Coronavirus: the blame game

By Richard North - August 17, 2020

The recent news that Public Health England (PHE) is to be scrapped and replaced by a new body specifically designed to protect the country against a pandemic is, to say the very least, jaw-dropping.

I hold no brief for PHE but do have a better grip on the structures of public health systems in this country than most. After all, my PhD was an evaluation of the public health surveillance system in England & Wales, and it is much the same system that we are dealing with for this Covid-19 pandemic.

With that in mind, I take the view that the public health system – in relation to the control of communicable diseases – has been dysfunctional for a very long time.

But, whatever problems it had in the past were not removed with the advent of the Health Protection Agency set up in 2003, and the situation was most definitely not improved when PHE replaced it ten years later in 2013.

The creation of PHE was part of the so-called Lansley reforms, brought about by the Health and Social Care Act 2012, under David Cameron’s watch during the coalition government period. History will record that these “reforms” were a disaster, presaging a major deterioration in the communicable disease control system in the UK.

But, as regards the control of epidemics of the nature of Covid-19, as I have recorded many times on this blog, the rot started in 2005 when the then government failed to develop a specific plan for a SARS-like disease, conflating the problems posed by this type of disease with those of very different pandemic flu.

The makings of the current trainwreck strategy, though, rest with the finalisation of the UK Influenza Pandemic Preparedness Strategy in 2011, also under David Cameron’s watch, but before PHE came into being.

The essential mistake here, in so far as it would apply to a SARS-type disease, was the assumption that it would “not be possible to halt the spread of a new pandemic influenza virus, and it would be a waste of public health resources and capacity to attempt to do so”.

For “new pandemic influenza virus” read SARS-Cov-2 as one of the main planning assumptions of the strategic framework was that “the plan should be adaptable, to be used in outbreaks of other infectious diseases”.

Therein lay the second mistake, in assuming that a single “one-size-fits-all” plan, designed primarily for influenza, could be in any way suitable for dealing with a SARS-type disease, or could be readily adapted to deal with it.

The third mistake, embedded in the 2011 strategy was to adopt a stage structure for dealing with the epidemic. There were to be five stages: Detection, Assessment, Treatment, Escalation and Recovery (DATER).

The first two stages – Detection and Assessment – together were supposed to form the initial response, the scope of which was extremely limited. This amounted to detecting the disease in the first instance and then assessing whether there was evidence of sustained community transmission of the virus, i.e., cases not linked to any known or previously identified cases.

Once evidence of sustained community transmission had been confirmed, the strategy required movement to the Treatment phase, with no attempt to control the disease. Beyond the assessment stage, there was no provision for community testing, nor any further contact tracing.

We then come to the next, but by no means final mistake, is the allocation of responsibilities. As we see from the Operating Framework for Managing the Response to Pandemic Influenza, “PHE leads the initial part of pandemic response which is characterised as Detect and Assess”. When the response then moves on to Treat and Escalate, the NHS takes the lead.

In other words, the shortest, and least-resource-intensive part of the response is controlled by PHE, but the moment community transmission is confirmed, PHE stands down and the NHS takes the lead (see illustration).

Because there was no intention to halt the spread of the virus, no staffing or material resource was available for mass testing or large-scale contact tracing. PHE was never expected to perform either function.

Thus, when it comes to the main responsibility for the poor response of the UK to the Covid-19 epidemic, the main fault lies with the poor planning, which in turn ensured that there were no resources available for anything significantly different to influenza.

And when it comes down to it, although plans are devised by the professionals, they are signed off by ministers, who take the ultimate responsibility. Rather than scrapping PHE, therefore, it should be Hancock who falls on his sword – for not querying the plans he inherited. That’s tough, but it’s also the way the system works (or should work).

Currently though, the Telegraph completely misses the point, as it does with so many things. In a comment piece, headed: “Farewell to Public Health England, and good riddance”, it lays the blame on PHE for errors which were partly the result of poor planning, party the result of the Lansley carve-up, and partly the NHS’s responsibility.

That is not to say that PHE walks away without a stain on its reputation. But, in a multi-agency scenario, with strong elements of political responsibility, to dump all the blame on PHE is absurd. And changing horses in mid-stream is never a good idea. We need a careful inquiry to work out what went wrong and why, before any major changes are made.

As it stands, the plan seems to be a merger of the pandemic response work of PHE with NHS Test and Trace into a new body, called the National Institute for Health Protection, modelled on Germany’s Robert Koch Institute. And the favourite to lead this new body is upwards failure Dido Harding.

Here, the Guardian is on the case, citing Dr Michael Head, a senior research fellow in global health at Southampton University.

He responds to the speculation, saying: “There are reports suggesting former telecoms executive Dido Harding will be given the role of overseeing the new institute, which makes about as much sense as [chief medical officer] Chris Whitty being appointed the Vodafone head of branding and corporate image”.

Prof John Ashton, a former regional director of public health, says “You don’t do this in the middle of a crisis, and certainly not put Dido in charge when she has been such a disaster with test and trace”.

To put that woman in charge of such a technical body would be a joke, and an insult to the staff engaged in the work. And it would almost certainly be a disaster, not least because of the incompetence of the woman. Likely, many senior staff would resign rather than work under her.

At least the Telegraph has the grace to retail a story headed: “Calls for a scientist to lead Public Health England’s replacement body, not Baroness Harding”. Experts say the new National Institute for Health Protection must be “science-led”.

However, Dr Amitava Banerjee, a Professor in Clinical Data Science at University College London, gets the point. He says: “PHE was set up as an executive agency of the Department of Health and Social Care by a Conservative government and is politically controlled, reporting directly to the Secretary of State for Health and Social Care”. Thus, he says, “if PHE has fallen short, responsibility lies firmly with the current government and health ministers”.

The chances of this government taking responsibility, though, is about as likely as Johnson telling the truth about anything – theoretically possible, but never known to happen.