How to fix England’s public health

Public Health England / WIRED

Public Health England (PHE) is doomed. The health secretary, Matt Hancock, announced last week that the organisation, an executive agency of the Department of Health and Social Care (DHSC), will be replaced by a new entity. Called the National Institute for Health Protection, the body is a result of merging PHE with the newly-launched Joint Biosecurity Centre and NHS Test and Trace, it will be led by the latter’s director Baroness Dido Harding, and focus its efforts on fighting off infectious diseases, pandemics, and biological weapons.
Experts and public health organisations have questioned the wisdom of such a shake-up in the midst of a global pandemic, while others have pointed out that several of PHE’s functions – such as tackling obesity and smoking – risk being sacrificed as a result of the new priority-setting.

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Others have underlined that while Public Health England’s response during the pandemic has been less than sterling, especially with regard to the decision to halt contact tracing in mid-March, the organisation is being blamed for decisions that in most cases were taken by the ministers and officials from which it depends. As it already happened with the constant invocations of “the science”, the government might just be scapegoating the experts in order to exculpate itself.
That said, something in Public Health England’s handling of the Covid-19 crisis certainly did not work as it should: something is seriously wrong when your pandemic-management plan can be characterised as “carry on Covid.” But what exactly went wrong? And how can the new National Institute for Health Protection get those things right? We asked public health and policy experts about that – here their answers.
Less political interference
Public Health England was born out of a reform that brought together a plurality of non-departmental health agencies, putting them under the DHSC’s control. According to Paul Hunter, a professor of medicine at the University of East Anglia, that had the negative consequence of making PHE part of the civil service. “It was now civil service and civil service culture isn’t really good science,” Hunter says. “Civil service is a process-driven culture and science cannot be done well, in a process-driven culture.”
He says that as a consequence of that, many scientists who used to work in PHE’s predecessor agencies left to teach in universities. “A number of them were to my knowledge quite unhappy about the culture within Public Health England and the more civil service bureaucracy-type culture.”

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Hunter says that while there is no just one good way of setting up a public health agencies, in most countries these agencies enjoy “a degree of separation and independence from government. And they create a culture where public health scientists can actually work and identify problems early, and respond to them. “
Hunter’s observation chimes with the position of the Independent Sage, a group of public health experts publishing advice about the pandemic. “Public health organisations need to be publicly accountable and not the subject of unwarranted interference by individual politicians and their political advisors,” Independent Sage members wrote in a statement about PHE’s scrapping.
According to the government’s announcement, the National Institute for Health Protection will report directly to the Health Secretary.
Let the science lead
Of course, change needs to start from the top. While PHE counted several doctors among its staff, it was not led by one: its CEO Duncan Selbie is a former hospital administrator. His replacement at the top of the new organisation, Dido Harding, is not a doctor, either – she is a former telecoms executive with a Philosophy, Politics and Economics degree and a Harvard MBA. Some public health experts find this worrying.

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“The claim that the new organisation is modelled on the Robert Koch Institute is clearly nonsense,” says Martin McKee, referencing a government document declaring that the National Institute for Health Protection would be fashioned along the lines of Germany’s public health institute. “[The Robert Koch Institute] is a much smaller organisation than the health protection part of PHE, it is independent of government, and is headed by experts in their field.”
Hunter shares these concerns. “It all depends on whether Baroness Harding is actually serious about its being a science-led organisation and whether she can actually do that,” he says. “If you look at the Robert Koch Institute: the president of the Robert Koch Institute is a highly respected scientist with a hugely successful career in science. And the whole culture of the Robert Koch Institute is around public health science. But already, we’re getting people in senior positions who actually aren’t scientists and don’t understand the needs of science.”
That could change, however: Harding was admittedly appointed as an “interim chief” of the new institute.
Make sure it’s local
Among the elements of Germany’s successful response to the coronavirus pandemic was its network of local health authorities, which were instrumental in the country’s contract-tracing efforts. In contrast, the UK’s contract-tracing strategy has been criticised for being too centralised. Some feel that Public Health England’s local offices might have been put to better use. “One of the big failings in the UK’s response was trying to manage it all centrally from quite early on,” Hunter says. “The fact that local public health teams were not included in that – that can’t be blamed on Public Health England. That is a ministerial issue.”
Criticism of that approach is deeply linked with the government’s decision to outsource its track-and-trace system to private contractors Serco and Sitel, which run the operation from a network of call centres whose effectiveness has been questioned amid reports of unpreparedness and confusion.
“Contracting out billions of pounds to Serco and Sitel, rather than giving additional resources to the local directors of Public Health was a big mistake,” says Linda Bauld, chair of public health at the University of Edinburgh. “PHE has regional offices around England, and they are led by people who are ex directors of public health or have good public health experience and they work very well with local teams.”
“Contact tracing shouldn’t be done by somebody sitting in a call centre in London, but by people who are local,” Bauld says, as contact tracers need a granular knowledge of the area and population they are monitoring.
According to Sarah Nickson, a researcher specialised in outsourcing at the Institute for Government: “The new National Institute for Health Protection will need to draw on the expertise of local councils and directors of public health when making decisions. At times during the pandemic, the central government has consulted its local counterparts far too late.”
Get the funding right
A lot of Public Health England’s ailments boil down to a lack of adequate funding. The agency’s budget has suffered cuts of over 40 percent in the seven years since it was launched.
Hunter thinks that that speaks to a wider trend that transcends the last decade of Conservative-enforced austerity. “The UK has been running down its public health services for 20 years. Twenty years ago, we had something called the Public Health Laboratory Service and it was widely recognised around the world as being one of the most effective public health protection organisations in the world,” says Hunter – who worked for the Service until 2001.
In 2003, the agency was disbanded, a decision that in retrospect made it much harder to respond to the current crisis. “We lost a lot of the laboratory capacity that the PHLS had, particularly its capacity to respond quickly to increased demands at testing. Twenty years ago, we wouldn’t have had this mess with testing because we had the labs.”
The post-2008 crash and the subsequent cuts compounded the problem. “At least half as about half of public health funding has been removed. And the consequences of that is that there’s been a lot less staff, and that a lot of people who have considerable experience have left work,” Hunter says.
Bauld agrees. “That’s been a real problem for the organisation itself, as the government gave a huge amount of money to private companies instead,” Bauld says. “Adequately resourcing the new National Institute of Health Protection will be really key.”
Gian Volpicelli is WIRED’s politics editor. He tweets from @Gmvolpi
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