pandemic threats

While the causative organism for the next pandemic is unknown, we consider the following characteristics when making preparedness plans:

Transmissibility

The pathogen should be easily transmissible from person to person, either through direct contact or through a vector. The pathogen should be able to cause infection in a high proportion of people who are exposed to it. R0, the average number of secondary cases generated by a single primary case in a population with no immunity from disease. If the number is above 1, this signifies growth and requires intervention to lower it. (Respiratory > Touch > Blood/ Sex > Vector > Oral (water and food))

Generation time and serial interval

Infections with a shorter generation time (the time it takes for an infected individual to infect another person) and serial interval (the time between successive cases in a chain of transmission) can help to determine effective isolation and quarantine periods. Infections with short generation times are harder to control through contact tracing as secondary transmission may have already occurred.

Severity

The disease caused by the pathogen should be severe enough to cause significant morbidity and mortality.

Prolonged asymptomatic phase while infectious

A pathogen which does not manifest external symptoms but can still transmit and cause disease in others is harder to detect and control (HIV and Hepatitis > SARS-CoV-2 > Zika > VHF).

Lack of immunity

The population should have little or no immunity to the pathogen, either through natural exposure or previous vaccination (emerging or re-emerging > prior infections or vaccinations).

Ability to mutate

The pathogen should have the ability to mutate and evolve, which can allow it to evade the body’s immune system and continue to spread (RNA viruses > DNA viruses > Bacteria > Fungi > Protozoa).

Ability to survive outside of a host

The pathogen should be able to survive for periods of time outside of a host, which can allow it to be transmitted through inanimate objects or the environment (airborne > surfaces > food and water > bodily fluids).

Influenza (particularly arising from zoonoses or recombinant), novel or recombinant coronaviruses, and parainfluenza virus families, are particular respiratory viruses which require ongoing surveillance and assessment.

Antimicrobial resistance is also a focus of cross government activity and has a long-term strategy and action plan. This will not be covered further in this paper.

UKHSA’s strengths to prevent and prepare for infectious disease threats

The UK has strong public health infrastructure in place, including robust surveillance systems, laboratories, and emergency response plans. Key components of this are outlined below, including developments to strengthen and improve. UKHSA will need to review the funding models available for each of these areas and agree the priorities for funding for future financial years. UKHSA has also enhanced its preparedness through the Centre for Pandemic Preparedness (CPP) and delivery and engagement with the G7 100-day mission for diagnostics, therapeutics and vaccines.

Public health laboratory infrastructure

The UKHSA public health laboratories are quality-assured laboratories, many providing reference laboratory functions for England and for some pathogens in the UK. More than 350 laboratory tests are available to access by clinical and public health staff. Testing that is performed for public health purposes (control of outbreak, national programme delivery, development of novel insights, or surveillance) is provided within the UKHSA budget. Testing performed for an individual’s clinical management (due to rarity of infection in the UK or difficulty in providing a validated test in NHS laboratories) is charged to the NHS trust requesting the test.

UKHSA also maintains capacity for laboratory animal models to understand disease virulence, improve vaccine development, and understand the biological response to therapeutics and vaccines; to rapidly validate a wide range of commercial assays for use in the laboratories or scale up to population testing, including working with regulators and industry; laboratory footprint and capacity, including access to suitable high containment category 3 and 4 laboratories for ongoing research and testing capabilities; and the development of surge laboratory commissioning (including reagents and equipment) and identify models to enable the rapid scaling up of wider population testing if required (other papers are in preparation to detail this further).

Pathogen genomics

Genomic sequencing of pathogens is increasingly critical for: public health interpretation of infection control; pathogen identification and discrimination; immunisation policy; and the monitoring of variants within the population. Prior organisations have initiated a pathogen genomics programme to allow microbial testing, surveillance, and outbreak investigation and antimicrobial testing since 2012.

Currently, routine whole-genome sequencing (WGS) is undertaken for pathogens outlined in Annexe C. For the key pathogens, transfer of traditional microbiology to pathogen genomics reduced the required laboratory staff by 75% and provided multiple efficiencies. This has enabled the rapid detection of outbreaks of food-borne infectious diseases, preventing surges of cases (for example, the salmonella outbreak related to Kinder Chocolate Eggs incident in 2022), and has supported the reduction of tuberculosis through the tracking of outbreaks and by improving our understanding of transmission patterns.

Traditional microbiology and virology are required to validate the genomic methods and results, and to be available where there are discrepancies. Some of the components require traditional laboratory components (for example, growth of some bacterial species, or DNA/RNA extraction). High-throughput automated sequencing techniques can then be used to generate genomes. Critical enablers for this work are the development, validation and use of bioinformatic tools to identify genes, mutations, relatedness between species, and provide information on antimicrobial resistance.

The UK has demonstrated the ability to scale pathogen genomics and enable world-leading insights and analysis through well-established programmes for tuberculosis, gastrointestinal infections and COVID-19 and has build partnerships with academic and industry that could enable us to develop a future pan-pathogen genomics programme.

Vaccines, countermeasures and non-pharmaceutical interventions

The UK delivers more than 30 vaccination programmes. UKHSA purchase, store and deliver many UK-administered vaccines to health sites (excluding seasonal influenza) on behalf of DHSC. Prior to introduction, new vaccine programmes undergo rigorous cost-effective studies developed by UKHSA. Once introduced, the effectiveness, public health benefit and impact on disease is measured by UKHSA through monitoring and research studies in collaboration with academic partners and industry. Transparent reporting of adverse events is reported by the Medicines and Healthcare products Regulatory Agency (MHRA) through the yellow card scheme and detailed investigations and studies are undertaken jointly by UKHSA and MHRA.

