THE CORONAVIRUS CRISISPublic Health EnglandFit for Purpose in a Pandemic?
As the UK struggles to meet its Coronavirus testing targets, and care home deaths triple, former MP Paul Farrelly takes an in-depth look at the agency fronting the response.
Work is still ongoing, despite lockdown, at the New Frontiers Science Park outside the challenged Essex town of Harlow, the site of Public Health England’s planned new £400 million headquarters to sharpen the agency’s ability to improve and protect the nation’s wellbeing.
It is a move a decade in the making, since the old Health Protection Agency first cast avaricious eyes on the former head office of SmithKline Beecham, deemed surplus to requirements after the merged drugs giant was swallowed in turn by rival GlaxoWellcome.
Aping the private sector, PHE took over its predecessor seven years ago, to become a pandemic’s first port of call, as part of the biggest ever shake-up of the National Health Service. At the same time, primary care trusts were swept away in favour of GP-led clinical commissioning groups (CCGs), overseen by a far less accountable monolith, NHS England.
The capital cost of the new Harlow health campus exceeds PHE’s annual operating budget, which is just shy of £300 million and has fallen year-on-year since it was first established – the agency’s mission statement, to be ‘credible, independent and ambitious’, notwithstanding.
And the effects of those NHS changes – the so-called ‘Lansley reforms’ of 2013 – on the UK’s wider public health system are still reverberating around the current Coronavirus crisis.
“They’ve been very much the poor relations, public health and PHE,” said the chair of one specialist NHS trust, a veteran scrapper for preventative health funding. “They’re funded in a totally different way to the rest of the NHS and their money’s not been ring-fenced. And there’s the paradox. They’re supposed to be the future. Public health should be front and centre, as we should always be looking at causes. They have the expertise. But they’re the Cinderellas, as they’ve lost so much money since the reforms.”
In its centralised, state-of-the art laboratories, PHE’s 2,750 scientists are right on the frontline of the pandemic: issuing guidance, testing the tests, seeking a vaccine to turn what’s being called the ‘new normal’, with social distancing, back to the old everyday.
It is well-represented on SAGE (the Scientific Advisory Group on Emergencies), the lead body advising the Prime Minister, with three senior staffers among its 21-strong membership (not counting No. 10 advisors Dominic Cummings and Ben Warner, who caused a rumpus when their attendance among the boffins was revealed last week).
But the organisation, spread across nine regional centres with offices in 21 English towns and cities, is responsible for much, much more: tackling obesity, tobacco and drug addiction, radiation and chemical poisoning, as well as infection control and international collaboration.
Its 57-year-old chief executive, Duncan Selbie, a well-regarded NHS lifer, is also the ‘accountable officer’ for the £3.3 billion being dished out to local authorities this year to tackle prevention and cure on the ground. But he has, in effect, no power over how the money is spent or pared back by relentless local government austerity cuts.
“Locally, public health directors used to be powerful people, but they’ve now lost much of their remit,” said Graham Stringer, Labour MP for Blackley and Broughton in Greater Manchester and a member of the House of Commons Science and Technology Committee – one of several now conducting Coronavirus inquiries.
“PHE was a creation of the 2012 Health and Social Care Act. It did great damage to the NHS as an organisation. And public health finds itself, sadly, in a similar category.”
“No One on the Ground”
At first sight, a £3 billion plus budget seems eye-watering. In cash terms, too, it has just risen, by £145 million from last year. But then it was already £850 million lower in real terms than in 2015/16, according to leading think tanks the King’s Fund and Health Foundation. With population growth, they say, an extra £1 billion a year is needed just to make good the cuts.
The grant is also spread thinly, with huge variations around the country. It is worth £133-135 per head to the best-funded councils in Blackpool and London’s Kensington and Chelsea and a meagre £31 to the worst, Surrey, and former Prime Minister Theresa May’s Windsor and Maidenhead.
That simply doesn’t pay for well-staffed public health teams to respond in normal times, let alone during a pandemic, experts say. Nor does PHE’s frozen £287 million budget, with £87 million spent on infection protection last year and £73 million on local authority liaison.
