Policy Proposals Affecting Health Protection Provision in England

Health protection is defined as “public health activities intended to protect individuals, groups, and populations from infectious diseases, environmental hazards such as chemical contamination, and from radiation”.1 Infectious disease accounts for one in every 50 deaths,2 with rates highest in the first two years of life and amongst the elderly.3

The Government has announced the creation of Public Health England (PHE) which will be part of the Department of Health (DH). Public Health England will take over all functions and powers of an existing arms-length public body called the Health Protection Agency (HPA). Health protection functions will, therefore, be directly accountable to the Secretary of State for Health and the DH. 4

Evidence of the possible benefits

The rationale for re-locating responsibility for health protection within central Government is to increase accountability, but evidence for this outcome is lacking. Cost reduction is one stated aim.5The Government’s strategy for Public Health cites the following benefits to this strategy 4:

• PHE aims to unite health protection and emergency planning and response functions by bringing together existing structures. It is proposed that this will integrate services, which the Government argues are currently fragmented.
• PHE aims to unite the efforts of local and central Government, the NHS, and the Big Society to lead health protection.
• There will be a clear chain of command from the top of Government to frontline health protection.
• The changes aim to strengthen the national response on emergency preparedness and health protection.
• The white paper states that a range of health protection functions are best performed at national level “to ensure the Government is protecting the population from threats”.

The Government anticipates releasing further health protection policy documents in autumn 2011. However, no evidence was identified from the literature that suggested that the proposed approach will be more effective than the current system and deliver the benefits outlined above. There is evidence that the HPA has previously been effective in managing an integrated health protection response to numerous major public health incidents, including SARS, pandemic H1N1 flu, several major floods and polonium 210 poisoning,6 so, for example, the allegation of fragmentation is questionable.

Evidence of the possible risks

It is argued that re-locating responsibility for health protection within central Government will increase accountability, but evidence to support this is lacking. The risks of this policy are detailed in the HPA’s response to the Government’s strategy for public health 7, and briefly summarised below:

• Loss of ‘independence’ from the government, both actual and perceived, may reduce public trust and confidence in the health protection advice and information they are given. This may increase the threat in the context of a major incident.
• The research income generated by the HPA will be under threat in the new arrangements, which, in turn, threatens the generation of new scientific evidence to support policy. The UK’s international reputation for innovative health protection research is put at risk if independent advice, funding and research functions of health protection providers are compromised.
• Realisation of the full potential offered by PHE is dependent on effective integration of a large number of public health information and intelligence functions.
• Insufficient understanding of new roles, responsibilities and lines of accountability will undermine the multi-agency response and resilience to major incidents in the short-term.

Evidence for the risks associated with this policy is weak. There is some evidence that a centralised model has not worked in the past. The HPA was established as an independent body in 2003, in part, as a response to the “catastrophic loss” of public confidence in DH scientists following the BSE crisis in 1996.8 The credibility given to incorrect public health advice about the MMR vaccine and subsequent fall in vaccine coverage is an example of what can happen in the absence of publically trusted scientific advice.7 The HPA argues that during the H1N1 pandemic, “the HPA, as an independent body, advised Government on flu and medical aspects of disease control but it is Government, and not the HPA, that determines overall policy”,9 which suggests the current system combines both accountability and independence.

The issue has been considered in other countries and, in some cases, the conclusions oppose those set out in the White Paper. In Canada, in 2003, a Governmental advisory committee considered how to establish a health protection agency and recommended, “a new agency operating at arm’s length would contribute to enabling quicker, more efficient and nimbler responses in the face of health emergencies…greater cooperation amongst all levels of government, thereby furthering the capacity to protect and promote health.”10

The HPA itself recommends the US model, wherein the Centers for Disease Control and Prevention (CDC) functions as an Executive Agency within the US Department for Health and Human Services.7 Establishing PHE as an Executive Agency within the DH may provide more accountability while mitigating some of the risks, but evidence for this is also lacking.

Implications for health and well-being

Given the lack of evidence, it is not clear that policy proposals to restructure Health Protection provision in England will make the provision of health protection in the UK more accountable to the public. Nor is it clear that direct political supervision will enhance the overall function of health protection providers and the safety of the population. Indeed, given some of the risks identified above, a significant threat of this policy is the potential to lose clarity around roles and responsibilities in the short-term. Given that changes are due to be implemented close to the 2012 London Olympics in 2012, there is some concern that multi-agency response and resillience could be vulnerable around the time of this important international event.

Author: Nigel Field, Academic Clinical Lecturer in Public Health, University College London

Conflict of interest: NF is a Public Health Specialty Registrar and is currently on placement with the Health Protection Agency (HPA) in the South East London Health Protection Unit (SELHPU).

UK area affected: England only

References

1.     Bracebridge S, Abubakar I. Developing a career in health protection. BMJ Career Focus. 2004;329:43-44.

2.     Office for National Statistics. Mortality Statistics: Deaths Registered in 2009. 2009;Available from: http://www.statistics.gov.uk/downloads/theme_health/dr2009/dr-09.pdf

3.     Dunnell K. Ageing and Mortality in the UK. National statistician’s annual article on the population. 2008;Available from: http://212.58.231.24/downloads/theme_population/Population-Trends-134.pdf#page=6

4.     Department of Health. White paper. Healthy Lives, Healthy People: Our strategy for public health in England 2010;Available from: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_122347.pdf

5.     Public Administration Committee – Fifth Report. Smaller Government: Shrinking the Quango State. 2010;Available from: http://www.publications.parliament.uk/pa/cm201011/cmselect/cmpubadm/537/537.pdf

6.     British Medical Assocation. Equity and excellence: liberating the NHS BMA response. 2010;Available from: http://www.bma.org.uk/images/whitepaperbmaresponsefullversion29sept2010_tcm41-200411.pdf

7.     Health Protection Agency. The HPA’s response to “Healthy Lives, Healthy People”, the Government’s strategy for public health in England. 2011;Available from: http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1296682855643

8.     House of Commons – Science and Technology Committee – Written Evidence. [cited 2011 Mar 29];Available from: http://www.publications.parliament.uk/pa/cm201011/cmselect/cmsctech/498/498we12.htm

9.     O’Dowd A. UK scientific adviser criticises UK planning for flu pandemic. BMJ. 2009;338: b2316-b2316.

10.     The Standing Senate Committee on Social Affairs, Science and Technology. Reforming Health Protection and Promotion in Canada: Time to Act. 2003;Available from: http://www.parl.gc.ca/37/2/parlbus/commbus/senate/com-e/soci-e/rep-e/repfinnov03-e.pdf