Who will take on PHE’s preventative health work?

Does England need a chief EHO? Tell us why. Email us at [email protected]

Calls for a chief environmental health officer for England were re-awakened following news that Public Health England (PHE) will be axed and its COVID-19 work taken on by a new National Institute for Health Protection.

Questions still remain around where PHE’s other work, particularly preventative health work, will be housed. Reaction to the shake-up has re-emphasised the need for a holistic approach to tackling COVID-19, and the importance of preventative health – and within EH many believe appointment of a chief EH officer for England is well overdue.

Northern Ireland and Wales have a chief EH officer but England lost this role around 20 years ago.

EH consultant Lisa Ackerley is calling for the role to be reinstated. Ackerley worked briefly with the English chief EH officer, under the Department of Health, during the 1990s.

She said: “I think we need to resurrect that post because now more than ever, we can see the cracks under the wall paper appearing in society. And it's that holistic approach that's so important.”

Former Wales CIEH director, and EHP and legal trainer, Julie Barratt, said having a chief EH officer was “fantastic”. She is currently on the board recruiting for Wales’ new officer. Barratt argued that currently in England EH issues are spread across portfolios – yet no one holds overall responsibility for EH and at the higher levels it is not properly understood. The local government minister, for example, she said seemed unaware that EH did contact tracing.

Barratt added: “You ask most of the directors for public health about the value of EH, they'll be very quick to tell you about it. It's higher up. It's actually in government. It's people sitting around the cabinet table - they don't understand EH. To have a voice at that level [would be really beneficial], to have a minister at that level that we could talk to, that we could brief and say, ‘this is really important, this is an up and coming issue, we need to be dealing with this’.

She added: “They think it's enough that the chief medical officer (CMO) can deal with EH issues, but most CMOs can't and don't. They have far too much on their plate in any event dealing with primary and secondary health stuff to be dealing with public health.

“When you look at what will happen with Brexit - people are talking about more food fraud, lower environmental standards, even though we're committed to keeping the standards, apparently. And in the same breath we're being told that water pollution standards will go down. Somebody in government needs to understand the consequences of all this.”

Some hopes have been expressed within EH that the new national institute might take on a better appreciation of the profession, but Barratt warned that the body has no enforcement role, and that EH works best in local government.

EHP Stephen Battersby said: “So far as PHE is concerned, while there may have been mistakes they were aware of the three pillars of Public Health - protection, promotion, prevention - the government has shown no understanding of this and the new organisation is unlikely to either - the government have neither learned nor bothered.

He argued that EH needed to be seen as part of the PH workforce, by those outside of the PH workforce including central government agencies. He was also concerned about the considerable expertise that could be lost from PHE’s work on the health impact of global heating and extreme events.

He said: “I am sure the food industry will be glad to see it go as PHE was supposed to be leading on obesity, which was for a short term this summer an important issue!

“While local authorities can do a lot, a national body is needed to take on the vested interests. This is something that local authorities cannot do, and will the government be bothered? There may be jobs for EHPs in the new body, but given that there is no evidence that this body will be any better at working with LAs and in communities, and is all about further centralising the work, I am not sure this will be helpful.

“PHE could never have had sufficient laboratories to deal with the amount of testing this pandemic needed. The government ignored people like Paul Nurse who called for the use of university and private laboratories to enhance testing. Instead we abandoned testing, tracing and isolating just when testing should have been ramped up. So if local capacity was not used then, when will it be used? Yet if you think of the Salisbury poisoning of the Skripals, PHE and the local PH team did work together.”

Rerturning to the idea of a chief EH officer for England, EHP consultant John Machin questioned whether more work was needed to ensure that English councils understood the role of EH. He added that there appeared to be lamentably few chief EH officers within local authorities.

Machin questioned whether the structure of local authorities in England was a factor, and felt that EH tended to be better understood and have better outcomes in unitary authorities where EH often sat in the same offices or building as PH.

He said: “[The structure] needs a complete re-think including all the health prevention work. Lots of professionals are well meaning but who is joining up all the dots together on these issues?”

RECAP: Reaction to axing PHE

Following the leak, the Royal Society for Public Health (RSPH), the Faculty of Public Health (FPH) and the Association of Directors of Public Health (ADPH) issued a statement standing in solidarity with the public health workforce, thanking them for their commitment to the public’s health.

Later RSPHs’ chief executive, Christina Marriott, described the shakeup, in the midst of the pandemic and even before a full inquiry into the pandemic response, as ‘risky’ and a ‘questionable use of resources’.

She added: ‘"The unanswered question is what happens to health improvement.

"We know that one thing that marked England out as Covid-19 hit was our poor public health including our high rates of inequalities, of smoking, and of overweight people and obesity.

"So COVID-19 makes it vitally important that prevention is not side-lined – but so does every year when 40% of avoidable deaths are as a result of tobacco, obesity, inactivity and alcohol harm."

Professor Maggie Rae, president of the FPH, said: ‘We hope that the successful aspects of PHE’s response to COVID-19 are retained and strengthened, that public health leaders will be at the centre of shaping the forthcoming reforms to the public health system and that public health will now face investment rather than the cuts of the past decade.’

The ADPH also argued a shakeup in the midst of a pandemic risked distracting efforts, and argued that it wasn’t possible to fight infections without tackling underlying inequalities caused by the social and commercial determinants of health.

It wanted assurances that the full breadth of PHE functions would continue throughout the transition, alongside increased spending on public health in both the short and long term.

On what a new system might look like, ADPH president Jeanelle de Gruchy said: "Lessons from other systems, including the German system, tell us that a strong public health system needs strong local leadership and responsibility with commensurate funding to deliver.

"Local does not mean national telling local what they have to do. ‘Local by default’ with the flexibility of local decision-making is what drives an efficient public health system.

"Assurance should be based on trust not centralising control. And it does not mean everything is devolved; some things are better done regionally, some done once nationally and shared. It should mean whole system working – a team of teams approach – local government, NHS, other public sector, third sector and business all have a part to play."