Dr John Ashton, a former director of public health, explores how the 2013 NHS reforms led to the shrinking and withering of our local and regional public health system.
Public Health England has played a central role in the COVID-19 pandemic but its determination to centralise at all costs has cost us dear. Delays in raising the threat level, testing and guidance over personal protective equipment (PPE) have had serious implications for all of us. Britain has always been at the forefront on public heath innovation and best practice – how have we let this relatively new organisation put us on the back foot?
In 1842, Edwin Chadwick’s Report on the Sanitary Condition of the Labouring Population of Great Britain – a forerunner of Michael Marmot’s modern reports on health inequality – laid the foundations for our world-leading public health system in Victorian England.
Britain’s first medical officer of health was William Henry Duncan in Liverpool. Appointed by a local Act of Parliament, his work with his colleagues, the sanitary inspector, Thomas Fresh, and borough engineer, James Newlands, paved the way for others to follow and for the first Public Health Act of 1848, which empowered local authorities to appoint their own medical officers of health.
An indication of the effectiveness of their efforts in Liverpool is provided by the local toll from cholera in 1849 with 5,425 deaths in under one year in a town of 300,000 people, compared with 1,146 when the pandemic returned in 1854.
The public health movement that began in Liverpool and the nation’s towns and cities flourished for more than 100 years, reaching its peak in the 1930s when the medical officer of health held responsibility for a wide range of functions that lay behind the health of the local population. These included the traditional environmental services of water supply, sewage disposal, food control and hygiene, for the health aspects of housing, for the control and prevention of infectious disease, for the maternity and child welfare clinics, and their attendant health visitors and midwives, for the TB dispensary and the VD clinic, for school health, and – before the advent of the NHS – for the administration of the local hospital. As late as the 1950s, Liverpool’s public health department included more than 5,000 staff and was a power in the land.
The post-war decline in the status and resourcing of public health ironically followed the establishment of the hospital-dominated NHS and the belief that, with infectious diseases on the run, the mission of public health had been completed. In 1974, the post of medical officer of health was abolished and the workforce dispersed.
Subsequent scandals involving a failure to get a grip on infectious disease outbreaks at the Stanley Royd geriatric hospital in Wakefield, with 19 deaths in 1984, and a Legionella outbreak at Stafford Hospital, with 22 deaths in 1985, led to a reboot of public health in 1988 and the rebuilding of its capacity and importance from the new base of the NHS.
This so-called ‘new public health’ – with its emphasis on public engagement, multi-disciplinary partnership working and the reorientation of health services away from hospitals towards primary and community health and prevention – gained momentum over the next 20 years, supported by the World Health Organisation’s Global Strategy For Health For All By the Year 2000, spawning on its way tangible initiatives focused on specific places such as the healthy city, the healthy school, the healthy workplace, the healthy stadium and the healthy prison.
But, in England, all of this changed in 2013 with the implementation of reforms by then Health Secretary Andrew Lansley and the establishment of Public Health England.
The Urgent Need for Local Boots on the Ground
The fragmentation and dysfunction of the NHS itself as a result of the reforms is now familiar. Perhaps less familiar is the consequences for a public health system which had established itself as effective and resilient and had dealt with, among other things, the epidemic of HIV/Aids, teenage pregnancy and a series of new viral challenges including SARS and Swine flu.
The profound weaknesses created by the establishment of a centralising and narrowly-focused national public health agency, which has neglected the need for local and regional underpinnings, has now been laid bare by the COVID-19 pandemic.
Since 2013, whilst Public Health England has expanded its national base in London, it has also greatly expanded both its overseas travel and its foreign spending and committed to spending the best part of £1 billion on a vanity project campus at Harlow. Meanwhile, the local and regional public health system has been allowed to wither and shrink.
The previous nine Regional Directors of Public Health and their specialist teams – providing leadership to local public health teams with natural geographies and well established wide-ranging networks, including strong clinical links with the NHS – have been replaced by four artificial regions each represented by a Regional Director of Public Health, whose loyalty lies with a chief executive with a hospital management background and to ministers, rather than to a local population, its Members of Parliament and natural communities.
Local Directors of Public Health, whilst notionally back home in local government, have had to stand silent whilst their team members have been decimated, along with their budgets. Many of them have to be line-managed by Directors of Adult Social Care as second-tier officers in the local authority with no automatic access either to the chief executive or to the leader of the council, their freedom of speech and health advocacy has been curtailed and their independent annual public health report co-opted as a corporate document. The commentator Roy Lilley has remarked that they have been put in a cardboard box in the cellar of the town hall.
The consequences of these changes are now coming to light, with a sad catalogue of commissions and omissions, accompanied by poor and misleading communications. At the heart of the solid work of medical officers of health were three core tasks: registration of births and deaths, notification of disease, and advice to councils. The progressive centralisation of previous local authority functions into Public Health England – but also into the Environment agency, the Food standards Agency and the Health and Safety Executive – has left the capacity for work in these areas threadbare, whilst exposing these national bodies as having claimed territory that they are unable to occupy.
The failure to plan for the Coronavirus pandemic and to build appropriate capacity and capability to respond to the emergency that now surrounds us; to provide joined-up and timely intelligence as to its extent – through the time-honoured public health measures of screening, testing, contact tracing, triaging, isolating and treating – have allowed an outbreak on an island that had a four-week opportunity to prepare. The failure to advise both the Government and the public in an independent, open and transparent way has led to thousands of unnecessary deaths and distress and no doubt to long-term morbidity as well as dire economic consequences.
On top of this, Public Health England still remains reluctant to set local Directors of Public Health free to provide the sort of trusted local leadership that is essential if further harm is to be minimised. This can only be done by people who know their local communities well, their demographics and cultural diversities. It can only be done if the directors are provided with adequate resources to do the job. It cannot be done by remote bureaucrats and a narrow range of academics in league with commercial consultancies sitting inside the M25.
In his latest letter to local Directors of Public Health, PHE Deputy Chief Executive, Richard Gleave, says that the directors are “involved in local discussions” (but not leading them) and that “staff will work under the leadership of the PHE-led national function alongside an external logistics partner”. It also gives too much credence to an NHS contact tracing app, preferring a technology in development to the tried and tested but manually intensive public health measures applied elsewhere.
After three months of over-promising and under-delivering, with deaths mounting, it is time for Public Health England to take on board Albert Einstein’s thoughts on insanity – “doing the same thing over and over again, but expecting different results”.
Dr John Ashton is a leading international authority on public health and a member of the Crown Prince of Bahrain’s Corona Task Force.