Strengthening health protection: right idea, wrong time

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It is a truth universally acknowledged that to rebuild an aeroplane in mid-flight is a sure-fire way to guarantee success. Or perhaps not. Which makes it all the more extraordinary that the government has chosen this moment – this moment of all times – to disband much of Public Health England (PHE) and merge it with NHS Test and Trace to create the National Institute of Health Protection.

It is extraordinary on so many levels. There will now be a whole bunch of people, whether on the pandemic-handling side of PHE, or the health improvement side (which covers everything from tackling obesity to improving child health to co-operating in global programmes to address antibiotic resistance) who will no longer be concentrating solely on their jobs but wondering whether they will be joining the rise in unemployment that Covid-19 is set to deliver; and thus whether they should focus not on their job but on getting another one.

It is extraordinary because the merger will be with Test and Trace, which has hardly been the howling success of the government’s handling of the pandemic. I prefer to avoid calling it NHS Test and Trace because it appears to have nothing to do with the NHS. It is essentially a contract with Serco and Serco’s sub-contractors. There is nothing wrong in involving the private sector. But in no obvious way does Serco have any expertise in either tracing or testing – as the patchy performance of the service demonstrates. And Serco has paid plenty of penalties for under-performance on other public sector contracts.

'It is extraordinary because if the judgement is that PHE has been a failure... merging it with the test and trace service right now feels like the public sector equivalent of melding two failing NHS Trusts... in the belief that hope will somehow triumph over experience. It rarely does.'

It is extraordinary because if the judgement is that PHE has been a failure – and only the promised public inquiry will reveal who took which crucial decisions and when – merging it with the test and trace service right now feels like the public sector equivalent of melding two failing NHS Trusts, or two failing private sector companies, in the belief that hope will somehow triumph over experience. It rarely does.

And it is extraordinary because if PHE has been one of the failures of pandemic response, one has to ask who is responsible? ‘Ministers’ might be the answer.

To understand why, we need to do a bit of history. Prior to 2013 and the implementation of Andrew Lansley’s infamous 2012 Health and Social Care Act, much of public health sat in the then Department of Health and in the NHS. Outside of both was a genuinely arms-length body called the Health Protection Agency (HPA) which ran the public health labs and the civilian bit of the germ warfare centre Porton Down. In other words, it had a sole focus on health protection, as opposed to health improvement. It was, ultimately and quite rightly answerable to ministers, but was able if push came to shove to express in public (at a price) its own view on what should or should not be done.

Under Lansley’s Act, much of the health improvement side of public health was transferred to local government (for which there was both a case for, and a case against), and much of the department’s public health function went into Public Health England – as did the HPA. The HPA lost standing, becoming, like the rest of PHE, an executive agency of the Department of Health, and thus subject to ministerial direction.

So if PHE has been the failure it is being painted as, one has to ask why health ministers failed to tell it what it was that they wanted – both ahead of the pandemic and during it. The six pages of ministerial priorities for PHE delivered in March 2019 makes no mention of pandemic preparedness. It lists instead a string of initiatives on health improvement. And one only needs to read the annual reports of the HPA, and subsequently of PHE, to realise that PHE was, unsurprisingly, heavily focused on the ministerial interests of the day: the health improvement agenda, rather than health protection.

'So if PHE has been the failure it is being painted as, one has to ask why health ministers failed to tell it what it was that they wanted – both ahead of the pandemic and during it.'

The tragedy of the test and trace service is that we as a country know how to do it. This is the sort of practical epidemiology that we had a large hand in inventing. And it is not a case (as some have portrayed it) of national versus local. You need both. Genuine national expertise, with an ability both to understand what is happening nationally and to shift resources to where they are most needed. And local to do the tracing, where the transfer of chunks of public health to local government may well have been the right decision, but at the wrong time. Local government budgets have been slashed since 2010, affecting not just the public health element but a reduction in Sure Start centres, libraries, support for youth clubs and more, whose staff, while not normally part of public health, can be roped in to help with contact tracing in a crisis like this because they know, and can help find, people locally.

It is, of course, true that if nothing had changed, it is more than likely that the HPA’s budget and that of public health within the NHS would have got cut as part of austerity. But the combination of austerity and the infrastructure changes of the 2012 Act have proved deeply unhelpful. The merger of the HPA into PHE seems to have led to a loss of focus, and local government has been weakened by austerity.

So does the idea of taking the health protection bit away from Public Health England make any sense? In the short term, no. In the longer term, yes.

If what eventually emerges out of this is a revamped and strengthened version of the HPA, with the independence to speak truth to power, and with the deep links into local government that it will need, that will be a real gain. There will also be gains if the health improvement side of PHE is embedded across government, as the health secretary has promised, though it should be noted that others have said this before. But to seek to do this mid-flight feels like the mightiest of gambles. A plane it might be better not to be on.

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