The future of public health: many questions still to be answered

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I wrote in January that 2020 would be a big year for public health. How prescient, but events have not occurred in the way I meant. England has seen more than 49,000 deaths where Covid-19 was confirmed or thought to be a contributory factor by early August and the announcement of the demise of Public Health England (PHE) as we know it.

Like many others, The King’s Fund was surprised to say the least, at plans to dismantle the nation’s public health agency in the middle of a pandemic. The Secretary of State’s justification for it, bringing together health protection expertise into one place, must be set against many other risks and uncertainties.  

Nonetheless the deed is done. There will be time enough to look back, and for PHE to face the trial it deserves, alongside the rest of government and its ministers. What matters now is ensuring that the new National Institute for Health Protection (NIHP) works, and quickly, and that the remainder of PHE’s expertise, people and functions are maintained in the short term, and future clarified quickly for the longer term. This in turn means a series of questions now need to be addressed: for the new institute, for PHE and for how the whole ‘public health system’ will be structured and work in future in England.

The new institute will have to prove itself extraordinarily quickly, in weeks if not days.

The new institute will have to prove itself extraordinarily quickly, in weeks if not days. We are potentially on the verge of a second wave of Covid-19, and even if we are not we will have repeated outbreaks that will change their nature as we move into autumn with the change in weather and of behaviours. The questions stack up quickly. The most immediate are purely operational questions: how will responsibilities and decision-making be clarified with the teams from PHE, NHS Test and Trace and the Joint Biosecurity Centre (at the latest count) coming together with inevitable overlap and gaps? How will these responsibilities be communicated to regional and local public health teams? Beyond that, there are long-term questions of transparency, accountability, who sets its strategy and how does the work of the NIHP develop and connect to the rest of government (including those in the devolved nations), given it will cover not just communicable diseases but also other threats to health, such as terrorism. These questions need to be answered publicly. For too long our health protection system, whether under PHE and its predecessor the Health Protection Agency, has been a black box and has not received the public scrutiny required; that must change with the NIHP.

For what remains of PHE, the immediate challenge is one of staff morale. It’s thousands of staff, who have worked every bit as tirelessly as colleagues in the NHS, will have found out that their futures are up in the air via a news article behind a paywall. To add insult to injury, the government doesn’t have a clear answer to the most basic of questions, ‘What happens to us?’. It is fortunate that its incoming interim Chief Executive, Michael Brodie, knows and understands the organisation well, having been its Finance Director until relatively recently. He and his senior leadership team will need to work hard to stem the inevitable temptation for hugely experienced, skilled and critical staff to flee the organisation. They will need answers from the government, and quickly, about what the short-term future holds, the answer to that must be stability at least until we get into the late Spring of next year. PHE provides data, analysis, evidence, advice, surveillance and support to local, regional and central government, the NHS and others, that must be protected as much as possible.

And what of the local? Directors of Public Health, those in the NHS and those working in other organisations involved in local delivery systems now have the complexity of responding to both PHE and the new NIHP as it sets up. As the President of the Association of Directors of Public Health has said collaboration needs to be ‘hard-wired’ into the new system as it is conceived. 

For the government, the strategic question will be what it wants from a public health system. I am sure some will be advising government that all it needs is the NIHP. Any sensible government looking at the evidence would see that the public’s health is determined and influenced by all government policy decisions, not just those with a health label. The opportunity in this chaos is therefore to re-invigorate what is left of PHE and ensure its expertise is genuinely used by and influences government policy as a whole. Who knows, this may have been exactly what the Secretary of State was alluding to in his speech when he said:

Levelling up health inequalities and preventing ill health is a vital and a broad agenda. It must be embedded right across government, across the NHS, in primary care, pharmacies, and in the work of every local authority. So we will use this moment to consult widely on how we embed health improvement more deeply across the board, and I’ll be saying more on this over the coming weeks.

These are difficult questions, and the government having robust answers to them is critical, or the health of all of us will be at risk. 

Giving what remains of PHE bigger and stronger teeth seems a pre-requisite for making headway on the above. Just how that is achieved – whether that means a change in form or remit, or clearer lines of responsibility and accountability (as we have argued for) – is less important than that it happens, and with minimum loss of the precious knowledge and expertise that remains.  

These are difficult questions, and the government having robust answers to them is critical, or the health of all of us will be at risk. 

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