Jacob Rees-Mogg, the Minister of State for Brexit Opportunities and Government Efficiency, recently announced that he seeks to improve government efficiency by ordering a review of all quangos. He suggests that by closing some, merging others and reclaiming direct government control over others, millions of pounds are going to be saved and our lives improved.

This is an important boast and relevant to the quality of health care in England as quangos play a major role in the running of the health and social care services. The National Institute for Health and Care Excellence (NICE), for example, is a quango. 

Quango culls are, of course, nothing new as successive governments regularly seek to conduct them. The Cameron-Clegg coalition government was the last to do so, only to end up creating new quangos and terminating fewer than claimed, because governments find them useful. 

Quangos, executive agencies, what are they?

Quasi autonomous government organisations or “quangos” for short are the popular name for non-departmental public bodies (NDPB). They enjoy legal and constitutional separation from ministerial control and carry out their work largely independently (supposedly) from ministers and are accountable to the public through Parliament. Quangos should not be confused (although it is easily done) with “executive agencies”, which are part of a government department, but are treated as managerially and budgetarily separate. An example of an executive agency is the now defunct Public Health England. 

“So what? Where is this blog going?”, we hear you ask.

The closure of Public Health England and the creation of two new public health organisations

The sudden and unexpected closure of Public Health England (PHE) in the middle of the Covid-19 pandemic resulted in the creation of two new public health organisations that are intended to take up the baton and become the leaders of public health: 

  • UK Health Security Agency (UKHSA) (another executive agency responsible since April 2021 for UK-wide public health protection and infectious disease capability), and
  • Office for Health Improvement and Disparities (OHID), a non-ministerial governmental body located within the Department of Health and Social Care (DHSC), which leads national efforts to improve public health policy across England – for example, reducing the prevalence of obesity and inequalities in life expectancy linked to socio-economic conditions.

We are now getting closer to the problem, as two of these organisations were in the news this month and not for their excellence of practice. First, a legal case was won against the government and Public Health England as a third defendant, the judgement being that in discharging patients from hospital to social care early in the pandemic without implementing Covid-19 testing and due regard for quarantining: 

“The common law claim succeeds against the Secretary of State and Public Health England in respect of both the March Discharge Policy and April Admissions Guidance documents to this extent: the policy set out in each document was irrational in failing to advise that where an asymptomatic patient (other than one who had tested negative) was admitted to a care home, he or she should, so far as practicable, be kept apart from other residents for 14 days”. 

Second, the UKHSA was reported by the Guardian to be in disarray, facing massive funding cuts, poor staff morale and no strategic direction for addressing the future challenges. 

Questions for the Covid-19 Inquiry on the future of public health 

Neither story was unpredictable given the circumstances, but they raise profound questions for the UK’s Independent Covid Inquiry, chaired by Baroness Hallett, concerning the future organisation of public health in England. 

We would add, however, that these deficiencies raise broader issues about how government functions and the place of quangos, particularly around how they are created, governed and disbanded

Peter Littlejohns, Toslima Khatun and David J Hunter

Researching the rise and fall of Public Health England 

At ARC South London, we are researching the circumstances surrounding the rise and fall of Public Health England. The study is in three parts: 

  • i) a rapid narrative review of the literature relating to the creation of Public Health England and its sudden closure
  • ii) interviews with senior public health officials and academics; and 
  • iii) a stakeholder workshop where preliminary findings from the first two stages were presented for a sense-check and to identify any gaps or omissions.

What has become quickly apparent is that the relationship between the organisation and government is key. Because of the haste to create new public health organisations following the closure of Public Health England (reported to be designed by McKinsey for an estimated £563,400), it is perhaps inevitable that both new organisations are destined to fail unless some key ground rules are agreed quickly and in a transparent manner.

Preliminary findings and recommendations  

Our preliminary findings offer a number of key messages and learning points which merit consideration:

  1. The two new public health bodies need a clearer remit than is apparent. This would allow for a stronger foundation and a timely coordinated response to crises that avoids fragmentation.
  2. The issue of resourcing in preparation for the changing Covid landscape needs to be addressed. Clarity is required on how everything will function and at what cost. This includes confronting the separation between communicable diseases (CDs) and non-communicable diseases (NCDs), which risks diluting public health skills and expertise by spreading them across different agencies, with a possible bias towards the UK Health Security Agency in terms of funding and attention. This is crucial as the cutbacks have already started, with significant reductions in staff and low morale among remaining staff. 
  3. Separating CDs and NCDs is seen as a serious error since, as the pandemic has shown, there are close links between them when it comes to those people and communities which suffered most in terms of illness and death. A syndemic understanding of diseases and their underlying social factors is pivotal in preventing disease in the future.
  4. Our interviewees expressed hope that the Office for Health Improvement and Disparities (OHID) being located within Whitehall as part of the DHSC may be better placed to influence, and have closer collaboration with, ministers. This optimism was accompanied by the caveat that there is a risk of OHID disappearing into Whitehall and becoming invisible, since it lacks even the limited degree of independence Public Health England had. To succeed, OHID needs to be visible and have allies inside government, including the Chief Medical Officer for England. How OHID staff will work with public health staff in DHSC needs addressing.
  5. If OHID is seen to be visible, there is the further issue that its working style will be important, especially regarding how it operates across government and builds relationships with other departments and sectors, as well as with local authorities and their public health teams. This will be challenging in a government which is topic- and department-focused rather than concerned with cross-government issues. 
  6. There needs to be a minimum national standard in England in terms of the resources allocated to local authorities and how they can best cater for, and meet the needs of, their communities. This includes recording disease prevention and outbreaks to enable the UKHSA to monitor developments. 
  7. Strong leadership is needed at the top of both new public health organisations (UKHSA and OHID) so that they can represent and safeguard their interests in appropriate and optimal ways.
  8. Finally, there must be close collaboration between UKHSA and OHID, as well as ministers, if the possible fragmentation noted above is to be avoided. 

The significant funding cuts required by the Government, the lack of a cohesive strategy and the continuing emphasis on the NHS to reduce lengthening waiting lists, with a disillusioned and overstretched workforce, does not bode well for the future adequate funding and strategic thinking for public health. It also raises issues around how quangos are set up and destroyed at the whim of (in this case very) transient politicians.

Peter Littlejohns, Toslima Khatun and David J Hunter

Health policy in this country urgently needs a more measured and strategic approach if we are to successfully address the challenges facing us over the next few years.  

About the authors:

  • Peter Littlejohns, emeritus professor of public health, King’s College London, public health and multimorbidity theme lead, ARC South London
  • Toslima Khatun, researcher, ARC South London, public health and multimorbidity theme, King’s College London
  • David J Hunter, emeritus professor of health policy and management, Newcastle University

Related content