Controversial from creation to disbanding, via e-cigarettes and alcohol: an obituary of Public Health EnglandBMJ 2020; 371 doi: https://doi.org/10.1136/bmj.m4476 (Published 20 November 2020) Cite this as: BMJ 2020;371:m4476
Public Health England was born from the most controversial reforms in NHS history—and it’s been killed off just seven years later, the first casualty of a blame game over tens of thousands of deaths from covid-19.
Under the Health and Social Care Act 2012 as championed by the then health secretary Andrew Lansley, Public Health England (PHE) was established as an executive agency of the Department of Health, meaning that it had operational independence but took instructions from ministers. In contrast, the Health Protection Agency, which PHE replaced, had had independence as a non-departmental public agency.
This lack of autonomy would undermine PHE’s relations with parliament, would stoke criticism from public health specialists, and would eventually prevent it from defending its reputation when the covid pandemic took hold.
As well as taking up the Health Protection Agency’s role of protecting the public from infectious diseases and environmental hazards, PHE absorbed numerous other organisations including the National Treatment Agency for Substance Misuse, the public health observatories, cancer registries, and national screening programmes. The Rare and Imported Pathogens Laboratory, at the government science facility in Porton Down,1 also came with the Health Protection Agency.
The new PHE agency, launched in April 2013, was responsible for both managing infectious diseases and tackling the social determinants of ill health, such as obesity and alcohol abuse. It promised to “protect and improve the nation’s health and wellbeing, and reduce health inequalities,”2 using “world-leading science, knowledge and intelligence.”3 Meanwhile, public health directors—already joint appointments between primary care trusts and local authorities—moved to local government when primary care trusts were abolished.4
Hertfordshire County Council’s public health director, Jim McManus, saw several strengths in the new structure. “You got health protection and health improvement joined up, and you gained a national champion for ideas such as using behavioural science in public health,” he says. “On work such as obesity and HIV, they brought stakeholders together in a way that hadn’t been done for a while.”
PHE’s creation brought together civil servants, academics, scientists, medics, and local government officers. Its first and only chief executive was Duncan Selbie, a career public servant who grew to prominence in the New Labour years as the director general for programmes and performance in the Department of Health, playing a leading role in the drive to improve quality and productivity in the NHS.
He had an unusual but appealing style, with a lugubrious charm and a soft Scottish accent that could leave you craning to hear. While many speakers try to finish on a crescendo, Selbie’s passionate talks on the root causes of ill health and inequalities often tailed away to silence, leaving his words hanging—and his audience reflecting.
He could be demanding, but his natural empathy won him support and even affection among staff. Despite his civil service and NHS roots he championed the move of local public health services to councils, and he spent a lot of time in the field.
As PHE was now reporting to a director general at the Department of Health, observers were looking for signs of whether and how it would exert independence. In what was seen as a bizarre decision, its first big report six months later was a review of the public health risks from fracking—then being championed by the government but hardly a priority for a new public health agency. It was attacked for writing the report and concluding that the risks were low.5
Gabriel Scally, former regional public health director, says that the report “showed an abandonment of the public health precautionary principle. It’s not good enough simply to say, ‘There is no evidence this will be harmful.’ You have to say, ‘What are the possibilities of being harmful? Where are the gaps in evidence?’ and so on. It didn’t do that, so that was a signal [of a lack of independence].”
Selbie was given a rough ride at a health select committee hearing in November 2013. Minutes after assuring MPs that he had “unfettered freedom to speak,” he said that it would be too controversial for him to identify government policies that were widening health inequalities.6 The select committee’s review of PHE the following year accused it of failing to provide a “fearless and independent” voice.7
The committee questioned PHE’s independence again in 2015 when Selbie acceded to pressure from the health secretary, Jeremy Hunt, not to publish a review of the scientific evidence around a sugar tax policy, which ministers opposed. He was hauled before the committee and subjected to interrogation by its chair, Sarah Wollaston, who accused him of undermining public debate around tackling childhood obesity.8
A craven response to cuts
Funding and staffing have been broadly stable over PHE’s lifetime, with a net expenditure of £4bn (€4.5bn; $5.3bn) in 2018-19 and around 5000 staff.9 Since the transfer of public health from the NHS to local government, however, funding for local services has been cut savagely. The core public health grant of £2.4bn for 2020-21 is 19% below 2015-16, and the Health Foundation estimates that around £1bn more would be needed to resolve the service cuts.10
But PHE’s response to the prospect of the sustained and severe reductions announced in the 2015 spending review—four months after an in-year cut to local public health spending of £200m—was craven. It told the health select committee that the planned cash cuts “are manageable. Local authorities have a demonstrable record of getting more for less and PHE will support local authorities in this task using our intelligence and expertise.”11
PHE’s biggest scientific dispute came when it concluded, in 2015, that e-cigarettes were 95% less harmful than tobacco.12 An analysis in The BMJ accused PHE of using weak and uncertain evidence,13 while some local public health directors worried that e-cigarettes would re-normalise smoking and could provide a new route for young people to become nicotine addicts.14 Cancer Research UK and the British Lung Foundation defended PHE.15
Scally says, “They alienated a great deal of the public health community. As everyone knows, a substantial proportion of the vaping industry has been taken over by big tobacco companies, and that alone should give people pause for concern.”
