Public Health England: the implications of this restructure go well beyond Covid-19

Last week Public Health England got the unceremonious chop from Secretary of State for Health and Social Care Matt Hancock. There’s a well-worn tradition followed by successive governments of setting up, then disbanding national public bodies, and replacing them with something looking suspiciously like a previously abolished body—the kind of thing you’d expect in The Thick of It. In PHE’s case, is this just another “act of casual vandalism” (as Lord Warner described the abolition of its predecessor—the Health Protection Agency—in a Lords debate in 2012)? Or is there method and could something good come of it?

The demise of PHE follows a similar pattern to that of many now-defunct national agencies: a sudden decision; no set-out diagnosis of the problem or justification for change; an orchestrated trial by a baying set of on-side media commentators; no apparent acknowledgement of the costs involved, nor the demotivating effect on staff or follow-on risks. News breaks often on a bank holiday weekend, or at a time with other media distractions—in the PHE case it was of course the weekend of the A-level grades fiasco. Then comes the official announcement at a friendly think tank, with an invited audience, where awkward questions to the minister can easily be deflected. Job done… onto the next policy announcement…

For sure, PHE’s record in the pandemic is mixed—on testing, tracing, even counting the number of deaths. But the government must take its share of responsibility. As an executive agency, PHE is already directly accountable to the Department of Health and Social Care and the secretary of state, and thus reflects their own performance. Looking back at the priorities for PHE set by ministers in 2019, preparing to leave the EU was top of the list, rather than pandemic preparation.

Hancock’s decision to axe it carries high-stakes risks, with such a distracting reorganisation in the middle of a pandemic. The reorganisation will consolidate the work of three key public health organisations—PHE, the Joint Biosecurity Centre and NHS Test and Trace—into a new National Institute for Health Protection. One objective, according to the secretary of state, is to provide greater “focus” (repeated eight times in his announcement at think tank Policy Exchange) to the government’s response to Covid-19. There is logic to linking these functions, and governments surely must make the reorganisations they think will be effective. The timing is presumably because there’s a lull in Covid-19 infections and hospitalisations (down from 17,000 at the peak to 545 now).

[su_pullquote]“There’s a well-worn tradition of replacing public bodies with something like what was previously abolished—the kind of thing you’d expect in The Thick of It”[/su_pullquote]

But three ironies. The first is that PHE in part replaced a similar institution seven years ago—the Health Protection Agency. The rationale was to create an executive agency that would “bring central government closer to its core role of protecting citizens” and integrate action on the related issues of infection control and broader public health. Second, the successor body is to be modelled on Germany’s Robert Koch Institute—a poster child internationally because of its successful response to the pandemic. Unlike the seven-year-old PHE, the Robert Koch Institute has been in existence for 125 years, its mandate hasn’t changed since 1994, and it has always been headed by independent scientists of distinguished pedigree. Third is that a review of PHE by a respected set of international peers in 2017 was glowing.

Time will tell whether the upheaval is worth it. Surely this will be the subject of extensive scrutiny in any subsequent inquiry, alongside of course the record of the government and the Department of Health and Social Care itself.

But just as important will be what happens to the other things PHE does apart from infection control, in particular “health improvement”—such as the promotion of healthy lifestyles and tackling health inequalities across the population.­­ No surprise that the outriders trailing the PHE announcement were quick to argue for an end to its role in “nanny statism.” But the continuing burden of ill health and death from inequality in England is far greater than that from Covid-19—and growing. This also affects “red wall” areas disproportionately, and might therefore have been thought a government priority.

To his credit the secretary of state, in announcing PHE’s demise, reconfirmed his commitment to prevention. He needs to—the health gap between rich and poor is wider than in most other European countries. If nothing else its burden will be a huge drag on economic recovery. The government is beginning to recognise this, for example publishing an obesity strategy in July, which the prime minister supported publicly. Beyond that, it remains to be seen whether the “levelling-up” agenda will extend beyond the economy and infrastructure and into health. There will be opportunity in the Autumn spending round to make more progress—although radical measures will be needed to have any impact on health by the next election in 2024.

So while all eyes are on how the new arrangements post-PHE will work to fight the pandemic this winter, the real area to watch is how the wider programme for health improvement takes shape. The huge opportunity to design something intelligent alas will take more thinking than tinkering with national agencies.