Public health reform: not the right time...

A massive reorganisation of public health in the midst of a pandemic, to a tight deadline, with no clarity over vital services. Really? Peter Blackburn asks why

Location: England
Published: Friday 13 November 2020
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At 12.16pm on 16 August an email entered the inboxes of all members of staff working at Public Health England.

It began: ‘Dear everyone, I am sorry beyond words.’
The executive agency’s chief executive, Duncan Selbie, was addressing leaked news, published in The Sunday Times, that the 5,500 members of PHE (Public Health England) staff were now working for an organisation which was to be disbanded, ‘amid concerns about its performance during the pandemic’.

It was a surprise and a shock to most, although, according to one senior source, those in leadership positions had felt the rumours swirling for several weeks.

‘You do not have a situation where thousands of people in a major organisation that is absolutely key to the pandemic response find out they may not have a job in a year’s time over Twitter, late on a Saturday night or in the papers on Sunday morning. That is absolutely inappropriate,’ consultant in public health and BMA public health committee co-chair Richard Jarvis says.

The chief executive’s apology expressed regret that the media had been briefed before staff had been given the news – and outlined the stark action the Government had taken.

It said: ‘The prime minister and secretary of state wish to recreate an organisation with a sole focus on health protection and to bring together our health protection services with the budgets and people of the NHS test and trace programme to create a new national institute for health protection.’

Rushed decision

The Government hoped, it added, to ‘boost our unique scientific capability and world leading health protection expertise with much needed new investment’.

The news caused great upset to many of those working in public health and consternation among observers with expertise in the area – with particular concerns around the future of all of the other areas of public health which do not sit under the health protection umbrella, the decision being rushed and following no significant engagement and consultation and fears of professionals having their independence eroded. The Doctor has spoken to public health consultants, directors of public health, academics and PHE staff members – and the first issue most raised was that of timing. In short, why now – in the thick of the current chaos and crisis?

The Health Foundation’s Tim Elwell-Sutton, a former assistant director and consultant in public health at Thurrock Council, describes the Government’s decision as a ‘risky move’. He says: ‘Whatever criticism there may be of it you have to be clear that this is not the time.’

It is an analysis supported by the evidence of those working for or with PHE, to whom The Doctor has spoken. One senior member of staff said that while staff were continuing with their work, the loss of CEO Mr Selbie had led to feelings of a lack of direction and made recruitment more difficult.

And there is, of course, the effect on staff wellbeing and job satisfaction, too. The senior member of PHE staff, whose identity has been protected so they can speak freely, says: ‘Most of our staff – once they recovered from the shock of the announcement – are reasonably resigned, I think, to the current situation, they expect to be doing a broadly similar job in the future in some new organisational structure but are frustrated by the uncertainty and disappointed by the implied lack of appreciation of what they do.’

Dr Elwell-Sutton adds: ‘There’s huge disruption caused when you abolish organisations and create new ones – it’s inevitable that staff will be unsettled, they will lose experienced, knowledgeable staff who will move elsewhere, people’s minds will be taken off the tasks and there will be a lot of financial costs as well. Even if what comes next is much better it seems hard to understand or to see how it’s worth the risk.’

A scapegoat?

The narrative of PHE being a scapegoat – a grand, destructive distraction to draw the eyes of critics away from other failings – won’t go away.

But, perhaps surprisingly, many of those in positions of power at PHE do not believe those were the intentions behind the move – and while many remain critical of the manner of the announcement and the lack of a proper process there is a sense of agreement that the moves haven’t been overwhelmingly driven purely by malice or political game-playing.

A senior member of staff at PHE says: ‘It became obvious that the Government needed to do something to put NHS track and trace on a proper organisational footing. The primary reason for the decision seems to be the need to merge PHE with NHS test and trace in order to give NHS test and trace access to a wider staff and to give it an organisational structure.

That, I think we were expecting but what we weren’t expecting was that the full abolition of PHE would be announced as a done deal at the same time. Especially not before any announcement about what would happen to the parts of PHE that were not going into the new combined function.

