Dismantling Public Health England may exacerbate the already significant health inequalities in England
In August of this year it was announced that Public Health England (PHE) will be dismantled, to be replaced in part by a National Institute for Health Protection (NIHP).
The new organisation will be charged with protecting England against infectious diseases, pandemics and biological weapons, and will combine functions currently undertaken by PHE, NHS Test and Trace, and the Joint Biosecurity Centre.
It’s unclear what problems this reorganisation hopes to solve, but many health experts have agreed that the Government has and will be deflecting blame onto the agency for perceived failings during the COVID-19 pandemic. Whether that is a fair decision will no doubt be the topic of many committee hearings in coming months and years. The Chief Executives of the Nuffield Trust, The King’s Fund and the Health Foundation are all in agreement that “PHE appears to have been found guilty without trial”, and that the Government risks serious consequences by dismantling its public health agency at such a crucial time. Some may argue that PHE, established in 2012 as a part of the Health and Social Care reforms, has not had an opportunity to prove its effectiveness or otherwise. Either way, the Government has concluded that there will be no second chances in order to try and head off another mishandled pandemic at the hands of the same agency.
Huge questions remain to be answered. Who will take charge of PHE’s other responsibilities around non-infectious diseases and health improvement? Its mission has been to “to protect and improve the nation’s health and to address inequalities”, with a focus on health concerns such as obesity, smoking, addiction and sexual health. This upstream approach to health, which is intended to benefit the NHS by preventing illnesses such as diabetes, lung disease, heart disease and now COVID-19, also addresses the health inequalities that are nearly always associated with these health concerns by educating and screening those at risk.
It is these health inequalities which cause a 10-year life expectancy gap between people in the most and least deprived areas of England. This population split is set to increase. According to the Think Tank IPPR, an estimated 1.1 million more people, including 200,000 children, could be plunged into poverty by the end of 2020 due to the economic impact of COVID-19.
Tackling obesity in Britain has been propelled into the spotlight this year due to the established links between weight and worse outcomes from COVID-19. The Government’s obesity strategy, released earlier this summer, was a welcome step in the right direction. It was not, however, without critique, namely for insufficient focus on a main contributing factor to obesity – health inequalities. The dismantling of PHE leaves campaigns such as PHE’s ‘Better Health’, part of the obesity strategy, with an uncertain future, and questions remain as to which agency will be responsible for taking these forward. Similarly, campaigns to reduce smoking, addiction and improve sexual health literacy, all of which are linked to social-economic status (SES), also risk losing momentum.
Many questions around the detail of the new organisation remain to be answered. It is unclear whether the agency that replaces PHE will be centralised or decentralised. Both options have advantages and drawbacks: centralisation ensures that there is a protected budget, but somewhat takes away from local authorities having the autonomy to adjust the focus of their work to reflect local needs – and we know that these diverge significantly. Decentralisation allows for this, but public health spending is taken from a local government’s general budget, meaning many councils are unlikely to have sufficient funding to cover a suitable level of care. Further details on budget must also be provided; PHE has faced a 16 per cent reduction in budget for their health improvement portfolio, and a 22 per cent cut to the public health grant for local authorities since 2015/16. Investment in preventative health and social care has significant economic downstream benefits for the NHS.
Some would call the decision to enact a massive reorganisation of England’s public health agency in the midst of a pandemic brave, others reckless. We shall see if it has unintended consequences for England’s ability to respond to a possible second spike later this year. The long-term consequences on health equity, exacerbated by the 800,000 additional households in poverty estimated by IPPR, could be enormous. The decision to axe PHE, with no opportunity for public and stakeholder consultation, may severely impact the health of those most vulnerable.