Some of the government’s most senior public health officials, including two directors of public health, warned the government that sweeping reforms to the NHS proposed by David Cameron’s government would severely impact Britain’s ability to cope with a pandemic, documents show.
Throughout 2011, experts wrote to the Health Select Committee about the impact of proposed changes under David Cameron’s health secretary Andrew Lansley — changes that would later be formalised in the 2012 Health and Social Care Act.
The director of public health for County Durham, Anna Lynch, warned that abolishing Strategic Health Authorities (SHAs) – which were responsible for improving regional health services and were axed in favour of a commissioning-based model – “means that the public will be less safe at times of outbreak or pandemic”. During flu seasons, the SHAs were vital “in co-ordinating responses to the challenges posed”, she said.
Dr Alison Merry, a public health consultant, said the changes would “fragment, weaken and ultimately destroy the specialty of public health” and “disrupt… the ability to effectively respond to an emergency or epidemic situation and undermine public trust and confidence”.
Professor Hilary Pickles, who spent 14 years at the Department of Health before roles in regional public health teams, told the Health Committee that the likely outcome of the huge reforms would include “important projects having to be disbanded, colleagues in the voluntary sector let down, and needed NHS service changes [being made] so much more problematic to deliver”. She then issued a warning that now seems gravely prescient: “When the next pandemic strikes,” she said, “expect public health systems to be in disarray”.
Pickles also predicted cuts to public health in the years following the reforms, warning that “public health and its budgets will be raided, yet again”. Analysis by the Health Foundation in March showed that local authority public health grants had fallen by £800m between 2015-16 and 2020-21, a 22 per cent cut in real terms.
The same documents show the British Retail Consortium and conservative think tank the Bow Group expressing concerns at the dismantling of the Health Protection Agency, which had led the UK’s response — commended by the WHO and the government’s own review — to the H1N1 pandemic in 2009.
Still more officials voiced similar concerns after the Act, in evidence given in 2012 and 2013 to the communities and local government select committee. The Association of Directors of Public Health (ADPH) warned that the creation of Public Health England, which took on many functions previously co-ordinated via the NHS, could create “a risk that emergencies, outbreaks and epidemic situations, will not be properly managed or responded to, may quickly escalate, and the public will come to serious harm… clarity is still urgently needed over who, within the various local agencies involved, has lead responsibility for ensuring that the response to an emergency or outbreak is effective and appropriate”.
The UK Faculty of Public Health gave an almost identical warning that transfer of power to PHE created a “grave risk” that both the public and the economy would be seriously damaged during an epidemic.
Professor Gabriel Scally, the former director of public health for the south-west, told the committee at a hearing in late 2012 that “the move of services, particularly community services, out of the NHS either to the private sector or to social enterprises will make it extraordinarily difficult to mobilise staff in the case of an emergency”. This week, he said that reading through minutes of the meeting “sent shivers” down his spine.
Scally quit the Department of Health in 2012 because of the changes, which were opposed by swathes of healthcare professionals. Scally said he and others raised concerns internally about the reforms, including their impact of disease outbreak and emergencies. Those concerns were “stamped upon”, he told me. “We weren’t listened to; rather the opposite. Every attempt was made to stamp on dissent, and stop people inside and outside the civil service expressing forthright views.”
As a regional public health director, he oversaw the South-west’s response to swine flu and foot and mouth disease, which showed him the importance of local structures, including SHAs and now-defunct Government Offices for the English Regions, in dealing with emergencies. “It was the whole system, the system was being dismantled and being replaced with a commissioning and contracting model… it undermines the opportunity of providing a smooth, organised response to problems, particularly when it’s a national emergency with health implications.”
Scally, who later advised then-shadow health secretary Andy Burnham and is now a visiting professor of public health at the University of Bristol, was one of the authors of a severe indictment of the government’s reaction to Covid-19, published in the BMJ and the New Statesman.
He told me that if the coronavirus crisis had hit ten years ago, before the Lansley reforms, local health authorities would’ve been able to mobilise staff far quicker, and the UK would not have had to abandon its initial attempts to contain the spread of the virus on 12 March. Many of the staff that could have helped with contact tracing, such as public health nurses, were lost during the reforms and in subsequent years, he said.
Jeanelle de Gruchy, president of the Association of Directors of Public Health, told the BMJ earlier this month that years of cuts to local government, including areas integral to contact tracing, have “undermined” public health. The Lansley reforms gave local authorities more power over public health, but “at the same time… you had these massive cuts, so a lot of people retire and leave. And there are fewer people to deliver, so there is no surge capacity”.
The evidence given to both committees was laid out, in full, in reports submitted to the Cameron government. These documents tell a story of a government that, immediately following an influenza pandemic and in the face of interventions by some of its most senior advisors, placed its political aims ahead of the threat of new infectious diseases.