“We’re a small team here, we don’t have great big teams like the NHS,” said Ann Fleming, PHE’s spokesperson for the West Midlands – one of the areas outside of London most affected when the virus was first detected in the UK at the end of February. “We give guidance – we wouldn’t specifically send people out – and then it’s up to local authorities and their local resilience forums, as well as the health service.”
So, as the UK plays catch-up with other countries, cue Health and Social Care Secretary Matt Hancock’s recent appeal for an extra 18,000 clinicians and public health specialists to perform testing and contact-tracing in the community, vital for any lockdown ‘exit strategy’.
This is certainly not a model adopted in Germany, from which Whitehall now admits the UK can learn painful lessons. There, with a much bigger population, proven Coronavirus cases stand at around 160,000 and deaths at just over 6,000, as it has been testing and contact tracing, early and widely.
That compares with an equivalent number of confirmed cases in the UK, but more than 22,000 fatalities in NHS hospitals alone. Additionally, deaths in care homes have now tripled to more than 3,000 a week, taking the tally above 4,000 as of mid-April. But that certainly under-estimates the toll, as the Government struggles to meet its 100,000-a-day testing target, and statisticians at the Financial Times put the true figure at over 40,000 – by far the highest in Europe.
In the ‘credibility, independence and ambition’ stakes, leading public health experts have lambasted the UK’s response, which focused exclusively on hospitals at the outset, followed by ramped-up testing targets.
Among the loudest critics are UCL’s Professor Anthony Costello, a former director at the World Health Organisation and Professor John Ashton, a former director of public health.
“In reality, I am not sure that we need 100,000 tests per day if we can get the epidemic damped down,” Costello told the Health and Social Care Select Committee’s current Coronavirus inquiry. “More important is to have the systems in place. I would like to know much more from Matt Hancock about how they are restructuring the public health teams and whether they have plans in place.”
Remote from Westminster’s grand, oak-panelled rooms, there was nothing ‘virtual’ about the rough ride Professor Yvonne Doyle, PHE’s Health Protection and Medical Director, received from MPs on the committee before Easter about the UK’s faltering reaction to the crisis. She is the highest paid PHE board member, on £255-260,000 a year, but struggled to convince as to why the UK had abruptly stopped community testing on 12 March, before the country went into ‘lockdown’ in a volteface just 11 days later.
Nor about PHE’s guidance on surgical masks, over which the committee’s chair, former Health Secretary Jeremy Hunt, cited clinical staff being in “near revolt”. Nor over the use of gowns, for which the agency has been lashed again this week for relaxing its rules, in evident response to shortages of vital personal protective equipment (PPE). Nor of the failure to include basic goggles in the PHE’s pack of gloves, paper mask and sleeveless apron given to GP surgeries.
“I don’t think anyone was overly impressed,” one Committee MP told Byline Times. “And the answers we’ve received since have been so bland, they were meaningless.”
Doyle also joined colleague Professor Sharon Peacock, PHE’s National Infection Service Director – who sits on SAGE and appeared the day before at the Science and Technology Select Committee – in talking up the “imminent” prospects of finger-prick, home-testing kits, set for distribution by Amazon, with help from Boots and other pharmacies, if need be.
In fact, 21 million kits, ordered from Chinese suppliers amid a blaze of publicity from Boris Johnson and Hancock, subsequently proved unreliable. Science Committee Chair Greg Clark has since written to PHE demanding details of the contracts, as Parliament tightens scrutiny.
Issues like this, affecting PHE’s perceived ‘credibility’ and ‘independence’, cropped up on the frontline, too, during Byline Times’ research.
“PHE have no one on the ground,” said a director at one of the north-west’s biggest hospitals. “They just feel like a website and an e-mail address to me. To be fair, they have stepped up to the plate compared with before, and the virus is new. But the trouble is they keep changing their minds all the time. We’re getting different PPE guidance every two or three days. And none of these antibody kits have proven to work, so why give credence to the claims?”
“No Plan Survives Battle”
Hancock’s 100,000 daily test target expires tomorrow, 30 April. But, with some fudging already, the Government has said that the verdict may wait until next week. And, with new telephone appointment lines shutting abruptly for want of kit, there’s a big difference, too, between laboratory testing capacity and actual swabbing at drive-in centres for the virus.
