A qualified success: a personal reflection on the passing of Public Health England

On 1 October Public Health England will cease to be, its functions largely subsumed into the United Kingdom Health Security Agency and the Office for Health Promotion, with some more clinical work going to NHS England. But did it deserve to go?

I only ‘knew’ Public Health England as an outsider, through my work at The King’s Fund, and in particular knew little about the health protection and emergency response arm. So this is a reflection from one standpoint only, there are other good sources on how PHE has acted technically through Covid-19, and those that have worked in it, or more closely with it, will have their own views.

'The argument for setting up Public Health England was that it would bring together expertise on public health that was fragmented in too many organisations and places'

The argument for setting up Public Health England was that it would bring together expertise on public health that was fragmented in too many organisations and places, to support the coalition government’s ambitions to ‘protect and improve the public’s health, improving the health of the poorest, fastest.’ Its goals were explicitly to support the new system locally but not performance manage it, and to advise government, but not to set policy.

Right from the start there was confusion about the interpretation of its role as an ‘executive agency’ of the Department of Health. The Cabinet Office states that:

An Executive Agency may have some role in the development of policy, not least because good policy development should always be closely informed by frontline delivery experience. However, this will generally be in highly specialist and/or technical areas of work and should never be to such an extent that it begins to overshadow the operational delivery role that should be the focus of the agency model.

After a quiet start Public Health England did start to publish its evidence and research work – notably on alcohol and the case for the minimum unit pricing of alcohol (not government policy) – but it also got into hot water about the sharing of its work in progress on the health effects of sugar. This, in part, reflected the ambiguity and discomfort in its role as an executive agency and how it was perceived: simultaneously as the nation’s public health body and a servant to parliament, while also having a more formal and restricted role as an adviser to the government. Just how influential Public Health England was, or was allowed to be, across government decisions that influence health has been a perennial concern of the various parliamentary committees that have looked at public health policy since its creation, and while it may have had some influence within government, it is hard for anybody outside to tell.

But its national role has been only one part of Public Health England remit – the others being its international work and its role in supporting the local public health system. While my interactions with Public Health England have not included the former, it’s clear it has played a critical role in global public health from the response to Ebola to sequencing Covid-19 variants. On the local role, it’s a tale of two halves. Public Health England, and the Department of Health and Social Care in which it sits, largely failed in persuading the Treasury to loosen the purse strings for local government public health spending, and after an initial honeymoon period the ring-fenced budget fell – its budget now almost a quarter less per capita in real terms than at its high point at the beginning of 2015/16. However, the money is only half the story. Unusually, and to its credit, Public Health England published annual warts-and-all, wide-ranging stakeholder reviews of its strengths and weaknesses. Over time these showed a local system that increasingly valued Public Health England for its data, public health intelligence, work and the evidence it provided to help local government and its partners make the most of the resources they had for public health.

Public Health England’s passing will not be mourned by some. Personally though, I have seen the dedication and commitment of its staff at close quarters and the intention behind its creation, to integrate a fragmented public health system in England, was right. On data, intelligence and evidence it has made important strides forward. And it has brought together and developed strong expertise in public health for the benefit of the system, this must not be lost with its demise.

'...the ambiguity over its role and position, while perhaps helping it behind the scenes in Whitehall at times, has been to its cost not establishing it firmly enough in the minds of key decision-makers, or with the public.'

But, as Paul Cairney and colleagues have concluded in comparing Public Health England’s trajectory with that of equivalent bodies in Australia and New Zealand, executive agencies are no magic bullet for the prevention agenda. With the benefit of hindsight, the ambiguity over its role and position, while perhaps helping it behind the scenes in Whitehall at times, has been to its cost notestablishing it firmly enough in the minds of key decision-makers, or with the public.

For me, therefore, Public Health England should be seen as a qualified success, especially given the environment in which it has had to operate and the restrictions of its organisational form. It is now incumbent on the government, the United Kingdom Health Security Agency and the Office for Health Promotion to clearly demonstrate that what follows PHE will be demonstrably better, building on the concentration of and synergies between the expertise it has developed in its short life. It needs to be given the resources to do the job, and sit within a wider environment that helps the new public health system thrive.