Written evidence submitted by Professor Sally Sheard, Head of Department, Public Health, Policy and Systems, University of Liverpool (DEL0267)
The Impact of DHSC/NHSE/PHE (mis)alignments
When the NHS was created in 1948 it adopted some pre-existing health services structures. In England and Wales, Public Health functions and personnel remained located within local government authorities [LAs], with a line management through councils, and professional oversight by the Ministry of Health and its successor departments. Interaction between NHS and public health personnel was dependent on local agreements. Since 1974, a series of reorganisations have relocated public health services several times, initially into regional and local health authorities. The 2012 Health and Social Care Act created Public Health England and once again put public health staff back into LAs. Specialised public health protection services, such as the Health Protection Agency [HPA; an ‘arms-length body’ formed in 2003], were dismantled and reorganised. The 2012 Act also established NHS England, with 44 Sustainability and Transformation Plan [STP] areas and Clinical Commissioning Groups [CCGs], whose geographical territories were not coterminous with LAs. These replaced the 28 Strategic Health Authorities [SHAs] that had been created in 2002 (and reduced to ten in 2006).
Epidemics of infectious diseases have been useful lenses through which to analyse the impact of structural dislocations in public services and leadership, and of cuts in public health workforce and expertise. Good examples are the response to the HIV/AIDS epidemic in the 1980s and the ability of the Chief Medical Officer [CMO] to respond to the BSE crisis in the 1990s, which was examined at the Phillips Inquiry in 1998.
The 2009 Swine Flu epidemic provides the most useful policy comparison with the COVID-19 situation, and evidence of the potential for learning from historical analyses. It demonstrates that there have been systemic failures in public health planning, delivery and leadership, which appear to have gone unaddressed, and that this is a routine government response to crises.
Two years before the Swine Flu pandemic, the House of Lords had raised concerns about the government’s contingency plans. This was substantiated by other independent reports, and by a planning exercise codenamed ‘Winter Willow’, which highlighted several problems with the preparations. The NHS was designated as the operational lead for subsequent flu epidemics, with the HPA allocated a supporting role. However, in 2009, when the Swine Flu epidemic emerged, the government asked the HPA to lead the response because the NHS’s planned National Pandemic Flu Service was not functional. The HPA had to rapidly establish flu response centres within each of the ten SHAs, develop protocols, find suitable premises and employ new staff to identify cases and trace contacts. At a national level, the HPA had an advisory role - providing situation reports (SitREPs) via the Scientific Advisory Group for Emergencies [SAGE]. There were tensions between the HPA and NHS authorities, and lack of clear local and national leadership on decisions about school closures and the use of algorithms to predict the epidemic curve. There were differences between the CMO and the HPA on how to communicate the epidemic trends and measures to the public.
Since 2012, Public Health England budgets have been progressively cut, and ring-fencing protection eroded. Staff employed in public health roles by LAs have been reduced. This has hindered their ability to develop and sustain effective working relationships with local NHSE and social care organisations.
The capacity of LA public health teams to deliver regular services, and to respond to urgent calls (such as ‘test, track and trace’ for COVID-19) varies widely across the country, reflecting the historical inequity in LA resources and cuts to central government grants. An urgent review of LA resources is required to ensure that public health and social care needs do not cause unnecessary further distortion of NHSE services. Cuts to local public health budgets are manifested in declining knowledge and skills bases, professional isolation, weakened ability to hold investigations and develop effective health governance systems.
The Use of Public Inquiries
Post-crisis/scandal/incident inquiries have become a standard UK government response. They are driven by a range of motivations, including need to identify systems failures and hold individuals and organisations to account, to a political demonstration of rapid response to appease public concerns.
The first NHS inquiry was initiated into the scandal of ill-treatment and abuse of patients at the Ely Hospital in Cardiff in 1967. It reported in 1969 and led to the creation of the first NHS inspectorate (the Hospital Advisory Service). Since then there have been more than 60 inquiries into health and social care incidents/crises, with similar processes and outcomes. Significant inquiries include the Bristol inquiry (2001); the Shipman inquiry (2005); the Mid-Staffordshire Hospital inquiries (2010 and 2013); Savile inquiry (2015).
Key ‘generic’ systems recommendations from health and social care inquiries include protecting whistle-blowers and establishing processes for concerns to be raised and addressed, improving communications between levels and types of public services and improving incident planning.
Public inquiries are expensive, often lengthy, and not connected to an implementation mechanism. There is no evidence that inquiries are effective or efficient use of resources. There has been no effort to understand and improve the inquiry process (how to structure, schedule, staff, report).
There have been public inquiries following previous epidemics in the UK. In 2010 Dame Dierdre Hine, CMO for Wales, led the inquiry into the 2009 Swine Flu pandemic. She made several key recommendations including the need for a transparent communication strategy on the numbers of cases, and the need for population-based surveillance through testing. She also highlighted the risks of relying on modelling as a foundation for government response. The Hine inquiry finding were subsequently endorsed by a 2011 House of Lords Science and Technology Committee report.
There is a clear pattern in UK government of failure to learn, either from historical precedents, or from the expensive inquiries conducted subsequent to crises. COVID-19 is an opportunity to systematise the implementation of inquiry recommendations, and to embed historical analysis in the heart of policymaking.
Black, N. and Mays, N. (2013) Public inquiries into health care in the UK: a sound basis for policy-making? Journal of Health Services Research & Policy, 18;3: 129-131.
Chief Medical Officer (2000) An organisation with a memory. Report of an expert group on learning from adverse events in the NHS, London: TSO.
Hine, D. (2010) Influenza Pandemic: An independent Review of the UK Response to the 2009 Influenza Pandemic, London: Cabinet Office.
House of Lords Science and Technology Committee (2006) Fourth Report of the Session 2005-2006 Pandemic Influenza, HL Paper 88, London, Stationery Office.
Sheard, S. (2010) Quacks and Clerks: Historical and Contemporary Perspectives on the Structure and Function of the British Medical Civil Service, Social Policy & Administration 44;2: 193–207.
Sheard, S. (2015) Why we never learn: abuse, complaints and inquiries in the NHS, The Conversation 26.2.2015.
Sheard, S. (2018) History Matters: the critical contribution of historical analysis to contemporary health policy and health care, Health Care Analysis 26: 140-154.
Professor Sally Sheard is Head of Department, Public Health, Policy and Systems at the University of Liverpool. She is a health policy analyst and historian. She receives funding from the Wellcome Trust, National Institute of Health Research and the Medical Research Council.