The Department of Health’s intention for Public Health England to strengthen the national response to public health crises alongside local bodies may not work in practice unless experiences of previous pandemics are learned from, write Drs Jacky Chambers and Andrew Rouse.
In the next few weeks the Department of Health will set out, in more detail, its proposals for Public Health England and how it will operate in relation to local NHS bodies and local government.
The rationale for creating this new body is “to strengthen the national response on emergency preparedness so there is a clear line of sight from the secretary of state to the front line”.
However, our experience of managing the swine flu pandemic in Birmingham raises serious doubts about the ability of this executive agency to operate independently and flexibly enough to support frontline health protection and respond swiftly to emerging public health crises.
In response to the Department of Health’s 2007 guidance on pandemic flu, we developed well-rehearsed contingency plans.
On 18 May 2009, the first cases of swine flu were detected in pupils attending a primary school in Birmingham. Within a few hours, public health, medical and other staff from the Birmingham and Solihull Health Protection Agency, Birmingham City Council, Heart of Birmingham Primary Care Trust and the school’s headteacher agreed an action plan consistent with the national framework. This plan included school closure, identification, swabbing and offering antiviral treatment to children who had became symptomatic within the previous 48 hours.
Over the weekend, the local HPA told us it had been contacted by the cabinet-level civil contingencies committee with a request to implement a different plan. Surprisingly, this plan did not conform to the national framework or other evidence. The plan required the PCT to issue antiviral drugs to whole year groups of healthy children as well as to children and staff who had been ill as long as seven days previously (clearly outside their licensing conditions).
Within four days the pandemic had spread rapidly to other schools. During the next six weeks, more than 250 schools and an estimated one in three children had been affected. Primary care and acute health services became overstretched.
Every attempt by the regional Health Protection Agency to convince the civil contingencies committee that this pandemic was now spreading rapidly in the community, and that the national policy of containment should be abandoned (at least in Birmingham) and effort should be directed at treatment, was rejected.
Likewise, our efforts to relay our frontline intelligence and experience of managing this pandemic directly to the chief medical officer, and to contact the regional directors of public health, the Local Government Association and other networks, were seen as disruptive.
Eventually tensions escalated to the point where a “command and control” structure was invoked regionally, stopping any local autonomy in handling the pandemic. Six weeks later ministers declared an end to the containment phase.
In our 28-page report, Reflections on the UK’s Approach to the 2009 Swine Flu Pandemic: conflicts between national government and the local management of the public health response, we describe the delays, barriers, costs and harm which resulted from having a rigid and hierarchical public health apparatus limiting our ability to provide a resilient local response.
Hopefully, capacity and expertise for health protection at local level should be strengthened with the formation of Public Health England. If the health secretary wants a stronger health protection system, our experience suggests that the operating model for Public Health England will need to be designed from first principles.
These are: respect for professional autonomy and independence of judgement; timely surveillance to support local decision making; an appropriate balance between central and local decision making; collaborative partnerships; openness and transparency; regional geography; and subsidiarity in crisis management. Only time will tell whether these are consistent with or indeed possible within an executive agency for the DH.