Public health campaigns and marketing are delivered by UKHSA, usually under the banner of the NHS, with each campaign requiring central government funding and approval. UKHSA scientists contribute to early vaccine development and laboratory evaluation working in partnership with industry and academia.

All of these ongoing activities contribute to high population acceptability of the vaccine programmes (for example, people aged over 70 years in the UK have more than 80% uptake of the most recent COVID-19 Autumn booster compared to an uptake of less-than 30% in the USA). However, there are population groups that remain hesitant in accepting vaccine uptake and have led to the requirement of booster campaigns to prevent the spread of serious childhood illness (for example, polio and measles) and we need to continue to work with partners, third sector and communities to improve uptake in harder to reach populations. Vaccines can also be used as part of a specific response to an outbreak or threat (for example, smallpox vaccination in MSM during the mpox outbreak and the polio booster with the detection of vaccine-derived poliovirus in wastewater in London). These interventions are agreed as part of response measures with the Department of Health and Social Care (DHSC) and the NHS, via UKHSA advice and endorsement by the Joint Committee on Vaccination and Immunisation (JCVI).

Substantial advancements in vaccine capacity and capability in UKHSA have occurred as an outcome of the COVID-19 pandemic, including the establishment of the Vaccine Development and Evaluation Centre; the transition of the COVID-19 Taskforce to the COVID-19 vaccine unit at UKHSA; and the recent government support of on-shoring vaccine capacity with the Moderna announcement.

UKHSA and external experts provide recommendations to DHSC on stockpiles for drugs, vaccines, and other treatments; personal protective equipment (PPE); and hospital equipment. UKHSA also deliver commercial and operational leadership in the management of health-related stockpiles for emergencies. We will continue to work with DHSC to review medical and non-pharmaceutical countermeasures, providing advice to Ministers.

Data, analytics and surveillance systems

UKHSA manages a range of surveillance systems, such as case reports, lab results, and demographic information to identify and monitor outbreaks, and track the spread of disease. It is important these are flexible to collect known, but also emerging or unknown, diseases. Case-based alerting for unusual syndromes as part of the health protection regulations to health protection and national specialist on-call services, provides intelligence on emerging diseases. For example, this occurred for both acute hepatitis and mpox, with alerting from clinicians who identified unusual syndromes and notified UKHSA.

UKHSA can integrate data to collect, analyse and report on the characteristics and outcomes of cases, such as risk factors, symptom complications, and the implementation and impact of control measures, such as vaccination campaigns or isolation and quarantine measures. Geospatial information is used to determine disease spread, hotspots, and the relationship with specific communities and index of multiple deprivation. The integration of surveillance systems can report on outcomes of cases, such as hospitalisation and mortality rates, and be used to assess the severity of the disease and the impact of control measures. Progress has been made during the COVID-19 pandemic, including the reporting of real-time data on healthcare and resource utilization, which is used to track the demand for resources and inform government decisions on interventions.

UKHSA will also need to maintain protocols and electronic data collection, and work with academic partners to allow a range of information to be collected for new and emerging infections (for example the first few hundred study, household transmission studies, secondary attack rate, asymptomatic transmission, and mode of transmission).

Maintain and enhance professional and public trust critical to behaviour change

UKHSA runs public health campaigns, develops guidance and media briefings to raise awareness of infectious diseases and how to prevent their spread. This requires UKHSA to continuously develop and disseminate public health messages to educate professionals and the public about ways to prevent the spread of infectious diseases and protect their health (for example the importance of preventive measures, such as vaccination, handwashing, and social distancing), as well as providing accurate and timely information about an outbreak and how to protect oneself and reduce transmission in health and care settings.

Providing information and having pre-existing plans in place for how to respond to infectious diseases, including measures such as quarantine and isolation, can help support individuals to understand the processes that may need to occur. Non-pharmaceutical interventions, also known as infection prevention and control (IPC), are critical to prevent infections in health and care settings and as wider measures to reduce infection transmission in the community.

UKHSA develops robust evidence based guidance to inform IPC guidance and public campaigns. We need to ensure Patient and Public Involvement and Engagement (PPIE) inform our activities, including wherever possible using co-production with affected communities, to design our communications and public health interventions. UKHSA has ongoing is perceived by the public in routine tracker surveys, including developing a ‘Trust Measure’ to understand levels of trust in UKHSA in the population and where we need to improve our work.

Exercising preparedness plans and evaluating responses

UKHSA develops internal and multi-organisation exercises to test the readiness of the healthcare system and other response mechanisms; identify gaps in preparedness; and improve coordination among different agencies and organisations.

Regular monitoring and evaluation of preparedness efforts can help to identify areas for improvement and determine the effectiveness of different interventions. This involves closely working with DHSC to consider the relevant countermeasures for emerging infectious diseases, surges of known infections, and pandemics.

