23 Mar 2022

The Inquiry's draft terms of reference (ToR) have just been published and are open to public consultation until the 7 April 2022. In this blog, we outline our response to the consultation, highlighting concerns that we have about the Inquiry’s limited terms of reference in relation to the role played by Public Health England during the pandemic, and its successor institutions in any future public health crisis.    

Since the last blog, Peter has established a group of researchers to explore the circumstances around the rise and fall of PHE. Over the last six months we have undertaken a narrative literature review, interviewed a range of senior people involved with PHE and are holding a workshop on 30 March, in order to learn lessons to support the two new institutions established out of the ashes of PHE – the UK Health Security Agency (UKHSA) and the Office for Health Improvement and Disparities (OHID). (For reference, the UKHSA was originally established as the Centre for Health Protection, but immediately had its name changed, as it was probably considered too close to the Health Protection Agency, which itself was closed down to create PHE in 2013.)

Scrutinising the rationale behind the closure of PHE

Because of the central role that PHE had at the beginning of the pandemic we were surprised to see that it did not appear at all in the UK Covid-19 Inquiry’s ToR.

The ToR specify that the Inquiry has two aims, to: 

  1. examine the Covid-19 response and the impact of the pandemic in England, Wales, Scotland and Northern Ireland, and produce a factual narrative account; and
  2. identify the lessons to be learned from the first aim to inform the UK’s preparations for future pandemics. 

The consultation on the Inquiry’s ToR is based on a series of questions and we present our proposed submission below. 

The first Inquiry aim is subdivided into three categories:

  • Category one: in relation to central, devolved and local public health decision-making and its consequences
  • Category two: the response of the health and care sector across the UK
  • Category three: the economic response to the pandemic and its impact, including government interventions

The first category, while listing 16 issues to be addressed, makes no mention of the specific organisations and structures that were established to deliver key public health functions. PHE was an executive agency, legally part of the Department of Health and Social Care, and was established in 2012 to “support local innovation, help provide disease control and protection and spread information on the latest innovations from around the world”. 

PHE was the lead public health institution in the UK at the start of the pandemic, yet was abolished in the middle of the crisis. Its closure was announced suddenly through the media, with no prior warning given to staff and without any consultation. It had a significant adverse effect on staff morale at a time when Covid-19 infection rates were rising. The reasons for PHE’s closure are likely to be influenced by the way that the public health function had been structured and managed pre-pandemic as well as how it performed during the pandemic.

The decisions and rationale for terminating PHE in such a dramatic and unprecedented manner merits careful scrutiny by the Inquiry and ought to, in our view, be included in category one

Peter Littlejohns, Toslima Khatun and David J Hunter

Under the second category, while the temptation may be to focus on the health care (NHS) and social care sectors, this must not be at the expense of paying adequate attention to public health at all levels of government.

Under the third category, the economic response to the pandemic must include the impact of a decade of austerity on the public health function, both nationally and locally. Some of the severest cuts in public spending were imposed on public health, as well as on other public services. The extent to which these impacted disproportionately on the poorest groups and places in society which suffered most during the pandemic should be a focus for the Inquiry. 

Lessons in governance for the UKHSA and OHID 

The second aim is to identify lessons to be learned. And yet it omits to mention the two new organisations established to replace PHE, the UKHSA and OHID, which must have a key role in taking any recommendations forward.

Given the rapid establishment of these organisations, they are at real risk of suffering the same challenges that resulted in the over-zealous closure of PHE

Peter Littlejohns, Toslima Khatun and David J Hunter

We consider that the ToR should specifically state that any emerging findings from the Inquiry relevant to these bodies should be considered urgently by the Government, with a requirement that a public response is given setting out how they are being addressed. For example, whereas PHE had responsibility for system leadership across the whole public health function, including communicable diseases and non-communicable diseases, there is a concern that having two new bodies in its place risks fragmentation resulting in negative implications for workforce capability and capacity. Also, there are concerns about how the two organisations are funded, as we are already seeing significant reduction in funding for tracking progress of the infection and its variants. 

Prioritising issues to be explored by the Inquiry 

The consultation goes on to ask which issues or topics should be looked at first.

We highlighted that while there will be considerable public interest in how high-profile individual decisions were made, for example, not continuing community testing for Covid-19 early on, it is imperative that the way public health organisations were structured and how their governance arrangements and interactions were managed is described and understood early in the Inquiry. It is likely that the overall governance arrangements in place laid the foundations for many of the subsequent decisions, especially given concerns expressed over PHE’s lack of independence and inability to ‘speak truth to power’.

The next question asked how the Inquiry should be designed and run to ensure that bereaved people or those who have suffered serious harm or hardship as a result of the pandemic have their voices heard. While it will be imperative to give an opportunity for all relevant voices to be heard, it is important that the timescales are such that the Inquiry can reach conclusions early enough to allow changes to be made in time for any new public health threat. 

As well as patients and bereaved people, it is crucial that both frontline workers and other more senior staff working in, and advising, public health bodies at national and local levels are invited to give frank personal testimony, without fearing that this will impact negatively on their professional position or future careers.

Ensuring openness and transparency 

Therefore, and bearing in mind the need for a time-limited process, while all should be able to submit written evidence, only a limited number of witnesses might be called upon to give oral evidence. In a spirit of openness and transparency, the Inquiry should meet in public and be live streamed. Finally, to make the Inquiry’s task manageable and to expedite its prosecution, it is likely that a range of subgroups will be required to report to a central group chaired by Baroness Hallett. We concluded that the Inquiry should run for 12 months, have a planned end date for its public hearings, with interim reports published every four months.

As the closing date is the 7 April, you still have time to say what you think should happen.

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

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