Farewell, Public Health England

Farewell, Public Health England. Hello, National Institute for Health Protection. As expected, the hammer has fallen on the agency that promised to ‘protect the public’s health from infectious diseases’ but floundered hopelessly when tested by coronavirus. PHE failed to expand diagnostic testing, failed to engage with the private sector, stopped contact tracing when the virus was just getting going, discouraged the use of face masks, refused to share infection data with local authorities and couldn’t even count the number of people who died of Covid-19 properly.

Good riddance. According to Matt Hancock, its replacement will have a ‘single and relentless mission – protecting people from external threats to this country’s health’. In his announcement yesterday, he made an important distinction between ‘health protection’ and ‘health improvement’. The former involves infectious diseases, antibiotic resistance and environmental hazards. The latter involves encouraging people to eat their greens, exercise and stop smoking. For too long, these two different agendas have been bundled together under the umbrella of ‘public health’. Covid-19 has forced us to relearn the distinction between risks that threaten us all and justify a certain degree of coercive action and those which are the result of individual choices and pose a threat only to the individual concerned.

The great conceit of the ‘public health’ movement over the last thirty years has been to conflate collective health risks with individual health risks. ‘Public health’ problems have been redefined to include any health risk that affects a large number of people, such as binge-drinking or obesity, rather than its original meaning of a health risk that can only be dealt with by collective action, such as air pollution or Covid-19.

The redefinition of ‘public health’ was more than a rhetorical shift. By portraying individual health issues as public health issues, the impression was given that collective action – which is to say, government action – is appropriate when it is not. This has allowed the likes of Public Health England to take an interest in every aspect of our private lives and to stick their noses into socio-economic issues that belong in the realm of politics, not medicine.

One consequence of this has been to give ‘public health professionals’ a megaphone with which to express opinions on issues that are beyond their expertise. We can all agree that environmental degradation, poor housing and gender inequality are undesirable, but there is no reason to expect the World Health Organisation to have any special insights into how to solve these complex problems. There is no reason to expect the Chief Medical Officer to understand how marketing works and yet Chris Whitty’s predecessor, Dame Sally Davies, had forceful views about advertising. No one expects Public Health England to be experts on food manufacturing and yet the agency spent years dictating the precise quantity of ingredients that can be used in processed food.  

The other consequence of broadening the scope of ‘public health’ to such an extreme degree has been that public health agencies have spread themselves too thinly over too many topics. Public Health England’s predecessor, the Health Protection Agency, focused on infectious disease and did not drift off mission by pontificating about ‘health inequalities’ and alcohol regulation. Unlike PHE, it did not dictate the maximum number of calories in a vol-au-vent (145, since you ask). The creation of the National Institute for Health Protection is an overt attempt to return to those happier times. Even its name evokes its forebear.

But what of ‘health improvement’? In his farewell email to staff, PHE’s chief exec Duncan Selbie wrote that the ‘obvious next priority is to secure the right and best future for all those other responsibilities of PHE that are not about health protection’. PHE’s empire building created many well remunerated jobs. Those who are on the low-fat gravy train will be understandably reluctant to get off and will be lobbying hard for a new agency that is Public Health England in all but name. Having set up the National Institute for Health Protection, the government may be tempted to set up a twin organisation, perhaps called the National Institute for Health Improvement (although Nanny State England has more of a ring to it).

Politicians love creating new bureaucracies, but they should resist the urge. Instead, the National Institute for Health Protection should take over PHE’s laboratories and science campuses at Chilton, Colindale, Porton and Harlow. It could be given a similar budget to that given to PHE for vaccines, counter-measures, infectious disease prevention and environmental hazards, which currently amounts to £550 million and is significantly more than the Health Protection Agency’s £176 million budget in 2012/13, its last year in operation (it is a myth that PHE has been under-funded). The new agency would be in charge of stockpiling vaccines (emergency and routine), genetic sequencing, diagnostic testing, surveillance, stockpiling of PPE, contact tracing, modelling and pandemic planning.

Responsibility for national health promotion campaigns should be restored to the NHS. Local health teams should continue running local public health services, including drug and alcohol services, children’s services, advice and contact tracing. Local public health budgets – which currently come from PHE’s £4 billion treasure chest – should be supplied directly from the Department of Health.

Academic work currently published by PHE, such as its evidence reviews on vaping, have always been largely outsourced to external authors and should continue to be so. Instead of PHE commissioning them, it should be the Department of Health.

Much of this amounts to little more than changing the letterhead. The NHS, the Department of Health and local authorities have the capability and resources to provide health education, advice and evidence reviews. They did it before Public Health England was formed – which was, after all, only seven years ago – and they can do it again. The last thing we need is Public Health England 2.0.