How the erosion of our public health system hobbled England’s covid-19 responseBMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m1934 (Published 21 May 2020) Cite this as: BMJ 2020;369:m1934
All rapid responses
Stopping contact tracing for Covid-19 infection in mid-March was doubtless one of the mistakes made by Government in the handling of the pandemic, and lack of capacity to continue it has been offered as one of the reasons for it stopping. In this context, it is surprising that the transfer of public health from the NHS to local government in 2013 was not given more prominence as a major factor in the weakening of local public health teams and hence their ability to respond.
Capacity and capability to respond was damaged in (at least) five ways:
First, on transfer to local government, public health budgets were plundered to pay for previously existing council financed programmes that would otherwise have been at risk. The fact that this was a reasonable response to councils' funding being cut severely by central government does not alter the fact that it happened.
Secondly, the Public Health Grant was itself cut by central government in the years following transfer. In contrast, NHS budgets were never cut, even if they were not increased as they should have been.
Thirdly, and linked to the above, the number of consultant posts was cut, as councils sought to make inadequate resources stretch further, and did not appreciate the benefits of having a cadre of highly trained experts leading the local public health function.
Fourthly, connections with NHS clinical services in both primary and secondary care were weakened, and connections with communicable disease control functions, already undermined by the removal of CCDCs from local public health teams with the establishment of the HPA in 2003, weakened further. Whereas prior to 2003 almost all public health specialists in Health Authorities (as were) would have had regular experience of communicable disease control activity, after 2013 practically none did.
Fifthly, the status of Directors of Public Health was downgraded. In the NHS, DsPH were executive directors sitting as full members of the most senior health decision making body locally (PCT Boards), whereas in local government they are at best at the second tier of decision making, quite often the third.
So it surprises me to read that 'there is little doubt among public health directors that local government is the best place for their service'. The larger teams, with more fully trained consultants and more of the relevant experience, of the NHS would surely have been in a much better position to set up effective contact tracing services. The supposed advantages of working from local government listed by Jim McManus were all there when we worked as Directors of Public Health in the NHS. Perhaps there is a form of 'survivor bias' manifest here?
For the record, I worked as DPH in both the NHS and local government, so these observations are made on the basis of experience of both.
Competing interests: No competing interests