The row highlighted Selbie’s approach of working with human behaviour to reduce harm rather than waiting for conclusive proof that e-cigarettes were safe. McManus says, “He tried to bring in a culture of getting stuff done and taking more risks. The e-cigarettes work would just not have happened in other organisations.”
With tobacco companies as significant players in the e-cigarette market, the dispute also exposed the issue of PHE’s relations with the manufacturers of harmful products. This was blown open in 2018 when PHE decided to launch a health promotion partnership with Drinkaware, an organisation funded by the alcohol industry. Ian Gilmore, hepatology professor and an expert on alcohol harm, quit as one of PHE’s advisers in protest,16 arguing that the campaign’s focus on personal responsibility was intended to divert attention from more effective policies such as minimum unit pricing.17
Martin McKee of the London School of Hygiene and Tropical Medicine agrees, seeing PHE’s approach to alcohol and tobacco as “all about individual level interventions, not tackling the upstream determinants” of poor health. “There was a sense that they were too close to industry groups,” he says.
Reflecting on the Drinkaware controversy, Sian Griffiths, emeritus professor at the Chinese University of Hong Kong and associate non-executive member of the PHE advisory board, says, “Lessons were learned from that. You really have to have a clear ethical framework you’re working [to] . . . How do we maximise the health improvement message within the safe confines of making sure it’s evidence based and not influenced by the industry?”
One of PHE’s most admired successes was its role in suppressing the Ebola outbreaks in 2014-16, with more than 150 staff deployed in Sierra Leone, Guinea, and Liberia. It trained new public health scientists to manage future outbreaks and helped to build laboratories and other health infrastructure. It also screened more than 14 000 passengers arriving from west Africa.
Back in England, the agency drove a 44% reduction in tuberculosis from 2011 to 2018 as part of its elimination strategy. National surveillance was stepped up, genome sequencing was used to determine susceptibility to antibiotics, and there was greater focus on helping people at high risk, such as those who were homeless.18
In 2015 PHE established the world’s first infant meningitis B vaccination programme.22 By the third year, cases of the disease among eligible children had fallen by 62%.
In September 2019 its review into addictive prescription medicines revealed the vast scale of consumption, as 11 million adults—a quarter of the adult population in England—were taking medicines such as opioid painkillers and antidepressants, with high rates among women and in deprived areas. It pushed the NHS to provide better information and support for patients.23
An assessment of PHE’s performance by the International Association of National Public Health Institutes said that its experience in change management and managing essential public health functions should be used as best practice by other countries.24
Each spring, a ministerial letter to Selbie set PHE’s goals for the coming year. The letter in March 2019 from Steve Brine, public health minister, identified 14 priorities. Pandemic preparation was not among them. Brexit was top.25
A year later, as community transmission of the SARS-CoV-2 virus took hold in the UK and modelling predicted that cases could quickly reach one million, the government decided to abandon its limited efforts at mass testing and contact tracing, and a week later the country went into lockdown. As the scale of the UK’s failure to manage the covid-19 outbreak became clear, with one of the highest mortality rates in the world, the government and parts of the press increasingly directed the blame towards PHE.
While ultimate responsibility for pandemic preparation rests with the Cabinet Office, PHE was blamed for failures outside its remit or control, such as organising mass testing, supplying personal protective equipment, and even ensuring that the NHS had enough ventilators.26 The former Conservative leader Iain Duncan Smith claimed that PHE was guilty of “arrogance laced with incompetence,” and Boris Johnson pointedly said that “some parts of government” had responded to the pandemic “sluggishly.”27 But there was no escaping blame for a spreadsheet error that came to light this October, in which PHE failed to transfer 16 000 covid-19 cases to the test and trace system.28
The agency undermined its case by handling crucial select committee appearances badly. On 25 March Sharon Peacock, director of the national infection service, had failed to give convincing answers on why the UK was not pursuing the mass testing strategy adopted by South Korea.29 The committee chair, Greg Clark, told the Financial Times that the hearing “shook confidence” and was “certainly material in raising questions about the kind of dependable role of PHE in all this.”30
Two months later John Newton, PHE’s director of health improvement, and its medical director, Yvonne Doyle, endured bad tempered exchanges at the same committee on the same question.31
PHE had the opportunity to make a powerful intervention in the management of the pandemic crisis with its review of the disproportionate impact on people from ethnic minorities. But its report, published in June,32 caused anger and frustration by failing to lay bare the reasons why death rates were so different or to make robust policy recommendations.33
Appropriately, after all of the briefing against it in the media, PHE’s staff discovered that the agency was being disbanded when the government leaked the decision to the Telegraph in mid-August.34 Selbie was forced out. A government source told the newspaper that PHE should have been on alert for pandemics instead of trying to prevent ill health. In a parting shot, Selbie pointed out that it was always the Department of Health and Social Care’s responsibility to deliver a national testing strategy.34
PHE’s pandemic response work is being merged with NHS Test and Trace and the Joint Biosecurity Centre35—which existed for only around 100 days—to form the National Institute for Health Protection. This will formally take over in April 2021.
In 2003 Sian Griffiths chaired the Hong Kong government’s inquiry into the SARS outbreak. She recalls, “We said, ‘We are not looking to apportion blame, we are looking at . . . what could be done better and differently in future.’ In the vilification of PHE, that has not been done. You do an inquiry on the basis of fact, not partial fact.”
As one PHE insider puts it: “Bring on the public inquiry.”
Competing interests: None declared.
Provenance and peer review: Commissioned, not externally peer reviewed.