Skilled multidisciplinary workforce

UKHSA has a multidisciplinary workforce contributing to the detection, prevention and mitigation of infectious diseases, through front-line activity by the regional HPTs and national subject matter experts who work with the NHS and community health delivery systems (including adult social care, homeless, drug and alcohol treatment centres, and sexual health services); health and justice system; and local public health systems. This is complemented by a skilled scientific workforce, including biomedical and clinical scientists, data scientists, modelers, economists, epidemiologists, behavioural scientists, and policy experts. Their work is facilitated by finance, commercial, people, technology, and communications experts.

We have commenced work on a People and Workforce Strategy that includes defined career pathways, an improved learning and development strategy and prioritisation of skillsets, and which manages the skill mix required for future work in the organisation

Partnerships and engagement

UKHSA is a valued partner, and we need to develop formal arrangements with other public bodies and government executive agencies to manage known and emerging threats. The regional health protection and microbiology teams provide the regional leadership for case, situation, and outbreak management in local populations. They also build relationships to ensure the delivery of longer-term proactive system actions with the NHS, local authorities and other organisations, to prevent and control infectious diseases. Local authorities and Directors of Public Health (DsPH) have a statutory responsibility for the delivery of prevention services for their local population – strong relationships with local authorities and DsPH are essential so they are capable of supporting prevention and response aspects of infectious diseases, especially where surge response may be required for their population.

The DHSC sets the priorities for the NHS and administers the local authority public health grant, which includes aspects of health service delivery that impact on infectious diseases (notably, sexual health services for the diagnosis and treatment of sexually transmitted infections, and drug and alcohol treatment and prevention services, which includes engaging with injecting drug users and needle exchange programmes to prevent blood-borne diseases). Ongoing work is required to ensure we work with partners to develop the evidence base and cost-effectiveness for these important interventions.

Working with other government departments is also critical for our work. Recent examples of cross-organisational collaboration for infectious diseases includes the management of diphtheria and other infectious diseases in asylum seeker populations with the Home Office and work to improve the detection and treatment of blood-borne viruses in His Majesty’s Prison Service and the NHS.

Key regulatory partners for food and water are the Food Standard Agency (food), Environment Agency (sewage and safe bathing waters), and OfWat (water quality). UKHSA must continue to engage with these organisations, highlight the risks to public health, and provide them with evidence to support their decision-making and regulatory action. The Department for Environment, Food and Rural Affairs (Defra) and the Animal and Plant Health Agency (APHA) work with us on the human-animal interface, zoonotic infections and other infectious diseases. MHRA is the lead regulator for drugs, therapeutics, blood and tissues.

Third sector and voluntary organisations are critical partnerships, and we need clarity on where we prioritise our engagement and action for the prevention and reduction of infectious diseases.

International cooperation

The UK has strong partnerships and works closely with international organisations such as the World Health Organization (WHO) to manage infectious disease threats. Building partnerships and collaborations with public health institutes, with trusted relationships and information sharing, will help enhance preparedness and resilience against infectious disease threats. The UK is recognised globally for open data sharing in a timely manner for many infectious disease threats. We need to fulfil our requirements to the International Health Regulations.

Investment choices and opportunities to improve preparedness

There are opportunities to improve preparedness but these will involve critical the choices for government to determine the investment and improve preparedness for future threats. The faster we can detect new and emerging pathogens, understand their route of transmission, severity, high risk populations and health consequences, deliver scalable testing, tracing and isolation services and develop vaccines and therapeutics will reduce the impact on the health system, the economy and the population. Increasing investment will have trade off.

Prepare

The current surveillance systems are highly dependent on NHS laboratories and clinicians identifying and reporting infectious diseases in individual patients and clusters of unusual disease.

UKHSA laboratories and genomics transformation services are critical to enabling improved detection of pathogens. In order to improve laboratory detection using molecular and serological methods, funding and capacity to deliver the following funded deliverables in the short term with constant robust horizon scanning:

  • develop the optimal methods for pan-genus or pan-family rapid PCR (as was present with a pan-coronavirus assay that was implemented post-SARS and used to detect MERS and the initial cases of SARS-CoV-2)

  • develop novel serological and neutralisation assays for the assessment of population immunity to determine effectiveness of vaccines, particularly in diseases with minimal population immunity

Genomics is a high-value intervention to improve preparedness. The estimated cost of a transformation programme is an additional £30 million to £50 million per year (in addition to laboratory, bioinformatics and analysis costs for current programmes). The level of investment and funding in genomics is a critical choice both within the agency and across wider government – including NHS laboratory transformation, investment in research and innovative technological solutions. Genomics is critical to provide platforms for transformation from traditional microbiological detections to robust pathogen agnostic laboratory methods and data pipelines for detection of new pathogens for syndromic diagnosis ( for example respiratory, fever syndromes, encephalitis, skin rashes).

Key deliverables to improve preparedness include:

  • validate a wider range of pathogens, from traditional laboratory methods to genomics and, most importantly, develop bioinformatic pipelines to deliver analysis for public health benefit, building on the work delivered to date

  • develop pathogen-agnostic methodologies, including metagenomics methods for the detection of new and emerging pathogens (for example these techniques were used to identify the cause of fulminant hepatitis in children in spring 2022) and high-risk syndromes for emerging pathogens (for example undiagnosed fever in returning travellers, encephalitis, and/or severe pneumonia in ICU)

  • develop the technology and infrastructure to collect genomics data and associated metadata generated from NHS and research facilities in the UK, to provide a future technological solution with greater surveillance, depth and breadth, of pathogens circulating in the UK working with Genomics England and the NHS

Respond

Analysis, including risk assessments, and the ability to share data with professionals, requires a modern data analysis platform and agility to deliver rapidly when necessary with a skilled workforce.

