Is it entirely sensible to dismantle Public Health England (PHE) in the midst of a public health crisis? I believe it isn’t and I’m in good company: the sudden demise of PHE seemingly hasn’t gone down well anywhere. Even on a human level it seems unfortunate – when public health staff, locally and nationally, have been working non-stop in incredibly difficult circumstances for months. And for many they first heard this news from the press. There are 5,500 staff in PHE.
What are the main concerns? It will cause huge disruption at precisely the wrong time – when there is the possibility of a new wave of infections in the winter and more local outbreaks. The new body, the National Institute for Health Protection (NIHP), is starting work immediately but won’t be formally constituted until next spring. And there are no guarantees about its effectiveness – PHE is being merged with NHS Test and Trace, which has not had the best record during the pandemic. The government seems to want to blame PHE for any problems – and PHE’s record during the pandemic hasn’t been perfect – but public health has had serious funding cuts in the last few years and any failures over PPE or care homes, for example, were ultimately due to political decisions.
For local authorities the key issue is what happens to those PHE responsibilities that are not included in NIHP. Matt Hancock has said that there have been no decisions made about these health protection functions and that there will be a consultation. It isn’t really a surprise that such a major reorganisation is determined before this has been sorted out. It looks like the role of local government is, as often the case, an afterthought. Although there were some hints about the future of PHE in government messaging about the agency over the last month, it looks clear enough that the actual decision was taken in haste.
There is, though, a lot of speculation about what happens now. The LGC reports that a senior sector source told them that the government now intends to build up the DPH role in health protection locally and that this provides a “key opportunity” for DPHs. Yet we also know that local government’s public health grant had been cut in the years before the pandemic. And it isn’t clear if directors of public health and local authorities will be involved in designing the new system. Will the decisions over NIHP take account of how the rest of the health protection function will work? What is going to happen to the work PHE does in tackling smoking reduction, addiction and obesity? Public health, locally and through PHE, has wide ranging direct and indirect roles in relation to crucial issues such as sexual health, health equity monitoring, mental well being, policies on air quality, and children’s health services.
The record of the government in imposing top down ‘solutions’ during the crisis does not bode well. Even if councils get wider responsibilities, these need funding. Will this be forthcoming?
Liverpool City Council’s DPH Matt Ashton in LGC asked whether local public health teams would lose their access to local health protection expertise, or would it be enhanced: “Is it moving to a national model or a local model? With wider focus on health improvement, will we see significant increase in public health grant, and with weighting specifically around inequalities and deprivation?”
These issues are fundamental. Covid-19 has exposed issues around deprivation and the impact on health inequalities that we knew existed but are now crystal clear. The pandemic has made them worse. Even in relation to specific health issues, such as obesity, there are question marks. The government has recently published its obesity strategy but how committed is it to developing it and what impact will the shock to the public health system have on its delivery? Not to mention that obesity is known to be a factor in the outcomes for people of contacting the virus.
Jennifer Dixon, the chief executive of the Health Foundation, called the reorganisation “a massive distraction” and said that health prevention and health promotion are “far bigger in terms of health” than the Covid part of PHE’s role: “how much is the government going to focus on that?”
The creation of PHE and the transfer of some public health responsibilities to local government in 2013 were widely welcomed by the sector. Of course, it hasn’t been plain sailing, but the 2013 reorganisation recognised the key role local government historically had in health promotion and prevention. The new reorganisation needs to confirm and enhance that role, fund it adequately and sustainably, and design the whole system to ensure all its parts can work together effectively – or the disruption and uncertainty caused by the abolition of PHE will definitely not have been worth it. Will that happen? It’s anyone’s guess.