About 20 years ago I was sitting with my family in a small cafe in the village of Trefin in west Wales. Apart from a small number of family groups, there was a large table with eight elderly women sitting around it. They were chatting and I was paying no attention until my ears pricked up on hearing the term “Spanish flu”. Fortunately the table was large, and their voices loud, so I was able to follow most of the discussion.
They were talking about various relatives who had died in 1919 when the flu had come to Wales. But one woman’s account, about the death of her grandmother, really captured my attention. She remembered clearly as a little girl being brought to her grandmother’s bedside when she was near death, and being cajoled into kissing her goodbye.
I had always assumed that such a disaster could never happen again: general health had improved significantly, and in 1919 populations across Europe were exhausted and malnourished after the first world war, and didn’t have access to effective vaccinations, antibiotics and antiviral treatments. I was working in public health at regional level in England at the time of the overheard conversation – and I was confident that we had a robust structure, both in public health and the NHS, that could deal efficiently with any mass infectious disease.
Now the world is faced with a virus with no readily available vaccine or treatment. The NHS has also had 10 years of significant underfunding – and England, in particular, has an operational and management system that is fragmented and lacks an effective command and control structure. The public health function in England has been removed from the NHS and incorporated into local government, where its budgets have been systematically raided to prop up local councils that have suffered catastrophic cuts in the name of austerity.
Local authority functions closely aligned with public health, such as environmental health and social services, have been notable casualties. Within the local government world, the once powerful directors of public health have seen their influence decline, along with their staffing and resources.
The impoverishment of the NHS and the public health system in England is not the only depletion that has occurred in civil society that makes us ill-equipped to respond effectively to the greatest global health crisis in a century.
One of the first acts of the coalition government when it came to power in 2010 was to dismantle the regional structures that had provided a coherent mechanism for integrating and carrying out government policy within the English regions. The government offices for the regions (GOR) were established in 1994 by John Major’s administration as outposts of central government departments. They were tasked with implementing government-funded programmes and monitoring their performance. They also had an important coordination role at times of national emergency, such as during the fuel protest crisis of 2000.
As well as doing away with the GOR as part of its spending review in 2010, the coalition also stripped the NHS of its regional management tier following the wide-ranging “reforms” of the 2012 Health and Social Care Act.
The result is the absence of any integrational, coordinating or management function at a regional level in England that could operate between Whitehall departments and the various bodies, often very local, that are charged with implementing government policy. The fact that some national bodies have adopted internal organisational boundaries that cover completely different geographical territories has also complicated the situation. This is notably and unfortunately true with respect to the key health bodies, NHS England and Public Health England.
This absence of useful civil society structures outside Whitehall, apart from elected mayors in conurbations such as Greater Manchester and London, means that the approaches adopted nationally to manage the enormous coronavirus crisis are just that – national. The daily announcements keep coming, but the mechanisms available to integrate and implement various initiatives around the country are weak to non-existent. This lack of a two-way communications and governance structure has reinforced the perception of a government that is Whitehall-centric, distant from the real world and managing things by press conference.
At the heart of a country’s response to a catastrophic public health crisis should be a robust, dynamic and integrated public health system. The hollowing out of England’s public health capability, and of the integrating structures outside Whitehall, has hampered our response.
• Gabriel Scally is a former regional director of public health and honorary professor of public health at the University of Bristol
