Public health must have independence to advocate for the public’s health

by Chaand Nagpaul

The abolition of Public Health England is a threat to impartial medical advice.

Location: UK
Published: Thursday 27 August 2020
chair of bma council chaand nagpaul

Public health doctors may not be the front-facing medical professionals patients see when they go to a GP surgery or hospital, but we all know they play a vital and far-reaching role in preventing illness, saving lives and improving health and inequalities.

They ensure resources are used within evidence and equitably, and of course have responsibility to control the spread of infectious disease. The health of our nation quite literally depends on them.

The pandemic has brought into the limelight the essential role that our public health doctors have played in each nation’s response to COVID. They have compiled essential data about the virus, its spread and impact on the population. They have advised ministers on policy, spoken directly to the public at daily government media briefings and managed outbreaks of local infection and contact tracing – this is their core bread and butter expertise.

I’m proud that the BMA has a dedicated public health medicine committee, with elected members drawn from local teams and those working at the centre in all four nations including in PHE (Public Health England) itself.

Our public health medicine colleagues have been instrumental and invaluable in helping the BMA, ensure that our policies and responses to the pandemic have been built on the best available evidence.

They’ve advised on the science of testing and tracing, interpreting infection rates, the use of PPE (personal protective equipment), policies to ease lockdown safely, mitigations to prevent spread in the community, the use of face masks, infection control in healthcare settings, public messaging, and quarantine policy for those arriving from abroad. These are just some examples of the range of issues on which our public health doctors have offered their expertise.

In their communities, many have worked long strenuous hours during the pandemic, as they have dealt with local outbreaks with responsibility to protect local populations.

The defining attribute of a public health doctor should be as the name suggests: being accountable for the public’s health, an advocate for the health of the individual, and collectively for societies and the nation.

When I first became a GP three decades ago, public health doctors were truly independent, and able to speak out in the public interest, regardless of political policy. I remember for example my local director of public health issuing in his annual report a damning indictment of the Government’s internal market reforms of 1990 – defying politicians, but always acting in the interests of the community he served.

That independence has been eroded over the years. In England in 2012, the Health and Social Care Act firmly embedded the function of public health in the form of PHE as an executive agency of the Department of Health and Social Care. Since then, it has been directly accountable to ministers and limited by civil service protocols.

Throughout the coronavirus pandemic, the voice of public health has often been relayed through the mouths of politicians. They have interpreted and been in control of the advice given to them. A glaring example is the PHE review into the disproportionate impact of COVID-19 on BAME (black, Asian, and minority ethnic) communities, which was handed by PHE to Government on time by the end of May.

But it was ministers who decided to delay publication of its recommendations until after the document was leaked to the media in mid-June. The imperative should have been to publish as soon as possible in order to act to mitigate further harm to our BAME communities.

Public health medicine has suffered significant reductions in funding over the years – a £850m drop in real-terms funding between 2015/16 and 2019/20, according to the Health Foundation and the King’s Fund.

This has directly resulted in cuts to vital services to help people quit smoking, free themselves from the demon of alcohol and drug addictions, or seek help for sexually transmitted diseases.

So many of the disadvantages and inequalities public health seeks to address in more usual times have been brought into sharp relief by this pandemic.

Twice as many adults are reporting symptoms of depression than the same time last year, figures from the Office for National Statistics show.

PHE’s study into the impact of COVID found that the death rates were double that in the most deprived sections of the community than in the least deprived. The same report found that people from BAME communities were substantially more likely to be admitted to intensive care departments and that black men and women were more than three times as likely to die as their white counterparts.

Homeless people are three times more likely to be chronically ill with the lung and breathing problems that are serious COVID risk factors.

With this evidence we successfully called with others for an extension on the ban on evictions in England. It goes to show what can happen when doctors speak out on public health issues.

Last week of the health secretary announced the abolition of PHE and the formation a new National Institute for Health Protection, which combines public health roles already carried out by PHE with NHS Test and Trace and the Joint Biosecurity Centre.

This raises serious unanswered questions and concerns about the future of public health medicine in England.

The new institute appears to be focused, in the Government’s words, on ‘advancing the country’s response to the COVID-19 pandemic’. Yet there seems to no information as to how it – or who – would also carry out the wider public health functions of PHE.

What of the promoting health, the preventing of illness, the addressing of the social determinants of health such as inequalities which are just as essential components of public health medicine? They have just as great an impact on the nation’s morbidity and mortality rates. And as the PHE review has shown, these have also directly affected the health outcomes arising from the pandemic in our nation.

Secondly, the announcement makes no mention of redressing the significant underfunding in public health which is already impacting on our ability to improve the nation’s health. It is vital public health receives the resources it needs – the pandemic is evidence enough that having the capacity to manage a pandemic could save thousands of lives. Yet the budget for PHE is around £400m compared to the £10bn allocated by Government for the test-and-trace programme.

Thirdly, the announcement was met with media reports implying that this was a reflection of ministers’ belief that PHE had failed to deliver on its role. The unreported irony is that, as an executive agency of the Department of Health and Social Care, responsibility for its performance is arguably just as much that of the DHSC.

And finally, PHE’s own hard-working staff were not treated with the courtesy they deserved. As I raised in a letter with the health secretary Matt Hancock, many of our members found it deeply unsettling to hear of the changes through media leaks prior to a ministerial announcement. It is vital their pay, terms and conditions are adequate and protected and that the BMA is involved as a stakeholder in the forthcoming discussions about the future of these services.

The BMA has indeed wanted to see reform of PHE – to free it from political shackles – yet this announcement appears to reinforce the control of ministers as the institute will be accountable to them.

The BMA remains firmly of the view that public health medicine must regain its independent voice and be able to speak freely and honestly to inform the public. Local public health teams must be provided with the transparent information they need to create healthier communities.

Putting public health under political control was wrong for PHE and will be wrong for its replacement.

It’s clear who the public trust most for advice and information, during this pandemic or at any other time – and it’s not the political class. It’s doctors, nurses and those who provide care to the nation.

Now is the time to make public health fit for the future.

We, our patients, and the most disadvantaged in our communities, cannot afford for another reform to fail.

Chaand Nagpaul is BMA council chair