While components of this work are funded, there needs to be 3 year time horizon applied in each area and require substantial long term investment.

To improve vaccine development and delivery of the 100 day mission, the immediate priorities are to:

  • develop a list of priority pathogens for vaccine and drug development (based on the threat assessment), work with research-funders and industry to encourage the funding and development of vaccines (including next generation modalities and optimal modes of delivery) and therapeutics and have the capacity and capability to deliver the 100 day mission for vaccines for a future pandemic

  • work with the DHSC and the NHS to consider future models of vaccine delivery (vaccine delivery is currently an NHS responsibility), especially for pre-school, school-age, and annual vaccination campaigns

Enabling population behaviour change and uptake of health protection interventions will require close work with academic partners and prioritisation within the behavioural health unit. This will require continuous analysis in the medium term to:

  • generate behavioural insights to improve our public health campaigns and risk communications

  • ensure our public health interventions are designed and optimised using evidence from the behavioural and social sciences, and their effectiveness systematically evaluated

  • conduct rapid research and evaluation to understand how the behaviour of the public and professional communities’ changes in response to novel infectious disease threats

UKHSA needs to make the case for prioritised funding to build on the work throughout the pandemic with the technological infrastructure to integrate, store and analyse data from a wide variety of sources with appropriate information governance, cyber and data security. Key additional elements in the short term include:

  • develop study protocols, funding and staffing required to deliver them available to improve knowledge on transmission routes, secondary attack rate, severity and determine high risk populations or inequalities for new and emerging pathogens

  • optimise exceedance detection methodologies for known pathogens, syndromic surveillance, and soft intelligence, with improved integration and insights to all hazard threat assessments for government

  • deliver the UKHSA Data Strategy to optimise the use and sharing of data, especially anonymous and/or aggregated data, on open-source platforms with appropriate APIs, to harness the secondary use of data from research, academia, and the public, to provide greater insights and intelligence

  • build capacity for modelling and health economics to provide evidence to policy makers on clinical and cost-effective interventions, including developing scenarios for planning and measuring the impact of interventions

Additional transformation work to improve preparedness are choices to consider for UKHSA and government and will require enabling capacity and capability with the NHS, ONS, other government departments, academic and industry partners. These areas will enable better and more rapid data insights and public health actions:

  • work with NHS data hubs to improve the ability for electronic data integration of NHS primary and secondary care data with social and economic data available in other government departments, with appropriate data sharing agreements and information governance

  • enable better real-time integration of incidents, cases and syndromes that are reported to health protection regional teams and integrate systems with the use of machine learning and natural language processing, to enable systems to identify and process reports, and allow rapid detection of unusual syndromes, presentations, or clusters (improving the use of local intelligence)

  • invest in cloud based and industry technologies to increase laboratory and analytical automation of clinical, laboratory, genomic, community data with highly-trained staff to improve capacity and capability, especially for new and emerging pathogens

Build

As an organisation, we are unique in providing the combined capability to deliver high quality science and public health with the ability to scale the operational delivery of interventions to protect the population from public health threats. However, the skills to deliver this and the speed at which we can scale response require sufficient residual capability require choices on investment and funding.

The less we retain capacity now the longer it will take to surge response. Investment in, for example, modern call centres, electronic notification from individuals themselves and high throughput laboratories will improve preparedness and need consistent investment to provide rapid scalable resources using 21st century techniques. Some critical examples include:

  • optimise the commercial, financial and operational ability of the organisation to deliver surge high throughput testing, contact tracing, and call centres to support control of infectious disease outbreaks

  • by developing improved automation, ChatBots, and other advanced call centre capacity support local delivery and provide information to individuals and organisations (including local authorities, integrated care systems, and long-term care facilities)

Essential for the delivery of these elements will require the UKHSA to have the capability to:

  • compete in a challenging job market with parity of pay for equivalent jobs in the NHS (for example biomedical scientists), other HMG departments (Digital, Data and Technology (DdaT) pay scales), and academic (post-doctoral or independent researchers/technical skills)
  • enable honorary contracts for academic colleagues and ensure individuals can move between UKHSA and other industry, HMG departments and NHS/academic organisations
  • support exchanges, secondments, and developments across government, with global organisations and industry
  • compete for research funding with academic collaborators to build the evidence base

Societal vulnerabilities that impact infectious disease risks

The UK has certain particular vulnerabilities in responding to health threats. UKHSA is not the lead agency for these complex system vulnerabilities. To reduce these vulnerabilities UKHSA require collaborative working across HMG and the wider health ecosystem, to deliver work to help mitigate the impact.

Population factors

Older age, higher levels of obesity than European peers, co-morbidities, and multi-ethnic populations make the potential burden and impact of infectious diseases higher in the UK. The UKHSA’s role will be to determine the risk factors for different diseases in different populations and to determine which populations are at higher risk of severe infection. Critically, maintaining the UKHSA data linkage, storage and analysis capabilities developed prior to, and during, the COVID-19 pandemic will be essential to detect and determine these factors for future emerging or pandemic infections.