‘I’ve never heard the secretary of state say anything other than positive things about PHE apart from when he’s quoted as telling jokes about us in the bar in the Commons. There’s no sense currently that we are being formally scapegoated but there is a lot of rumour. It feels more as if we are, if anything, collateral damage in this reorganisation.’

And, in his email of 16 August, Mr Selbie said: ‘No one remotely close to our work of the past eight years, and since January on the pandemic would agree with the headlines that this change reflects “pandemic failure” on our part. Certainly, this is not what the secretary of state believes or says in public or private.’

Fragmentation fears

peter english 29667 ENGLISH: 'It's rushing ahead too quickly'

Among the greatest concerns surrounding this decision is the future of vital parts of public health which are not included in the remit of the new organisation.

And now, three months on from the announcement, the experts and the staff are united in having gained very little clarity. There is indeed a feeling in PHE that the Government came into the pandemic not even aware of the full range of the organisation’s roles and responsibilities.

A senior member of staff at PHE says: ‘A lot of the functions not going to the new National Institute for Health Protection are acknowledged to be core functions – the work we do on screening, drugs, mental health, tobacco control, disease registration, sexual health – all of these things. There’s no suggestion that ministers don’t want these functions to continue, it’s just that we don’t know what the structures are going to be and we don’t know the relative priority of those functions.’

The staff member was concerned about fragmentation of services and the separation of health protection and health improvement.

The biggest concern is perhaps that successive governments do not have great records in this area. Promises of protected budgets were made when the responsibility for public health moved from the NHS to local authorities but budgets have repeatedly been slashed, with often a severe effect on outcomes.

There is uncertainty over what the Government will do next. A ‘stakeholder advisory group’ and trade union working group have been set up, but members of the group and the former BMA public health committee chair Peter English say there is a lack of detail.

The deadline for restructure – April next year – strikes everyone as remarkably tight, given the context and the amount of planning required.

A brief consultation document from the Government in September proposed a dizzying range of options, including the devolving of PHE functions to local authorities or creating a wholly new organisation for prevention and health improvement.

Dr English says: ‘We would like them to pause what they are doing – it’s rushing ahead far too quickly. We would like them to have the consultation but make it not have many pre-conditions and definitely to consult widely at a time when the key players are not involved in running the pandemic. That means parking it in the knowledge that the timing is wrong and there cannot be further changes for the time being.’

For staff in PHE, and those in the wider public health community, if these changes are to have any great effect they will need to encourage the return of investment and priority to this woefully neglected, but crucial, area of medicine.

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

Need for resources

Chaand Nagpaul NAGPAUL: Public health must receive the resources it needs

BMA council chair Chaand Nagpaul says: ‘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 with the £10bn allocated by Government for the test-and-trace programme.’

It is crucial the process places genuine clinical engagement and expertise at its heart, from now on.

A BMA document drawn up by public health doctors representing their colleagues working across the system suggests a future public health system should balance meeting short and long-term challenges of responding to the pandemic and wider health inequalities.

It also outlines the importance of all parts of public health being strongly interconnected, the importance of a close partnership with the NHS and social care, the vital role of accessibility of high-quality data and analysis, consistent national terms and conditions of service at least equivalent to those of the NHS.

Whatever the look and feel of new structures, doctors leaders will also demand protection and rebuilding of the rights of public health professionals to remain independent and to express their professional views in public and in meetings in order to properly advise the population openly.

A senior member of staff at PHE told The Doctor the current plans looked likely to draw functions closer to Government with less independence.

Ask many doctors for their views on the situation and they’ll say, ‘well, I wouldn’t start from here’. A hastily-written apology email to staff, a leaked report in a national newspaper, heavily questioned political motivations, beleaguered staff and, not least, a global pandemic. But what is also striking is the determination to make the new structures as effective as possible. The stakes are simply too high.

As Dr Nagpaul puts it: ‘We, our patients, and the most disadvantaged in our communities, cannot afford for another reform to fail.’