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expert reaction to speech by Matt Hancock on ‘The Future of Public Health’ and the launch of the National Institute for Health Protection (NIHP)

In a speech this morning titled The Future of Public Health*, Matt Hancock, the Secretary of State for Health and Social Care, announced the launch of the National Institute for Health Protection (NIHP)**, as had been widely expected after reports in the media on Sunday.

 

Professor Neil Anderson, ACB President, and Dr Robert Shorten, Chair, ACB Microbiology Committee on behalf of the Association of Clinical Biochemistry and Laboratory Medicine (ACB):

“The ACB welcomes any approach to support the public health of the nation. We would firstly like to wholeheartedly thank the many ACB members who work at Public Health England for their tireless efforts over the previous eight months and also recognise their dedicated work on essential non-COVID-19 public health issues. The work carried out by senior Clinical Scientists, who are world leaders in the field of novel and emerging pathogens, has led to the rapid development and validation of diagnostic tests for COVID-19. This has enabled the swift adoption of COVID-19 tests and ensured effective testing processes. It is regrettable that this dedicated workforce learned of the plans to replace their organisation in such a manner. However, I know that they will approach this next challenge with their usual professionalism and diligence.

“We need a collective, concerted effort to tackle the next phase of the COVID-19 outbreak, and Clinical Scientists and laboratories should be at the heart of this. The proposed remit of the new National Institute for Health Protection must support the mitigation of risks around climate change and population growth, that have made outbreaks of novel and emerging pathogens more likely. It is vital that any agency with the remit to tackle this pandemic, and whatever infections follow it, has a strong scientific core. It should combine the current world-leading scientific expertise, with the resource to respond on an appropriate scale.

“PHE was a scientific organisation at its heart, we hope the NIHP will build on that strong tradition. Science is led by evidence, which can change over the course of time, and will inform the best response and outcome. In addition we hope the NIHP will also support the many other aspects of public health that describe the population’s health, in particular the high incidence of obesity, type II diabetes and vascular disease that have been identified as having a significant effect on outcomes from COVID-19 infection. We hope that the NIHP will work constructively across systems and with the NHS to achieve improved public health.”

 

Professor Christine Williams, Trustee, on behalf of the Academy of Nutritional Sciences, said: 

“The Academy notes the proposal to establish  a new public health body to replace Public Health England. Although the Academy recognises the government imperative to prevent a second wave of COVID during the winter of 2020, we share concerns regarding the timing, preparedness and scale of the proposed changes given that the full details of these have yet  to be fully worked through.

“In particular we note scant details of how the other parts of PHE that have responsibility for disease prevention are to operate in the future.  Whilst recognition of obesity as a complicating factor in the severity of COVID is a very recent finding,  the influence of body weight and body fatness on risk of chronic diseases such as cancer, cardiovascular diseases and type 2 diabetes, has been known for many years. Many common cancers such as colorectal and breast cancer that have shown increased in prevalence in recent years, are strongly and consistently associated with heavier body weight and greater body fatness. These are anticipated to rise further in future years with significant consequences for health care costs and population well-being.

“We hope the re-organisation of public health structures in the UK will take due account of the high prevalence of obesity and overweight in the UK compared with many other developed countries and the consequences of this for wider public health. We look forward to hearing about the government’s detailed proposals for supporting these and other nutrition-related aspects of UK public health in the near future.”

 

Prof Patty Kostkova, Professor of Digital Health, Director of University College London Centre for Digital Public Health in Emergency (dPHE), said: 

“In 2013, the Tories restructured the world-class scientifically independent Health Protection Agency and created underfunded Public Health England while cutting public health operation at local level. The decision to abolish PHE in the middle of the deadly COVID-19 pandemics without consultation while the UK Parliament is not sitting is scandalous. Setting up a new National Institute for Health Protection by a merge with dysfunctional private NHS Track and Trace operation under leadership of Dido Harding who has no expertise in public health seems yet another purely politically motivated move to shift blame for government’s failures over handing of the COVID-19 crises.

“What we need is truly well funded scientifically independent national public health agency, operating without government’s influence, working together with re-established local public health function responsible for local policies, disease prevention and control, including test and trace.”

 

Professor Dame Anne Johnson FMedSci, Vice President, International at the Academy of Medical Sciences and Chair of the Academy’s Improving the health of the public by 2040 report, said: 

“The COVID pandemic has brought to public attention the importance of a strong, efficient and well-funded national public health system. We welcome the recognition from the Secretary of State for Health and Social Care that our public health system needs more capacity to deal with health threats on such a large scale. The Academy has long called for investment in public health and associated world leading research.

