By Karen Taylor and Samrina Bhatti, Deloitte Centre for Health Solutions
This week, we launched the third report in our future of public health series, Bridging the gap: Protecting the nation from public health threats. Health protection requires targeted and cross‑functional approaches to tackle multiple, diverse and challenging public health threats. These threats need to be managed in an optimal way to reduce health inequalities, avoidable disability and premature death. Our ‘Bridging the gap’ report examines the UK’s policies and approaches to health protection. The pandemic has, however, exposed critical gaps in the health protection system, including workforce and funding shortages, a lack of surveillance capacity, and fragmented and unclear accountabilities. This week’s blog discusses the challenges pre-COVID-19, the impact of the pandemic and what the future might hold, based on key findings in our third public health report.
Pre-pandemic management and control of health protection
Health protection threats include infectious disease incidents and outbreaks, environmental hazards (chemical, biological, radiological and nuclear incidents), and climate change. Public health risks such as sexually transmitted diseases, hospital‑acquired infections and the rapid increases in drug resistant pathogens need to be proactively identified and reducing the impact on the population should be priority. While national governments have the ultimate responsibility for health emergencies and protecting the population from serious health threats, the complex array of health protection services needed involves a broad network of stakeholders including local government, public health experts, the NHS, academia, industry and the public (Figure 1).
Figure 1. The complex array of key stakeholders with a role in health protection.
Source: Deloitte, adapted from PHE Infectious Disease strategy framework 2020-2025.
The UK has historically been recognised as having a world leading national health protection system, however, in 2012 the Lansley (Health and Care Act) reforms in England transferred accountability for health protection to Public Health England (PHE), an executive agency of the Department of Health and Social Care (DHSC). It also transferred responsibility for public health service delivery, under the leadership of local Directors of Public Health (DsPH), to local authorities. Between 2013 and 2019, increasing demand for services, alongside significant cuts to public health funding and growing staff shortages, created a more siloed, reactive and fragmented approach to public health protection. This was despite numerous reports warning of the challenges that the world was facing in relation to infectious diseases, antibiotic resistance, and climate change.
Health protection requires local systems to have access to and deploy effective surveillance, analytics and population health management (PHM). It also involves health screening, vaccination programmes and, more recently, clinically validated whole genome sequencing. There are also many evidence-based toolkits for managing and controlling infectious disease incidents and outbreaks; environmental hazards; referrals to and use of diagnostic testing; antibiotic prescribing and more.
COVID‑19 has changed how countries perceive public health threats
COVID‑19 exposed the extent to which the UK, like many countries across the world, was ill prepared for a pandemic caused by a novel pathogen like COVID-19. Indeed, health systems in most countries were overwhelmed by this new, fast‑moving, virus. Those countries that seemed relatively unscathed during the first wave, found themselves struggling during later waves. In the UK, the Health and Social Care and Science and Technology Committees’ joint enquiry concluded that the pandemic highlighted a lack of vigilance in preparing for pandemics, including inadequate surveillance, unclear accountabilities and a lack of investment in the health protection infrastructure. The enquiry also highlighted the fact that much of the UK’s preparation was for an influenza like pandemic and not one characterised by asymptomatic transmission which meant testing was important.
Our interviewees, 85 public health experts, highlighted the lack of investment in the health protection infrastructure due to year‑on‑year cuts to the public health grant as a critical factor in the inadequate response. They also emphasised that improving preparedness will require not only sustained investment, but also a new approach to the leadership dimension and accountability for protection services. Concerns were also raised that the health protection system was too fragmented and that there were too few people in the workforce, undermining the capacity for an effective, population-wide response.
Compliance with health protection mitigation strategies is important for recovery
The UK’s history of strong surveillance capability and wide range of facilities and scientific expertise (including genomics) meant that it was well placed to take a leading role in developing a scientific understanding of COVID‑19. There also existed a wide network of effective partnerships with national and international government agencies and academic collaborators. Despite these successes, disconnected roles, responsibilities, and accountabilities across national, regional, and local organisations, alongside insufficient workforce capacity, made it difficult to steer a fast and consistent response, including the deployment of mitigation strategies.
Figure 2 below illustrates the response strategies needed to enable an effective recovery from the pandemic. From the outset, the development of an effective vaccine was seen as essential to the recovery. A critical challenge facing many countries, however, is overcoming vaccine hesitancy which requires organisations to have shared goals, underpinned by robust scientific evidence and data, which reflect local needs. In the UK, the ability to draw on local expertise and the support of community leaders, including faith leaders, is seen as critical in helping overcome people’s hesitancy as well as encouraging greater compliance with other mitigation strategies such as mask wearing.
Figure 2. Health protection response strategies
Responsibility for health protection in the UK
In September 2020, the government announced plans to close PHE on 1 October 2021 and reform public health and, in March 2021, set out its plans to transfer the health protection capabilities of PHE and the NHS Test and Trace Service (including the Joint Biosecurity Centre) into a new UK Health Security Agency (UKHSA). It confirmed that DsPH and their teams will remain part of local government. The UKHSA intends to deploy state‑of‑the‑art technologies and expert capabilities in behavioural science, data analytics and genomic surveillance to tackle coronavirus and future threats locally, nationally, and globally. Its immediate priority is to fight the COVID‑19 pandemic, including supporting the development of vaccines effective against new and emerging variants. In the longer term, UKHSA expects to build on the infrastructure developed for COVID‑19 to tackle and prevent other infectious diseases and external health threats.
The planned reform of public health and, specifically, health protection and the creation of the UKHSA provide an opportunity to re‑prioritise protection services and address health inequalities in more coordinated and collaborative ways. Going forward it will also be important that the changes in health protection work are translated quickly into clinical pathways where needed- so that there is a truly integrated approach to care.
Learning the lessons and shaping the future of health protection
What is incontrovertible is that the COVID-19 pandemic has been a pandemic of inequality and has been particularly severe on people who are already marginalised or disadvantaged. The pandemic has also tested the ability of every government to protect its citizens. While there have been failings there have also been successes. The successes include the rapid development and roll out of effective vaccines to bridge the health protection gap; the establishment of a testing infrastructure that has enabled the UK to maintain the highest level of population testing per million; and the outstanding genomics capabilities that are enabling the identification and tracking of variants.
Nevertheless, the pandemic has and will continue to have, a negative impact on health and care. Going forward it will be important that the changes to health protection are translated quickly into clinical pathways to ensure a fully integrated response. It will also be important to use scenario planning to improve preparedness at every level and combat threats as they arise and, most importantly, to engage the public much more effectively through consistent and evidence based communication strategies.