For its part, PHE has been crucial to ramping-up capacity, with its own eight linked laboratories and the NHS’ 29 laboratory networks, too. But, as for ‘ambition’, it has been careful to distance itself from hanging on Hancock’s 100,000 hook.
In their select committee evidence, Doyle and Peacock were at pains to point out that PHE’s responsibility lay, with the NHS, for the first 25,000 tests, of sick patients only. Beyond that, bringing in universities and private labs, fingers pointed firmly back to the Secretary of State and yet another body, the obscure Office for Life Sciences.
Unlike other European countries, such as Germany, the UK started the crisis with no wide network of smaller diagnostic labs. Critics, including Valerie Bevan, Chair of the British Society for Microbial Technology, have pointed to the dismantling since 2003 of the Public Health Laboratory Service – with a network of more than 50 – in favour of centralisation and cost savings. Others go further, laying part-blame on PHE.
“As this has gone on, I’ve come to the conclusion that one of the reasons we’ve not done as much testing is that Public Health England has been territorial,” said another MP on the Science and Technology Committee. “It didn’t want small, private labs stepping on its turf.”
As for pandemic planning, that’s central to PHE’s remit. It warned the Government in a secret briefing earlier this year that the epidemic could last until next spring and lead to 7.9 million people being hospitalised, overwhelming the NHS. And it played a lead role in 2016’s Exercise Cygnus, to test the NHS’ readiness for a new flu pandemic, the reportedly critical results of which – including lack of ventilators and PPE – remain firmly under wraps.
As for maintaining stocks of vital kit and getting them to where they’re needed, that lies squarely with the cash-strapped health service. “There was a distribution plan, but no plan survives battle,” Doyle told the Health Select Committee. “I think that is maybe what happened, but I cannot answer any more than that, I’m afraid.”
When contacted, PHE did not comment on further answers to Parliament. On the extra costs of the crisis, it said: “It is too soon to assess what sum of additional funding will be required as PHE’s response activities and costs are driven by needs and ministerial direction”.
A spokesman added, however, that chief executive Duncan Selbie, who was ‘self-isolating’ at the time of the committee sessions, had recovered and was back at work.
The Office for Life Sciences, shared between the Departments of Health and Social Care and Business, Energy and Industrial Strategy, was also contacted. Both said, however, they had no one responsible for comment on its role. Its website, last updated on 20 February, also contains no information on its efforts during the epidemic.
Following ‘Exercise Corona’, MPs will not be the only people demanding an inquiry into the planning and co-ordination of the UK’s response to the Coronavirus crisis.
CASE STUDY: Early and Efficient – The German Response
The German reaction has been led by the highly respected Robert Koch Institute (RKI), the country’s equivalent to Public Health England, founded in 1891 and named after the Nobel Prize-winning founder of modern bacteriology.
An independent federal agency, based in Berlin and Wernigerode in the Saxon Harz mountains, and reporting to the central Ministry of Health, it has a similar budget to PHE’s for infectious disease control, but a tighter focus. In Germany’s federal system, it works closely with the country’s 16 Länder, who run the highly decentralised health service, and maintains a network of around 60 public, private and university laboratories.
Germany also has a strong pharmaceutical and local diagnostic base, helped by its insurance-funded system, with more annual health checks, involving testing and scans.
Headed by Professor Lothar Wieler, an expert in animal-human infection, RKI was co-ordinating 160,000 tests weekly by March and, as a result of rapid scaling-up, German labs can now produce 500,000 a week. It has also been contact-tracing, detecting hotspots early on and first developed a diagnostic test in January, which has since been adopted by the WHO.
The German Chancellor Angela Merkel is also a scientist by background, able to speak plainly to explain technical terms and has seen her approval ratings soar.
Germany started to ease its lockdown last week, but is reviewing the situation, as infection rates have rebounded. This week, all 16 Länder introduced a Maskenpflicht, making masks compulsory on public transport and in shops. The UK, though, is still divided on the issue.