“Creating a new national public health body is a huge and complex task. Making such big changes during a pandemic risks temporarily impeding public health functions and is a high risk strategy.

“We need more information about how and when these changes will be implemented as well as how health protection initiatives will be delivered in future and will be aligned with wider health promotion. We also need to know how lessons learned from the pandemic response will feed into the design of a strengthened public health system.

“The new organisation will only be fully effective if it receives sufficient and sustained resources, is sufficiently independent from government and is given the ability to lead cutting edge research in collaboration with academic and other partners including industry.

“It is also essential that we retain the wealth of expertise that can be found at Public Health England and that the new organisation creates an environment that attracts the brightest and best. Finally it will need to be fully integrated with services in local authorities and linked into the NHS and academia at both a national and local level.

“From the announcement today, there is not yet enough information to judge how well the new National Institute for Health Protection will fit these criteria.” 

 

Professor Sir Robert Lechler PMedSci, President of The Academy of Medical Sciences, said:

“Public health monitoring and interventions are critical to the good health of our society. This is an extremely complex task that requires broad and evolving expertise, independence, agility and close connections with researchers, healthcare systems, industry, government and local authorities.

“Any changes the government makes should be carefully thought through and informed by the best experts in this area in the UK and internationally.

“We should resist the temptation to entirely redesign our public health system through a COVID lens. We must keep in mind that illnesses such as HIV, heart disease, cancer and diabetes remain significant causes of UK ill health and premature death. Increasing rates of obesity and an ageing population also present complex health challenges. Any changes we make to our public health system now must give benefits both throughout the pandemic and beyond. This must include the prevention ambitions outlined in the recent green paper.

“We should also ensure that public health services and research are seen as a priority for investment going forwards. Keeping everyone healthy, rather than simply focussing on treating illness, could improve all of our lives and take the strain off the health and social care systems. When the public health service is working well it is not as visible as new hospitals or treatments, yet it is essential to head off future health crises and improve the health of the nation.”

 

Dr Simon Kolstoe, Senior Lecturer & University Ethics Advisor at the University of Portsmouth, said:

Is this a good move?

“This is an interesting move because it has the feel of political dissatisfaction rather than long term scientific strategy. I imagine it is being driven by failures of communication and coordination rather than lack of capacity or expertise.

Is now the right time to make these changes?

“No. We are in the middle of a pandemic. The worst time to rebuild a ship is in the middle of a storm.

Is it sensible to separate health improvement and external threats to health?

“Possibly, so long as the health improvement is not forgotten about. Although ‘external threats’ make more headlines, long term health issues (like obesity) kill more people. Health improvement also sits closer to social care than emergency response.

What does the NIHP need to do to be a success?

“Have a very clear remit alongside an easy to understand ‘chain of command’ extending down to the local level. Modelling it after the military in terms of structure would be no bad thing.

Do you have any concerns?

“Yes – this is happening very suddenly. While I am sure there are immediate problems that need addressing, large-scale bureaucratic and administrative re-organisation comes with both financial and time costs. This sort of change should really come about following a careful inquiry rather than as a reaction to situations on the ground.”  

 

Prof Gabriel Scally, Visiting Professor of Public Health, University of Bristol, said: 

“The government needs to be aware of the risks involved in undertaking major organisational restructuring in the midst of this public health crisis. It is highly concerning that the organisational structures that the government has created so far (such as NHS Test and Trace, and the Joint Biosecurity Centre) have not been transparent, coherent or obviously successful.”

“It is impossible to support  the course that the government appears to be taking and I am concerned that it will further destroy the confidence of public health staff at this crucial time. The changes are of such magnitude and importance that they should be the subject of close parliamentary scrutiny.”

 

Prof Sian Griffiths, Emeritus Professor at the Chinese University of Hong Kong & Past president of the Faculty of Public Health, said:

“Whilst we would all agree tackling COVID is a global priority a major reorganisation of public health expertise whilst in the midst of the pandemic is potentially harmful. Having co-chaired the Hong Kong SAR Inquiry into the 2003 SARS epidemic one of the most important lessons we learnt was to review how decisions were made in the light of the circumstances at the time of decisions, and to share and use the learning for recommendations of what needed to change in the future. As yet there has been no such Inquiry.

