David Rowland examines the reasoning behind the decision to restructure Public Health England and the consequences of this move – both now and in the future – for the government, the general public, and those working within the system.

When former health minister Matt Hancock announced the abolition of Public Health England (PHE) – the national public health body responsible for protecting and promoting the public’s health – six months into the biggest public health emergency since the Second World War, there was consternation amongst those at the forefront of fighting COVID-19.

Not only was the decision taken without a clear plan in mind as to what would replace it, the axing of PHE also threw up into the air the future of the thousands of public health specialists, including scientists, public health consultants and epidemiologists, who were uncertain where they would end up working next.

In the end, the government split PHE into two separate bodies: first, the UK Health Security Agency (UKHSA), tasked with protecting the population from threats from disease and other hazards including bio-terrorism. Second, the Office of Health Improvement and Disparities (OHID), moved under direct Ministerial control in the Department of Health and Social Care and was given responsibility for improving the health of the population. This included tackling what used to be known as health inequalities but were re-branded by the government as “health disparities,” seemingly as a result of its ideological dislike of the idea that the root causes of ill health can only be addressed through making society more equal.

Why was PHE abolished?

This act was thought by many within public health to have been motivated by a desire on the part of the government to deflect blame for its inadequate response to the pandemic. The extent to which it destabilised the public health system when it was under great stress is something the COVID-19 inquiry, which started taking evidence last week, will need to consider.

Undoubtedly, the pace and scale of change has had an impact on the UKHSA which has seen its budget reduced by a staggering 85 per cent (or £12 billion) and its staffing reduced by 60 per cent as the mainly outsourced Test and Trace function – which it assumed responsibility for – was wound down as the pandemic receded. It also reached the end of its first year in operation unable to gain sign-off from the National Audit Office for its accounts as it did not have in place adequate governance arrangements, nor did it know what its budget was for the current financial year until the last minute – hardly signs of a highly functional organisation.

What happened next?

Despite the unprecedented impact that the public health system has had on our lives since March 2020, restricting civil liberties, shutting down the economy and mandating vaccinations for some key workers, the media and parliament have paid almost no attention to what has been put in place after PHE was abolished, nor whether the new arrangements have put the country in a better position to respond to future pandemics, which most experts agree are highly likely.

The media and parliament have paid almost no attention to what has been put in place after PHE was abolished.

Our report into how Directors of Public Health based in local authorities in England view these radical changes paints a worrying picture of a system which is confusing, poorly joined up and more susceptible to political interference. When asked whether the new arrangements would make the UK better prepared for a pandemic, almost half of the directors that we surveyed said that it left it much worse or slightly worse prepared. This was in part because the government had downgraded and almost silenced those working on tackling the root causes of ill health by moving them into the offices of the Department of Health and Social Care, under direct ministerial control and with no independent voice.

As the 2021 study by Professor Sir Michael Marmot has shown, the UK’s high mortality rate from COVID-19 in certain parts of the country was heavily influenced by the overall poor health of the population. While some of the directors we spoke to recognised the advantages of a health security agency with a focus on preparing for, and responding to, emerging threats, others argued that treating public health purely as a security issue was likely to mean that even fewer resources would go into addressing the things which make people unhealthy, leaving the population highly susceptible to future viruses.

Directors were also unclear of the goals and objectives of the new organisations, and almost half said that it was now much less clear who took decisions at national level than under the previous arrangements. Given that the key to any effective emergency response is a “clear line of sight” from the those at the top issuing decisions to those operating on the front line, this shows that more work is needed to be done by ministers and those leading the new organisations to be able to clearly answer the basic question: who is responsible for what?

Concern was also raised about how joined up the system was at local level between the NHS and local government, with 53 per cent of directors stating that the system was now not very joined up or very disjointed compared to the previous system. In addition to radically revamping the public health system, the NHS has also been re-organised through the creation of Integrated Care Systems, meaning that those working in public health have had to adapt to new people, new governance structures and potentially overlapping responsibilities. Without careful management, institutional changes such as this have the potential to seriously damage the “hidden wiring” – the personal connections – which give resilience to any complex system.

Broader ramifications for democracy and future pandemics

Given the low levels of public trust in government, it was also concerning that a significant number of directors considered that those working in the new national public health bodies (UKHSA and OHID) were less able to offer advice to the public without political interference than under the previous system.

While public health is legitimately under the control of democratically elected ministers and local authority chiefs, the mantra deployed frequently over the past 3 years that government was “following the science” can hardly ring true if the experts cannot speak freely without undue interference from those in power.

The success of any future pandemic response will depend heavily on public health advice being accepted as evidence-based.

In a future pandemic, it is likely that politicians will have a much harder time getting the public to accept lockdowns, mask wearing and to take up vaccinations, both due to rising scepticism and the lack of rule compliance by ministers and special advisors over the past three years. The success of any future pandemic response will depend heavily on public health advice being accepted as evidence-based and with no suspicion that it has been tainted by the ideological proclivities or political self-interest of ministers.

To a certain degree, the problems with the newly created system are those experienced as a result of any major re-organisation. However, due to a lack of parliamentary scrutiny or media interest, very little is known about how this vital part of the government machine is currently functioning nor whether it is fit for purpose.  Arguably a failure to inquire about the role and capability of Public Health England, and the wider system in the run up to the COVID-19 pandemic, meant that its previously highlighted weaknesses were not addressed, leaving the UK badly exposed. We cannot afford to make the same mistake again.

All articles posted on this blog give the views of the author(s), and not the position of LSE British Politics and Policy, nor of the London School of Economics and Political Science.

Image credit: Number 10, Attribution-NonCommercial-NoDerivs 2.0 Generic (CC BY-NC-ND 2.0)