Is the abolition of Public Health England a risky move?

Following a recent announcement made in the Sunday Telegraph by Matt Hancock, Public Health England (PHE) has been abolished and replaced by a National Institute for Health Protection (NIHP), which will focus on external threats to the UK, including pandemics and infectious diseases.

At first glance this seems a rather similar agency to the Health Protection Agency, which was abolished in 2013 as a result of Andrew Lansley’s NHS reforms. It will now be combined with the two organisations recently created during the pandemic, namely the Joint Biosecurity Centre and NHS Test and Trace. Given the faltering performance of these agencies so far, the omens for this new entity seem rather unfavourable. Past experience shows that every time public health goes through a major reorganisation it loses around one third of its skilled and experienced staff. PHE’s 5000 or so committed staff, who have been working extremely hard during the pandemic, possess a wide spectrum of specialist skills, and it may be hard to convince them to stay in an ‘improved organisation’ created rapidly in the midst of a pandemic.

A serious question mark also hangs over the non-COVID-19 elements of PHE’s responsibilities. Its work on health inequalities, obesity, tobacco, alcohol, as well as a number of other important public health problems facing the country should not be abandoned or forgotten. In particular, obesity is an important risk factor for the severe form of COVID-19, and smoking as well as drug addiction are especially hazardous to men’s health.

The choice of Dido Harding, former CEO of Talk-Talk, to lead NIPH is also controversial. Baroness Harding is a Conservative member of the House of Lords, married to a Tory MP. She admits that she has little expertise in public health, and as she is not a minister, she is unaccountable to Parliament. However, the prospects of a budget of several tens of billions, compared with the miserly £300 million allocated to PHE, does offer considerable potential for the new entity, provided that the money is well spent.

Choosing this moment to completely recast England’s public health structures looks risky to many. What are your views? Please do post them here on this blog.

Comments (13) Add yours ↓
  1. John Ashton Consultant adviser to the Crown Prince of Bahrain’s COVID-19 Task Force

    There can be little doubt that Public Health England has had a bad epidemic. The criticisms that have followed it since its inception of over centralisation, of failing to stand up for local and regional public health, and most recently of failing to deliver on testing, tracing and providing adequate and timely intelligence to enable public health teams to rise to the challenge of COVID-19 have finally caught up with it. But this is no time to change horses in midstream when what is needed is reform and strengthening of the national agency and rebuilding the local and regional Public Health Service . The vacuum that is about to be created and the replacement of one dysfunctional over centralised organisation with another over centralised dysfunctional organisation is a reckless leap too far .

    August 27, 2020 Reply
  2. Roger Kirby President RSM

    This is why PHE’s anti obesity drive should not be derailed by its recent abolition: a global assessment of health data gathered since the start of the the pandemic by researchers at the University of North Carolina has found people with a Body Mass Index (BMI) of more than 30 were 113 per cent more likely to be hospitalised. Those admitted to hospital were found to be 74 per cent more likely to be admitted to an intensive care unit, while the risk of death among obese patients increased by 48 per cent.

    August 27, 2020 Reply
  3. Jenny Vaughan Consultant neurologist

    Totally agree with you Roger. I am concerned about the impact on the public of losing such experienced staff. And theree points you make are absolutely vital : “ A serious question mark also hangs over the non-COVID-19 elements of PHE’s responsibilities. Its work on health inequalities, obesity, tobacco, alcohol, as well as a number of other important public health problems facing the country should not be abandoned or forgotten.”

    This seems to all have happened under the radar and announced without any proper due process. I have met Dido Harding and she does say she will listen. My issue is that there is a clear conflict here in her background and this role should be strictly independent from government and be held by someone with an excellent knowledge of public health. Both of these important issues have been ignored in this appointment which undermines her credibility. The government is responsible for this decision.

    August 27, 2020 Reply
  4. Stewart Fleming Former US Editor Financial Times

    The choice of another political appointee to such a crucial managerial role is disturbing, especially, as Professor Kirby points out, because Ms Harding has no accountability to Parliament. British advocates of such political appointments often cite the example of the United States where up to three of the top layers of the executive branch in departments such as the US Treasury and Department of State, and some top Federal agency positions, are selected by a new President on the basis of their party loyalty not just their expertise.

    Out of ignorance, or wilful ignorance, rarely if ever to British advocates favouring the introduction of such constitutional reform in the UK point out that in the US these appointees are subject to Congressional oversight by the relevant committees in the Senate which must endorse their appointments before they are actually allowed to take office. Checks and balances on presidential power are complex and rigorous. Even the key officials in federal agencies such as the Securities and Exchange Commission and the Federal Trade Commission, while appointed by the President, have to be approved by the Senate, which, of course, can be controlled by senators who are not members of the President’s political party. For some appointments there are provisions that ensure that there is political balance at the top of the relevant federal agency. Once in office top government and agency officials can be required, under subpoena, to come before Congress to account for their decisions and, under the law, can face criminal penalties for, amongst other things, providing deliberately misleading answers to Congressional hearings. There is also, in the US, an independent Inspector General function which also provides oversight of both government departments and Federal agencies.

    If the ruling governmental party in Britain wants to further politicise the nation’s administration, so far-reaching a constitutional innovation must not be allowed to take place without, at a minimum, proper oversight procedures being put in place first. It must not be permitted to slither through merely because the current executive happens to enjoy a large majority in the House of Commons.