“The break up of PHE focuses on one aspect of public health- health protection. But health protection skills and expertise are an integral part of wider public health practice, interrelating with health improvement and engagement with health services – the three domains model used universally in training public health specialists. This inter relationship enables an integrated and co-ordinated professional approach at national and local levels to the challenges of health inequalities, obesity, preventing cancer, promoting mental health and successful operation of services such as immunization, screening and sexual health as well as protecting the public from infectious diseases- to name but a few of PHE’s current responsibilities. But little was said about the future of health improvement today.

“The separation of health protection without open discussion and plans for how the whole of public health practice will be delivered is potentially harmful for the health of the population in addition to being disruptive and stressful for PHE staff once again facing reorganisation at an already stressful time. The future of the public’s health in England requires concerns for systemwide clarity across the whole of public health practice to be openly and rapidly addressed.”

 

Prof Linda Bauld, Professor of Public Health, University of Edinburgh, said:

“Addressing COVID-19 is front and central now and the launch of NIHP is intended to provide a more coordinated approach to achieve that. But we shouldn’t forget that the overwhelming burden of death and disease in this country is not caused by ‘external threats’ as Matt Hancock put it, such as infections and biological weapons. Instead it is caused by chronic diseases – cancer, cardiovascular disease, diabetes, dementia and others. A significant proportion of these diseases are preventable and Public Health England plays a central role in that through its health improvement functions. This involves addressing health inequalities, overweight and obesity, smoking, harmful use of alcohol, drug misuse, air pollution and a huge range of other important public health priorities. PHE has also played a key role in maternal and child health improvement. There is a real risk that reorganisation threatens these functions. We don’t yet know how or where they will continue to be delivered. Clarity is needed on this as soon as possible. What we don’t want is for the establishment of NIHP to result in any disinvestment or dilution of PHE’s role in prevention. That would be short-sighted and potentially harmful.”

 

Dr Beth Thompson, Head of UK/EU Policy at Wellcome, said:

“COVID-19 has clearly demonstrated the importance of investing in a strong, trusted and resilient public health system that can turn the UK’s deep expertise into action that improves health. Public Health England wasn’t set up for success and has faced years of under-investment, so despite the UK’s scientific strengths inside and outside PHE, we were not as prepared for a pandemic as we should have been.

“The pandemic has also shown that we need to find better ways to connect data with public health interventions locally and nationally. These mistakes must not be repeated in setting up a replacement. And we mustn’t lose sight of the fact that public health threats are not limited to COVID-19 and other infectious diseases. We cannot afford to neglect urgent public health challenges such as mental health and drug-resistant infections.”

 

Dr Gail Carson, Deputy Chair of the Global Outbreak Alert & Response Network (GOARN), said:

“We are regularly reminded of the unprecedented challenge the pandemic presents us with therefore, where is the evidence, the independent review that has informed such a significant organisational change to the national public health response for England at such a critical time? It takes time to build an organisational culture and the way the tired, hardworking PHE staff heard via a leak at the weekend is shocking. Are we going back to the Health Protection Agency (HPA) format, which was disbanded in 2013 to evolve with the inclusion of many other organisations into PHE? There are still unknowns about SARS-CoV-2 but we do know that the social determinants of health have been laid bare by the pandemic and pre-existing co morbidities put one at higher risk of severe COVID-19. Now is the time to strengthen the integration of these functions with response, which already exist under PHE.

“Why is the focus solely on the public health element of the response and has for example the Government’s response been reviewed by an independent panel? The WHO has appointed their panel, perhaps a WHO representative could sit on a UK COVID19 review panel.

“Change may well be required but one usually does this after a review and certainly PHE could benefit from further investment. PHE is an executive body of the Department of Health and they have had no voice to stand up to the criticisms that have been made of them in recent months. With the change to interim leadership one would surely expect the CEO of PHE and the new body (NIHP) to have extensive experience in exactly what they are leading on – all hazard preparedness and response at a national & international level.

“PHE was reviewed by the International Association of Public health Institutes (IANPHI) in 2017 and received a good report, which included the chair of the Robert Koch Institute, cited as one of the organisational role models for the change for PHE to NIHP. IANPHI also, said that, ‘a strong, unbiased source of scientific advice to political leaders at local, regional and national level cannot be underestimated’.

“Decisions are made based on the information available at the time during an outbreak, there is no perfect response. The review process is so important, to learn how to improve for the next time, or indeed in this case, to be better prepared for resurgences of the SARS-CoV-2 virus.”

