Who is responsible for the failure of England’s pandemic response? Ultimately, that must be Boris Johnson, whose absenteeism from Cobra meetings as the crisis developed, and whose cavalier attitude to coronavirus prior to his own hospitalisation illustrate his shaky grasp of, and grip on, events.
Yet Johnson has now settled on his scapegoat, and it seems it is to be Public Health England (PHE). Health Secretary Matt Hancock confirmed on 18 August that the government intends to abolish the seven-year-old PHE – punished, according to “senior ministerial” sources, because of its “sluggish” response in the early months of the pandemic, particularly in respect of the national failure to rapidly expand testing capacity.
On the face of it, the Johnson government seems to have a point. PHE does indeed run the network of microbiological laboratories that, back in the “contain” phase in February and early March, were undertaking Covid 19 testing as part of efforts to isolate cases and contacts. Capacity was necessarily limited: no country can maintain the infrastructure to undertake pandemic levels of testing for years on end, on the off chance it will be needed. The key decision point was when sustained community transmission of coronavirus was acknowledged in mid-March. This marked the transition to the “delay” phase of the English pandemic plan. Crucially, that involved the abandonment of test, trace and isolate (TTI) and the adoption instead of social restrictions that were supposed to allow the infection to move through the population in managed levels. Nowhere in our planning was there any contingency to “ramp up” TTI capacity.
Was that crucial mistake PHE’s responsibility? It more reflects the group-think that has long run through England’s political establishment for health. All agreed that the next pandemic was only ever going to be a flu. It would have an infection fatality rate of at most 1.5 per cent. Once sustained community transmission occurred, it had to be allowed to move through the population until case numbers and/or vaccination achieved herd immunity. Failure to imagine a different kind of pathogen – one like Covid-19 – causing multisystem disease and sending health-service-breaking percentages of patients into hospital; one for which a vaccination methodology didn’t exist: that was England’s real problem.
Other countries managed it; and the government’s stated ambition for what it envisages taking over from PHE tells you some of the reasons why. PHE is going to be replaced by a National Institute for Health Protection (NIHP), which will combine the scientific staff of PHE with the operational structures of NHS Track and Trace. The NIHP will, it has been suggested, be modelled on Germany’s Robert Koch Institute (RKI) – a federally funded body that, like PHE, runs a national network of testing laboratories; but which, unlike PHE, distinguished itself by turning Germany into a testing powerhouse right at the onset of the pandemic.
How did the RKI achieve this? Its laboratory network differed in two crucial respects. Like PHE, the RKI directly runs some laboratories, but it also maintains a federation of others around the country – housed in universities, charities and private companies. Second, across RKI’s diffuse network, each laboratory was a designated expert in testing for one particular type of pathogen – not just flu, but a huge range of viruses, bacteria and other microbes. Germany had a reference laboratory highly skilled at testing for coronaviruses. Its knowledge and expertise could be rapidly disseminated across the whole network.
This harnessing of existing laboratory capacity was exactly what the distinguished scientist Paul Nurse, head of the Francis Crick Institute in London, was calling for in April. Nurse couched his suggestion in terms that ought to have caught Johnson’s imagination – comparing the university, charity and private laboratories ready to contribute to national testing capacity to the fleet of boats that evacuated Dunkirk. But the historical reference evidently failed to inspire Johnson to Churchillian decisiveness: Nurse’s overtures were rebuffed, apparently due to PHE’s insistence on maintaining direct control over Covid-19 testing.
In fairness to PHE, it seems likely that had it foreseen the need to plan for a non-flu pathogen, it would have been ignored. PHE ran Exercise Cygnus in 2016, a simulation to test national preparedness for a pandemic flu. Reading the report’s recommendations now has an eerie quality: Cygnus identified many of the problems that have since manifested themselves, including issues with PPE stockpiles; discharges of hospital inpatients to care homes; and central government’s failure properly to engage with local and regional public health services. The Conservatives were, at the time, preoccupied with driving forward austerity. Public health is concerned with prevention, precaution; nothing it does seems immediately tangible, and so it was a target for deep cuts. The recommendations of the Cygnus report were quietly shelved.
PHE should have been appraised as part of a larger review of English public health, rather than being scrapped in a knee-jerk reaction. And the new-found admiration for Germany’s RKI exemplifies another truth that Covid-19 has exposed. Time and again during the crisis, our most authoritative voices have come from experts on the outside: Paul Nurse; former regional public health directors such as professors John Ashton and Gabriel Scally. The appointment of Dido Harding – the businesswoman who has presided over the lacklustre start to NHS Track and Trace – as interim head of the NIHP is yet another mistake. The government must appoint to the role a scientist steeped in traditional public health.