    August 28, 2020 Reply
  5. Tony Jewell Dr

    One big risk is signalled in the name – Health Protection is one of three domains of public health practice. The other two are health improvement ( physical activity/diet etc) and the other is health and social care quality ( working with the NHS in evidence reviews/needs assessments and policy). All three domains need to be supported by information and evidence. The Public Health system needs to work with national and local government and the NHS and have an effective mechanism to communicate with local communities. The other problem is the use of the term Institute which implies an academic institution presumably linked somehow to a credible university and by the way led by someone who is not a political appointee but is a credible PH expert with leadership skills.So the money spent on a private consultancy Was not well spent

    August 28, 2020 Reply
  6. Juliel Hotchkiss Consultant in Public Health

    All of the above, plus the crucial role of Public Health England as the central creator and repository of public health intelligence. It selects indicators, defines methodology and produces statistics at various levels of aggregation, from local, to regional, to national, so that the various areas can make true comparisons of each other. It is much more efficient to do this centrally and there is no longer any resource or expertise within the NHS to do this, and no central coordination of local government to take on this function. When Public Health England was formed it “scooped up” the regional Public Health Observatories, which all had a national lead in some area (e.g. diabetes, drugs and alcohol)as well as the regional focus. The Knowledge and Intelligence function is one of Public Health England’s best, and under-sung strengths, despite having suffered cuts. Intelligence needs to be independent – it’s been bad enough when everything had to be OK’ed by the Secretary of State – see the recent incomplete publication of the report into ethnicity and COVID, I shudder to think how unwelcome findings will be handled in an organisation which they can rest assured will be free of scrutiny.

    August 28, 2020 Reply
  7. Culley Carson Distinguished Professor of Urology

    As in the UK, politicians think that they can stop the pandemic, cure COVID-19 and ensure public health by creating new bureaucracy. Here in the US, The government doesn’t seem to respect the medical advice that they get from excellent physicians and epidemiologists at the NIH and schools of public health. There is a suspicion of the veracity of the medical establishment because they don’t have all of the final answers immediately. Indeed, there is rumor that the vaccine development is being delayed to enhance the profits of the medical and pharmaceutical industries. The change in the UK reminds me of the old saw that “they are merely rearranging the deck chairs on the Titanic.”

    August 28, 2020 Reply
  8. Satya Bhattacharya Consultant Surgeon

    I agree entirely with your concerns. This whole business raises more questions and concerns.
    1) Why do this now in the middle of a pandemic?
    2) Public Health is not just infection control, health protection and biosecurity. What about health improvement, quality assurance and equity of access to healthcare? Why are those remits being lost?
    3) Why choose a political appointee who herself admits her lack of experience in the field, to head the entity? The head should be someone who carries gravitas in this area of work.

    August 29, 2020 Reply
  9. Mike Kirby Professor

    This seems the wrong time for such an upheaval.
    Some of us have bad memories of the last NHS reorganisation!!
    PHE has a good track history on Men’s health issues.

    August 29, 2020 Reply
  10. Roger Kirby President RSM

    Quote from Richard Murray, Chief Executive of The King’s Fund:

    ‘Public Health England (PHE) appears to have been found guilty without a trial. It is unclear what problem government are hoping to solve by carving up PHE and redistributing its responsibilities. Undoubtedly, there are questions to be answered about England’s handling of the Covid-19 crisis, but the middle of a pandemic is not the time to dismantle England’s public health agency.

    ‘History is littered with reorganisations of the health system that are costly, time consuming and demoralising for staff. It is risky to undertake such a shake up while the nation is still grappling with Covid-19, ahead of an anticipated winter spike in demand for health services and with the looming threat of a second wave of the virus.

    ‘The proposed changes could bring greater accountability and transparency to England’s track and trace system. While that would be welcome, the reshuffling of public health duties risks significant collateral damage. PHE’s role goes far beyond pandemic response and includes, among other things, tackling obesity, reducing health inequalities and improving life expectancy, all of which will be key to the country’s recovery once the worst of the pandemic has passed”.

    August 31, 2020 Reply
  11. Nicola Stingelin (Dr) Ethicist

    Great opening comment, Roger.
    Equally great contributions from all in response.

    There is a long queue of lessons waiting to be learnt from COVID-19.

    As this learned organ (excuse the pun) has pointed out in their curated blogs, one thing we should have learnt is the centrality of inter-, trans-, cross-disciplinary in the face of a health pandemic.

    Like all countries, England (and the whole UK), needs to put this lesson into practice when setting strategy and making plans to be in a better position to deal with pandemics.

    As Roger points out, a first lesson in Public Health 101 is to grasp the multiple interconnected web of drivers, causes, effects, and reactions that make up the Health of a Public.

    Public health must be predicated on understanding all the determinants of public health, including addressing health inequities and inequalities – the whole gamut of social, economic (and political?) determinants of health.

    The National Institute for Health Protection (NIHP) only has a chance if built on multi- disciplinarity analysis. The official Press release “Government creates new National Institute for Health Protection“ suggests that this is acknowledged. Let us hope that professionals from all the relevant disciplines are involved and granted equal power at the NIHP top-table.

    August 31, 2020 Reply
  12. Roger Kirby President RSM

    The underlying reasons for the widely publicised data collection failure of Test and Trace are unclear. But human and technical errors have contexts. It is not possible to say conclusively that the decision to abolish Public Health England in the middle of the pandemic and put the Conservative peer, Dido Harding, in charge of a replacement body, the National Institute for Health Protection, was a factor in last week’s mix-up. But it is reasonable to suggest that it might well have been.

    October 6, 2020 Reply
    • Nicola Stingelin (Dr) Ethicist

      Tks Roger for this balanced comment. A good point well made.

      October 7, 2020 Reply

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