 

Prof Robert Dingwall, Professor of Sociology, Nottingham Trent University, said:

“Matt Hancock has the right diagnosis but it is less clear whether he has the right prescription. There is a real challenge for governments in planning and resourcing responses to low-incidence, high impact events. The current pandemic is actually a good example. The successful pandemic influenza plan of 2007 was shown by the Cygnus exercise of 2016 to have depended upon an infrastructure and resources that no longer existed and were not replaced by 2020. The once-in-a-century capacity had been eroded by reorganisations and austerity. The loss of institutional capacity and memory went beyond the health sector and into emergency planning in the Cabinet Office, which should have been co-ordinating a cross-government response. The targeted role of the NIHP may avoid that, at least initially, until memory of this event fades and the Treasury start to question what it is doing.

“This raises the danger that I would see as a sociologist, namely that the agency has to invent work to justify its existence. It is a paradox that is familiar to criminologists, that the police have no interest in clearing up too much crime because it would lead to cuts in resources and a reduction in careers and opportunities. There is already an argument to be made that the response to COVID-19 has been disproportionate to the population risk of serious or fatal outcomes. The creation of NIHP reinforces that problem by creating an agency that will need to identify any infection as a significant risk to humans, regardless of the consequences for social and economic activity. It is not clear where the push-back will come from. In its absence, we may find social distancing continuing for ever in the hope of interrupting minor inconveniences like seasonal influenza or the common cold.

“A better solution might have been to reinforce multi-disciplinary emergency planning in the Cabinet Office, possibly by creating something like the Federal Emergency Management Agency in the US, rather than looking purely to the health sector for models elsewhere. This would be a mechanism for ensuring that concerns other than those of the biomedical world were properly reflected in response planning and management, and that infectious disease was considered in fairer proportion to other risks affecting modern societies. NIHP may get in the way of living alongside viruses and bacteria, as humans have done for millions of years, rather than taking a wrecking ball to society in the hope of eradicating them completely – and creating new evolutionary niches for other organisms to occupy…”

 

Dr Ian Johnson, Nutrition researcher and Emeritus Fellow, Quadram Institute Bioscience, said:

“Whilst the emphasis on the role of the newly reorganised institute in managing the UK’s response to the pandemic is understandable, the important responsibilities of PHE in relation to non-communicable diseases must not be forgotten. I very much hope that the excellent contributions that PHE currently makes to the field of public health nutrition, particularly in relation to food policy and the management of obesity, will be supported and strengthened for the future.”

 

Prof Derek Hill, Professor of medical imaging science, UCL, and expert in medical devices, said:

“This new institute aims ‘to ensure we have the best capability to control infectious disease and deal with pandemics or health protection crises’. One aspect that seems to have been omitted is around medical equipment. Major challenges in this pandemic have included adequate PPE, ventilators and testing kits. The regulatory approval of such medical equipment is in the domain of MHRA – who have done excellent work under immense pressure. But it seems important that this new institute has expertise in these areas and can interface with MHRA and ensure the right strategies are put in place to ensure demands are met by safe and effective equipment.”

 

Richard Torbett, Chief Executive of the Association of the British Pharmaceutical Industry (ABPI):

“Public Health England has played a critical role during the pandemic, but more widely in delivering important initiatives on disease prevention and public health.

“Our members have worked closely with PHE across many areas; from our world-leading vaccination programmes to diabetes prevention, through to critical work on AMR.

“Preventative healthcare should be front and centre of plans for the NHS post COVID-19. It’s important we understand how the wider work on prevention and public health will be taken forward, where responsibility and accountability will sit, and how the new organisation will work with health partners.”

 

Dr Joshua Moon, research fellow in the Science Policy Research Unit (SPRU) at the University of Sussex Business School, said:

“The creation of the National Institute for Health Protection is a further centralisation of the UK’s response which, to date, has failed because it lacks decentralised capacity.

“As we saw with the creation of UNMEER during Ebola, new institutions are the least effective way to deal with a crisis. Strengthening PHE and building up the decentralised and local capacity would be a much more effective use of whatever resource is being channelled into this change.

“To create a new institution in the middle of the pandemic is going to be utterly chaotic. To top it off, Baroness Harding has been selected as head of this new institute in the absence of a transparent selection process or the identification of anybody with public health leadership expertise. The UK has a plethora of experts who could have run this.

“Finally, to announce all this on a Sunday, via newspaper and not an official statement is truly awful. Many colleagues in PHE had no idea this was going to happen and woke up on Sunday morning fearing for their jobs. Given the excellent work PHE has been doing, this is a slap in the face.