Social and economic factors

Poverty and health have a particular impact on recent immigrant populations and other communities (for example, coastal, or homeless). Working across HMG, particularly with the Office for Health Improvement and Disparities (OHID) and the Department for Levelling Up, Housing and Communities (DLUHC), will be required to continue to reduce health inequalities and improve the health impact of poverty, homelessness, and other socioeconomic factors. Engagement across HMG can aid in the development and synthesis of an evidence base for policy development.

International travel

The UK is a hub for international travel, which means that diseases can easily be imported from other countries. Developing, piloting, and evaluating novel methods of surveillance at the UK Borders, and working with global health systems, will be essential to reduce that risk.

Health and public health system

The English health and public health system have undergone a number of structural and organisational changes over the last 10 years. Clarity on the elements of response in each part of the system, coordination responsibility, and key deliverables for each component is essential to ensure operational resilience.

Key system factors to prepare and which require coordination from DHSC

DHSC is the NSRA risk owner for emerging infectious diseases, pandemic preparation and antimicrobial resistance. Their responsibilities and deliverables require close worker with UKHSA to ensure success include:

System-wide preparedness plan

DHSC leads the system wide preparedness plan outlines the actions and assurance needed to prevent, detect, and respond to infectious diseases threats. Learning from the COVID-19 pandemic is being incorporated into future delivery plans.

Healthcare capacity to manage infectious diseases threats

The delivery and funding of effective health systems which includes diagnostic laboratories (including the ability to rapidly implement and scale new diagnostic tests), information systems, trained healthcare personnel, capacity for managing and isolating patients with infection, treatments (including prophylaxis), PPE, and clarity on roles and responsibilities of system partners. Consideration of how to manage surge and outbreak response within the health system is essential. The recent mpox outbreak has demonstrated that the commissioning model for sexual health services does not include the automatic ability to fund emerging infectious diseases.

Coordination, Contingency and Communication

DHSC have clear lines of communication and coordination among different agencies and organisations, with clarity on roles and responsibilities of the parts of the system. They provide a coordinating role with other departments and agencies of HMG and international partners. DHSC also have a key role to ensure resilience and contingency planning related to global supply chains for drugs, therapeutics, and other essential equipment for the delivery of health.

Research and development

DHSC are a key funder for UK Research and Innovation (UKRI) (including the National Institute for Health and Care Research (NIHR)) to ensure that the UK identifies new technologies and approaches to prevent, detect, and respond to infectious diseases threats. This includes the development of new vaccines, medications, diagnostic tests and non-pharmaceutical interventions. The NIHR Clinical Research Networks, new approaches to social care and local authority research funding will enhance the ability to generate research insights from the wider health and care system.

Professor Susan Hopkins Chief Medical Advisor January 2023

Annexe A: Burden of infectious diseases

It is estimated that individuals develop 1 to 2 respiratory tract infections each year and women of childbearing age have at least one urinary tract infection every 2 years. An infection diagnosis is the most common reason for urgent or emergency GP attendance, the primary reason for admission to hospital for approximately 7 to 10% (~1.2m per year) of all admissions; and 25% to 30% of emergency admissions (HES data). Approximately one in three individuals in hospital at any one time are on antibiotics for infection. (PPS Surveys). In 2019 to 2020, there were 280,000 admissions for pneumonia, 170,000 admissions for URTI and almost 30,000 admissions for flu or viral pneumonia.

The estimated incidence (new cases) and burden (disability adjusted life years, or DALYs) for key infections from a 2019 PHE evidence review on infectious diseases are included below.

Table 1: Estimated annual incidence, DALYs per case and total annual DALYs in England for sexually transmitted infections

Pathogen Typical annual incident cases in England (range over latest 5 years) DALYs per case (unless otherwise stated) Total DALYs estimates in England per annum
Syphilis 5,240*
(3,340 to 7,100)
0.04
(0.04 to 0.05)
210
(134 to 357)
Gonorrhoea 38,200*
(31,200 to 44,700)
0.02
(0.01 to 0.04)
764
(312 to 1,787)
Chlamydia 206,400*
(202,600 to 211,400)
0.02
(0.01 to 0.05)
4,128
(2,026 to 10,567)
Anogenital herpes (HSV) 33,630*
(32,737 to 34,288)
0.04**
(0.02 to 0.08)
1,345
(655 to 2,743)

*not inflated for any under ascertainment.

**assumed to be double that of gonorrhoea.

Table 2: Estimated annual incidence, DALYs per case and total annual DALYs in England for other infections

Pathogen Typical annual incident cases in England (range over latest 5 years) DALYs per case (unless otherwise stated) Total DALYs estimates in England per annum
Legionella 332
(285 to 384)
3.04
(2.73 to 3.36)
979
(778 to 1,290)
Invasive group A streptococcus 1,340*
(1,215 to 1,574)
  6,698*
(6,075 to 7,870)
Respiratory syncytial virus (RSV) ~2,250,000*   9,380*
Borrelia burgdorferi (Lyme disease) 2,500
2,000 to 3,000
0.07 *
(0.06 to 0.09)
175
(120 to 270)
Mycoplasma pneumonia 28,250*
(25,200 to 29,500)
0.33* 9,300
(8,300 to 9,700)
Group B streptococcus 604*
(566 to 643)
6.27 * 3,790
(2,550 to 4,030)

*Taken from last HPR for each of the past 5 seasons, which may be incomplete.

