PHE, RIP- The botched elimination of England's public health agency is just a symptom

The problem is here.

Photo: @stanleydai

You might think that public health workers across the UK have enough to think about right now, but over the weekend the UK government gave them something else. Late Saturday, a paywalled article in the Sunday Telegraph  trailed a big announcement. Public Health England is to be abolished, merged with NHS Test and Trace into a new National Institute for Health Protection modelled. There is little effort to explain how all this will work, given an extraordinarily short timeline, NHS Test & Trace's own problems, PHE's work in international and devolution contexts, and so forth. All we have is a paywalled newspaper article that promises something will happen next week. 

In a sense, the demise of Public Health England (PHE) was certain by mid-March. Regardless of its performance, it would be scapegoated and abolished. How was this so obvious? Because agencies such as PHE, no matter how well-resourced or elaborately legislated, are ultimately the plaything of the executive in a Westminster system like the UK. UK governance makes executive-driven change with no clear rationale far easier than in other countries. The performance of any agency, or its responsiveness to ministers, is less important than the government's needs for politically visible action, and a global pandemic creates plenty of need for politically visible action. (As the joke goes: something must be done; this is something; therefore this must be done).

In other words, a poorly timed and disruptive reorganization of public health with no clear goal was pretty much assured. The underlying issue is governance. It is problems of UK governance that public health workers, advocates, and scholars of the UK have to confront. Holly Jarman, Martin McKee, and I argued earlier this year in the Journal of Public Health  that what they have to think about now is the governance of the United Kingdom. 

We identified executive dominance, partisanship, and opacity as the three features of UK governance that make for bad public health policy decisions, and show how they characterized the Brexit debacle as well as less remembered failures such as the inability of Parliament to coherently reform the House of Lords. They also explain the PHE decision and its inevitability: there is almost nothing stopping the executive making this decision for what can be the most trivial of motivations (a silly-season news cycle, a minister or special advisor with an agenda, or even the classic office-politics move of creating and destroying organizations in order to advance or get rid of individual people). 

Executive dominance is at the core of governance in the UK, and especially England (devolved administrations are, by design, less executive-dominated). Big decisions, from the HSCA to Brexit to the PHE reorganization, are taken by a small number of people. Journalists and politicians normalize the pattern with explanations focused on the interpersonal politics and agendas of a few people in SW1 rather thank asking why a policy might or might not make sense.

Partisanship means that the theoretical power of Parliament to control the executive is in practice limited; a prime minister with a strong majority, such as Johnson, will face little scrutiny. Parliamentary committees and oversight often produces well-researched and valuable reports and can indeed inconvenience government, but party loyalty and hierarchy means that they generally try to enable and improve the government's plans. Short of a Conservative rebellion- unlikely on an issue such as the reorganization of public health agencies- Parliament will be no obstacle because of Conservative party loyalty. 

Opacity, then. It is emblematic that instead of announcing the changes before Parliament, a minister announced them in a newspaper closely associated with the Conservative party and, specifically, his Prime Minister. The quantity and quality of the reasoning behind the decision, the planning for its (extraordinarily ambitious) timeline for implementation, and endless loose threads such as the relationship between the new agency and the devolved administrations is unexplained and will go largely unscrutinised. 

In the article, we argue that these three features of UK governance produce what Albert Weale called the UK's traditional constitutional casualism. If they are enough to make the UK casual about fundamental constitutional issues like the voting system, devolution, and European Union membership, then there is little hope that such a system will treat a mere public health agency with much deliberation, sobriety, and responsibilty. None of them are unique to the UK, but they are combined in an unusually strong dose in the UK, and the effect is to make the public sector a plaything of reckless opportunists.  

The JPH article is paywalled; DM me at @scottlgreer or drop me an email if you want a PDF. 

-Scott Greer