“All in all, these proposals and the way they were revealed is another absolute mess, hot on the heels of the A-Level results fiasco.”

 

Prof Paul Hunter, Professor in Medicine, The Norwich School of Medicine, University of East Anglia, said:

“It was in fact a good speech by Matt Hancock that promises much. Much of what he said was very laudable especially the need to focus on health protection, to reduce bureaucracy, the importance of the science, the need to have a flat structure and the importance of an organization whose culture fosters its public health scientists rather than hinders them. The other important thing is that no major change to such a change will be made at a time when public health professionals are preparing to deal with a likely re-emergence in the coming weeks.

“The issue will be whether or not this will be deliverable. Will the new Health Protection Institute be adequately funded, will it really have the freedom from political interference and will its organisational culture really allow its scientists and medics to have the freedom and support to respond appropriately and rapidly to new and emerging threats rather than succumb to creeping bureaucracy? Only time will tell.

“There remain, however, a number of key uncertainties. First and foremost of these is the relationship between the new institute and infection services in the NHS. One of the criticisms of the handling of the pandemic to date has been the perceived exclusion of the medical microbiologists and virologists based in hospital laboratories. The group representing medical/clinical virologists who are only recently wrote to the CMO voicing their concern that their expertise and facilities were being ignored. Many of the difficulties in providing testing early in the outbreak could have been avoided if this group have been involved earlier. Unless this bridge with NHS infection services is repaired the new Institute will not be able to achieve.

“The other main uncertainty is the role of the private sector. The private sector really has an important contribution to make to public health, but any such involvement must be supportive and not put public or private organizations or individuals in a position where conflicts of interest may arise or even be perceived to arise. Public Health must not be directed by commercial interests only by what is most important for the health of the nation.”

 

Prof Jonathan Ball, Professor of Molecular Virology, University of Nottingham, said:

“The UK response to the initial outbreak of COVID-19 did appear disjointed and insufficient – especially around early introduction of community testing and infection control and clearly these two key elements will need to be more effective, timely and joined-up if we are to prevent a significant second wave.

“The timing of this announcement and more importantly the proposed changes to public health responses seems odd. It is important that we make ready now for what many consider to be an inevitable second wave. To my mind, this will require strengthening the systems we have now, rather than announcing changes that will come into effect next spring.”

 

Dr Doug Brown, Chief Executive of the British Society for Immunology, said:

“Supporting public health and preventing disease is a critical part of our country’s health system, the importance of which has been brought into sharp focus during the current COVID-19 pandemic. While Public Health England has been central to our country’s response to COVID-19, we should not forget that they also lead on work in numerous important health areas such as immunisation, infectious disease surveillance and reducing health inequities. Their staff include some of our most talented scientists and specialists who have dedicated their lives to working in this field and improving the lives of others.

“Investing in the public health of our country and preventing disease occurring in the first place is vital, and will prevent spiralling healthcare costs while improving our nation’s health. Public health has seen a significant decrease in investment over the last decade and to be able to reap the significant benefits that a focus in this area has the potential to deliver, it’s crucial that public health is adequately funded across all its functions.

“COVID-19 has presented this country with a new and unprecedented challenge and news of a co-ordinated approach to this from the Government is to be welcomed. From today’s announcement, the British Society for Immunology looks forward to engaging with the Government on how all the current functions that Public Health England carries out will be fulfilled in the future, and to working with the new National Institute for Health Protection to advance their science-led approach to responding to the COVID-19 pandemic.”

 

Steve Bates, CEO of the U.K. Bioindustry Association, said:

“UK life science companies look forward to working with the National Institute for Health Protection on its vital mission. If the UK is to successfully bring on new technologies and have the ability to scale up at pace it’s imperative to consider the incentives for, and desired capacity within, the UK life science industry for the long term, which will compliment and work alongside the newly announced Institute and its world leading scientists. The UK’s ground breaking innovative companies are already working on COVID solutions in partnership with the public sector –successfully embedding this culture for the long term will be a key for the country’s response to future threats and the NIHP’s success.”

 

 

* https://www.gov.uk/government/speeches/the-future-of-public-health

** https://www.gov.uk/government/news/government-creates-new-national-institute-for-health-protection

 

All our previous output on this subject can be seen at this weblink:

www.sciencemediacentre.org/tag/COVID-19

 

Declared interests

Dr Gail Carson: Worked for HPA 20018 – 2012

Dr Ian Johnson: No conflicts

Dr Doug Brown: “I’m a Trustee of the Association of Medical Research Charities.”

None others received

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