Table 3: Estimated annual incidence, DALYs per case and total annual DALYs in England for vaccine preventable diseases

Pathogen Annual incident cases in England (range over latest 5 years) DALYs per case (unless stated otherwise) Total estimated DALYs in England per annum
Diphtheria, toxin producing 5
(1 to 7)
1.16 5.8
(1.2 to 8.1)
Polio 0 1.67 0.0
Pertussis 4,500
(3,400 to 5,900)
0.01 45.0
(34.0 to 59.0)
Tetanus 5
(4 to 7)
2.02
(1.91 to 2.15)
10.1
(7.6 to 15.1)
Measles 530
(90 to 1,910)
0.08
(0.07 to 0.08)
42.4
(6.3 to 153.0)
Rubella 5
(2 to 65)
0.02
(0.01 to 0.02)
0.1
(0.02 to 1.3)
Mumps 2,600
(540 to 3,750)
0.005 13.0
(2.7 to 18.8)
Haemophilus influenza b 20
(14 to 36)
3.43
(3.39 to 3.47)
68.6
(47.5 to 124.9)
Influenza 1,500,000
(1,000,000 to 2,000,000)
0.01 15,000
(10,000 to 20,000)
Invasive Pneumococcal Disease (IPD) 600 to 1,000
(PCV13)

4,500 to 4,900
(Non-PCV13)
2.74
(2.71 to 2.77)
15,070
(13,800 to 16,343)
Pneumococcal pneumonia* 41,800
(37,300 to 43,600)
0.33** 13,800
(12,300 to 14,400)
Rotavirus 100,000 to 200,000 0.005 750
(500 to 1,000)
Herpes zoster (shingles) 35,000 to 39,000
(70 to 79 year olds)
   
Men B 395 to 405 5.64
(5.59 to 5.70)
2,256
(2,208 to 2,264)
Men C 40 to 60 5.64
(5.59 to 5.70)
282
(224 to 342)
Men W 190 to 225 5.64
(5.59 to 5.70)
1,170
(1,062 to 1,283)
HAV 780
(337 to 2,943)
0.07
(0.06 to 0.08)
55
(20 to 235)

*Second Generation Surveillance System (SGSS) reports in sputum/LRTI which has been assumed to represent hospitalised patients and scaled by 0.33, the mid-point of the estimate of proportion of hospitalised cases. This slightly underestimated the often used 0.5% incidence of community acquired pneumonia, which assuming 25% of which as S. pneumonia would estimate 68,650 cases per annum.

**Assuming 10% of hospitalised cases die within 30 days, and their average years of life lost is 10. Thus, only YLL are used in this estimate, meaning morbidity effects are not considered, which would underestimate the total DALYs per case.

Table 4: Estimated annual incidence, DALYs per case and total annual DALYs in England for gastrointestinal infectious diseases

Pathogen Typical annual incident cases in England (range over latest 5 years)* DALYs per case (unless otherwise stated) Total DALYs estimates in England per annum
C. perfringens 263,500
(73,900 to 919,000)
0.001** 263
(74 to 919)
Campylobacter 500,100
(293,100 to 831,100)
0.01 5,001
(2,931 to 8,311)
S. enteritidis 9,940
(2,440 to 41,000)
0.02 199
(49 to 820)
S. typhimurium 7,980
(1,970 to 31,430)
0.02 160
(39 to 628)
Other salmonellas 10,620
(2,630 to 43,640)
0.02 212
(52 to 872)
E. coli STEC 4,120
(100 to 98,760)
0.05
(0.05 to 0.06)
205
(5 to 5,926)
Other E. coli 15,070^
(710 to 258,700)
0.01$ 151
(7 to 2,587)
Listeria monocytogenes+ 706
(157 to 3,258)
3.56
(3.52 to 3.79)
2,513
(553 to 12,347)
Shigella 9,810^ (393 to 215,064) 0.03
(0.02 to 0.03)
294
(8 to 6,452)
Giardia 62,580
(16,180 to 254,160)
0.001** 63
(16 to 254)
Cryptosporidium 34,430
(7,770 to 156,690)
0.001** 34
(8 to 157)
Adenovirus 521,000
(319,040 to 915,800)
0.001** 521
(319 to 915)
Norovirus 1,810,800 (1,291,100 to 2,559,700) 0.001** 1,810
(1,291 to 2,560)

*SGSS laboratory reports for feacal/LGT isolates scaled to community/reporting ratio from IID2

**Arbitrarily assumed to be one tenth of that for a campylobacter. Giardia and cryptosporidium published as <0.01.

^Scaling factor has been assumed to be that for E. coli STEC.

$Arbitrarily assumed to be equal to that for a campylobacter.

+All specimen types used.

✝Scaling factor has been assumed to be that for salmonella.

Table 5: Estimated annual incidence, DALYs per case and total annual DALYs in England for chronic infections

Pathogen Typical annual incident cases in England (range over latest 5 years) DALYs per case (unless otherwise stated) Total DALYs estimates in England per annum
HIV 1,200
(600 to 2,100)*
6.03
(5.86 to 6.20)
7,236
(3,516 to 13,020)
HCV 4,300 **
(3,400 to 5,400)*
2.79
(1.46 to 4.45)^
12,000
(9,500 to 15,000)
HBV 459 2.79
(1.46 to 4.45)
1,280
(670 to 2,042)
Tuberculosis 6,037
(5,102 to 7,265)
3.58
(3.55 to 3.62)
21,612
(18,112 to 26,299)

*95% credible interval rather than range over recent 5 years.

