Global pandemic was top of the Cabinet Office National Risk Register even before COVID19. We now know it presents a greater risk to Britons than any state or non-state actor. Health, not defence, holds the toolbox for tomorrow’s battles.
Preparatory work for the Integrated Security, Defence, Development and Foreign Policy Review was well underway across Whitehall when I left the Foreign Office in February. The pandemic has thrown a spanner in the works – a COVID makeover will push the Integrated Review well into the new year. However, the review could not have come at a better time since it will tell policymakers if they have what it takes to discharge the State’s primary responsibility of keeping its citizens safe. Indeed, the Prime Minister said on 26 February that it would identify reforms to government systems and structures needed to address the risks and threats we face. So, let’s have a look at how we’ve been doing on this number one threat made flesh and anticipate candidates for reform.
The UK mortality rate from COVID19 is in the mainstream of European countries. That means there’s no cause right now for either mud-slinging or back-slapping. However, we shouldn’t hold back because another bug could well be mutating its way in our direction.
A supporter of the government throughout this crisis, I’d say much has gone well, some of it staggeringly so – the Nightingale hospitals for instance has been a truly world class effort. That’s despite the great clinical cathedrals that have sprung from nothing overnight being left empty thanks to squashing the curve by making everyone stay at home. However, the talk is that ministers have been handicapped by flaws baked into our public health system. Knocking them out can’t wait for the recommendations of the longwinded public inquiry to come. The Integrated Review must intervene.
The modern public health function grew out of the need to control urban infectious disease that regularly washed through the slums of Victorian England. From time to time it spilt into the posh end of town, prompting city fathers to appoint medical officers of health. These stalwarts essentially just dealt with infectious disease – largely bacterial in a pre-antibiotic age. They would have been baffled by their discipline’s modern preoccupation with lifestyle related morbidity and bewildered by their successors, Directors of Public Health, often not medically qualified, perched precariously between local government and the NHS.
In 2012 Andrew Lansley’s Health and Social Care Act - I was Andrew’s bag carrier throughout his time as health secretary - created Public Health England. For years public health had been reinventing itself, responding to what were lazily seen as modern epidemics – obesity, smoking, alcohol – with occasional reminders that, for all our sophistication, organisms were still capable of blowing our world apart as we found with AIDS in the 1980s.
The last Labour government had put a lot of effort into reducing the lifestyle-related morbidity that contributes to health inequality. PHE was established by the coalition government to advance this version of public health, implying less emphasis on infectious disease. The process continued with the dismantling of the Public Health Laboratory Service in 2013.
PHE’s annual report and accounts published in July [https://www.gov.uk/government/collections/phe-annual-reports-and-accoun…] are insightful. We learn about the organisation’s work on lifestyle disease, tackling health inequality and illness overseas, but very little about global pandemic. PHE’s annual report certainly does not suggest - despite warnings from the 2016 pandemic planning exercise Cygnus – an organisation fired up and ready to tackle the number one threat on the National Risk Register.
Contrast with Germany which, so far, appears best in class. At federal level Germany has the edge in Berlin’s Robert Koch Institute, roughly equivalent to PHE but unequivocally focussed on infectious disease. The conduct of public health is heavily devolved. In March Germany’s states acted swiftly and decisively and have had a consistent and unwavering commitment to test, track and trace.
In contrast, Care England’s Chief Executive, at the raw end of PPE and testing, is brutal; ‘I have serious concerns about PHE’s performance throughout this pandemic.’ I agree with him.
So, what’s to be done? This crisis suggests public health needs to get back to its roots and spend much more time protecting the public against infectious disease. PHE is right to tackle lifestyle disease that generates health inequality. However, who has been disproportionately affected by this pandemic and who is most likely to suffer from the next? Throughout history the burden infectious disease has fallen most heavily on the poor and disadvantaged.
The case for infectious disease control to be overseen by our own version of the Robert Koch Institute is now very strong indeed. But epidemic management involves basic, practical skills like contact tracing. Apps might help but it’s still street by street, door to door. It’s a function requiring shoe leather that should be inserted unambiguously back into the top tier of local government. The need for this will become more apparent as the pandemic evolves and ‘R’ is seen to vary widely across the country and in different settings. At the moment it looks like test, track and trace will be procured centrally and contracted out. I’ve been experiencing contracted out processing as a COVID volunteer NHS returnee. It hasn’t been great. Expecting contracted out test, track and trace to be a runaway success would be a leap of faith. Surely PHE itself with Directors of Public Health on the ground should be gripping this most elementary public health function?
Ministers have insisted policy is lifted from expert advice from SAGE, a weighty contribution to whose membership comes from PHE. Time will tell if SAGE warrants its acronym but an obsession with ‘soft’ behavioural science, second guessing how people under lockdown will conduct themselves, at the expense of hard data on the behaviour of coronavirus in the Far East may have been an early mistake. A mistake too to dust down existing plans for a known unknown, influenza, rather than contemplate an unknown unknown, coronavirus. The advice to ditch test, track and trace after just a few days suggests a lugubrious adherence to the pandemic flu rulebook rather than the translation of what appeared to be working in the Far East.
It looks like the UK has been managing this crisis overall at least as well as most comparable administrations. However, I sense ministerial disappointment with system failures and an appetite for better. The Integrated Review is a timely opportunity. Never letting the excellent be the enemy of the good, let’s make sure the next pandemic encounters a refocused, properly resourced and staffed, public health system that’s best in class.
Dr Andrew Murrison is MP for South West Wiltshire and a former minister