**Not inflated for any under ascertainment.

^DALYs per case not available so that estimated for HBV has been assumed.

Annexe B: Further context on modes of transmission and notifiable diseases

As detailed above, there are 5 core modes of transmission by which infection can spread:

Airborne (droplet or aerosol) transmission

This occurs when an infected person coughs, sneezes, or talks (droplets) containing the infectious agent are expelled into the air and inhaled by someone nearby OR when an infectious agent is suspended in the air and inhaled by someone (aerosol) because the infectious particles are much smaller and can remain suspended in the air for long periods of time. For example flu, RSV, COVID-19, TB, measles, C. diphtheria, Strep pneumoniae.

Vector-borne transmission

This occurs when an infectious agent is transmitted by a vector, such as a mosquito, tick, or flea. The vector becomes infected by biting an infected host, and then transmits the disease to a new host when it bites again. For example, malaria, Zika, chikungunya, Lyme, tick-borne encephalitis, West Nile encephalitis, dengue.

Oral (food or water-borne) transmission

This occurs when an individual consumes food or water that is contaminated with an infectious agent. For example, STEC, Salmonella, campylobacter, norovirus, hepatitis A.

Sexual, blood or perinatal transmission

This occurs when an infectious agent is transmitted through sexual/ blood contact. This can include contact with genital secretions, blood, or other body fluids. For example, HIV, hepatitis B/C, syphilis, gonorrhoea, mpox.

Contact (touch) transmission

This occurs when an individual comes into direct contact with an infected person or surfaces that an infected person has touched. This can happen through skin-to-skin contact, fomites (the environment) or through contact with bodily fluids. For example, viral haemorrhagic diseases, Staph aureus, HSV, scabies, Clostridium difficile, Gram negative bacteria in environment, mpox.

Diseases notifiable to local authority proper officers under the Health Protection (Notification) Regulations 2010:

  • acute encephalitis
  • acute infectious hepatitis
  • acute meningitis
  • acute poliomyelitis
  • anthrax
  • botulism
  • brucellosis
  • cholera
  • COVID-19
  • diphtheria
  • enteric fever (typhoid or paratyphoid fever)
  • food poisoning
  • haemolytic uraemic syndrome (HUS)
  • infectious bloody diarrhoea
  • invasive group A streptococcal disease
  • Legionnaires’ disease
  • leprosy
  • malaria
  • measles
  • meningococcal septicaemia
  • mpox
  • mumps
  • plague
  • rabies
  • rubella
  • severe acute respiratory syndrome (SARS)
  • scarlet fever
  • smallpox
  • tetanus
  • tuberculosis
  • typhus
  • viral haemorrhagic fever (VHF)
  • whooping cough
  • yellow fever

Organisms (causative agents) notifiable to UKHSA under the Health Protection (Notification) Regulations 2010:

  • bacillus anthracis
  • bacillus cereus (only if associated with food poisoning)
  • bordetella pertussis
  • borrelia spp
  • brucella spp
  • burkholderia mallei
  • burkholderia pseudomallei
  • campylobacter spp
  • carbapenemase-producing Gram-negative bacteria
  • Chikungunya virus
  • chlamydophila psittaci
  • clostridium botulinum
  • clostridium perfringens (only if associated with food poisoning)
  • clostridium tetani
  • corynebacterium diphtheriae
  • corynebacterium ulcerans
  • coxiella burnetii
  • crimean-Congo haemorrhagic fever virus
  • cryptosporidium spp
  • dengue virus
  • ebola virus
  • entamoeba histolytica
  • francisella tularensis
  • giardia lamblia
  • guanarito virus
  • haemophilus influenzae (invasive)
  • hanta virus
  • hepatitis A, B, C, delta, and E viruses
  • influenza virus
  • junin virus
  • kyasanur Forest disease virus
  • lassa virus
  • legionella spp
  • leptospira interrogans
  • listeria monocytogenes
  • machupo virus
  • marburg virus
  • measles virus
  • mpox virus
  • mumps virus
  • mycobacterium tuberculosis complex
  • neisseria meningitidis
  • omsk haemorrhagic fever virus
  • plasmodium falciparum, vivax, ovale, malariae, knowlesi
  • polio virus (wild or vaccine types)
  • rabies virus (classical rabies and rabies-related lyssaviruses)
  • rickettsia spp
  • Rift Valley fever virus
  • rubella virus
  • sabia virus
  • salmonella spp
  • SARS-CoV-2
  • shigella spp
  • streptococcus pneumoniae (invasive)
  • streptococcus pyogenes (invasive)
  • varicella zoster virus
  • variola virus
  • verocytotoxigenic Escherichia coli (including E.coli O157)
  • vibrio cholerae
  • West Nile virus
  • yellow fever virus
  • yersinia pestis

Annexe C: Further context on pathogens genomics services

Pathogens for which genomic sequencing is currently in place ca 50,000 genomes:

  • rare and imported pathogens – 300 sequences per annum
  • influenza – 3,000 sequences per annum
  • SARS-CoV-2 – 18,000 sequences per annum*
  • hepatitis C virus – 400 sequences per annum
  • E. coli, Shigella and related taxa – 6,000 sequences per annum
  • corynebacteria spp. – 100 sequences per annum
  • campylobacter spp. – 1,000 sequences per annum
  • listeria spp. – 2,000 sequences per annum
  • salmonella spp. – 10,000 sequences per annum
  • mycobacterium tuberculosis and other species – 9,000 sequences per annum
  • staphylococcus aureus – 6,000 sequences per annum
  • streptococcus pneumoniae – 6,000 sequences per annum
  • GAS outbreaks (application only) – 200-400 sequences per annum
  • GBS outbreaks (application only) – 200-400 sequences per annum
  • legionella outbreaks (application only) – 100 sequences per annum

*the added current COVID-19 sequencing capacity for P1 and Research Studies (additional capacity at an annual cost of £11 million from SR-COVID.

Additional capacity of 5,000 per annum has been used over the last 5 years in support of outbreak investigation of emerging threats as part of acute response or studying more complex national and international outbreaks. Including supporting Ebola genome sequencing in managing transmission locally and internationally and guiding vaccine campaign for control of subsequent outbreaks, outbreak of a carbapenemase producing (very resistant) Enterobacteriaceae in large hospitals, CBRN-related investigation including anthracis, WHO request for support of MERS sequencing, Zika and haemorrhagic fever. In the last 12 months, genomics has been an essential part of the response to Mpox, Poliovirus in wastewater, and metagenomics allowed the identification of the adenovirus and Adenovirus associated virus in children with hepatitis.

Pathogens for which genomic sequencing should be supported as routine practice and are currently at an evaluation or pre-validation phase to support integration into service delivery (for context as options for transformation of current reference services and preparedness for a range of pathogen threats):

  • core: core genomic service for all isolates (bacterial) or positive samples (viruses)
  • public health: genomics use for surveillance of pathogen or immunisation programme support
  • infection prevention and control: outbreaks and resistance importance
  • clinical significance: high mortality, economic impact or other and use for clinical management to inform treatment
  • parasites were excluded
  • characterisation of clinical strains derived stocks and in vivo samples for Research, EQA schemes

Across the 4 categories of Core, Public Health, infection prevention and control and clinical significance then all containment level 4 pathogens (typically haemorrhagic fevers) should be supported as a priority (variable depending on outbreaks, but typically less than 100 year)

For the same 4 categories all Imported Containment Level 3 organisms (viral and bacterial) on the Rare and Imported Pathogens list. This requirement is variable depending on source or outbreak but typically less than 500 year currently but with increased capacity and improved methods this is likely to increase significantly, with discretionally requirement for level 2 organisms with unusual clinical presentation for public health significance.

To improve surveillance systematically across a wide range of pathogens, increasing sequencing capacity from 50,000 genomes per year to 150,000 genomes per year over the next 3 to 5 years with appropriate funding.

Annexe D – Key partner organisations for the delivery of preparedness

The Food Standards Agency (FSA) is a non-ministerial government department in the UK that is responsible for protecting public health in relation to food. The FSA is responsible for setting food safety and standards in the UK, including those for food additives, contaminants, and food labeling. The FSA also works to ensure that food products on the market in the UK are safe and accurately labeled, and it provides guidance to consumers on how to safely handle and prepare food. In addition to these responsibilities, the FSA also works with other organisations in the UK and internationally to coordinate food safety efforts and promote public understanding of food safety issues.

In England, food premises are inspected by local authority Environmental Health Officers (EHOs). These are professionals who are trained to ensure that food businesses comply with food safety and hygiene regulations. They are responsible for inspecting food premises, including restaurants, supermarkets, and food production facilities, to ensure that they are clean and well-maintained and that food is being handled, prepared, and stored safely.

If an EHO finds that a food business is not meeting the required standards, they may issue a notice requiring the business to make improvements, or they may take other enforcement action, such as closing the business temporarily or permanently. In addition to inspections, EHOs may also provide guidance and training to food businesses to help them understand and comply with food safety regulations.

England, the water regulator is the Office of Water Services (Ofwat). Ofwat is an independent regulatory body that is responsible for regulating the water and sewage companies that operate in England and Wales. It sets the prices that these companies can charge for their services and ensures that they provide a high-quality service to their customers. It also works to protect the environment and promote the sustainable use of water resources.

The Medicines and Healthcare Regulatory Agency (MHRA) is responsible for regulating blood and blood products in the United Kingdom. It works to ensure that these products are safe, effective, and of high quality, and that they are used appropriately.

The Care Quality Commission (CQC) is an independent body that regulates healthcare services in England. It has the authority to inspect and regulate a wide range of healthcare services, including hospitals, GP surgeries and other primary care services, nursing homes, dental practices, and many other types of healthcare providers. CQC’s role is to ensure that healthcare services in England are meeting certain standards of quality and safety and to protect the public from harm. It does this by inspecting and rating healthcare providers, publishing reports on the performance of individual providers and the wider healthcare system and taking enforcement action where necessary. The CQC is responsible for regulating all providers of NHS care in England, as well as some independent and voluntary sector providers. It works closely with other organisations, such as the Department of Health and Social Care and the relevant clinical commissioning groups, to coordinate the regulation of healthcare services in England and ensure that patients receive high-quality, safe care.

UK Research and Innovation (UKRI) is a non-departmental public body that was established in 2018 to bring together the research and innovation funding activities of a number of different organisations in the UK. UKRI’s mission is to ensure that the UK’s research and innovation capabilities are able to make a positive contribution to the country’s economic growth and societal wellbeing.