Public trust and the public’s health: two sides of the same coin?

The recent exposure of Dominic Cummings’ behaviour has quite rightly caused grave concerns about its effect on our trust in government, and our compliance with public health messages. The truth is that this trust was already plummeting. The inability to make enough testing available and the failure to establish proper track/trace/isolate capacity, let alone adequate surveillance systems are just some of the reasons behind the public’s perception that our Government’s performance is much worse than for example Germany’s, Australia’s, or South Korea’s. Combined with the high mortality rates and with week eleven of the lockdown looming, the public mood is justifiably friable. 

This is at a critical time. The pressure to lift lockdown mounts, but we still do not have the basic public health systems required for outbreak control in place. There have been impressive local initiatives, but the scale of the crisis and the decimation nationally of public health capacity means the gaps are large. Local public health teams still do not have access to the information they need promptly to detect local flare ups, or the capacity to deal with them effectively. The number of contact tracers required to identify and subsequently follow up and support the contacts of the currently more than two thousand daily new positively tested cases, let alone of the estimated six thousand untested ones looks huge. Lifting lockdown under these circumstances could well prove reckless.

Urgent action is now needed if we are to be adequately resilient in the event of a second wave. Given the very short time scale, what form can this take? A mechanism has recently been proposed to kick off a rapid and transparent review of several components of the government machinery that have been found wanting, and in a way designed to lead to action. Recent events, though, suggest that this may not be rapid enough. Public trust could perhaps be sufficiently preserved to allow an orderly lifting of lockdown if we all now saw that the necessary infrastructure really was at last being put in place quickly, and that it was effective. A repeat of a “strategy based on massaged numbers” as with testing would be disastrous.  

Why has it taken so long to do what is necessary? There are several reasons, but a significant one is the lack of organisational coherence of the public health function in England. For the first time since 1855 the Chief Medical Officer (CMO) post became part time in 2010, split with Director of R&D responsibilities within the Department of Health and Social Care. The CMO is an adviser to government, and no longer responsible for developing the public health function or holding it to account. Public Health England’s formal connection with the government is not through the CMO, but a second-in-line civil servant, reporting to DHSC’s permanent secretary. Nor is there the clear line of sight, if necessary transformable to unambiguous professional leadership, of the public health system at a local level. Several of the components vital to controlling the epidemic—for example establishment of track/trace/isolate systems—are being developed in parts of the government machinery which do not report to the CMO. The world beating track and trace system is “about to be implemented.” The latest addition to the galaxy of new involved parties is the new Joint Biosecurity Centre.  The CMO apparently does not chair this. This all needs to change.

In my view, the CMO needs to return to the role of the nation’s doctor, speaking truth to power and to the public. At least for the duration of the epidemic he needs to be established as the leader of the public health function, residing as it now does in numerous discontinuous silos. It is the CMO who should enunciate the overall strategy, and oversee its implementation, in as devolved a manner as possible, making best use of existing resources within government, local government, the NHS, and the public at large. NHS England needs to collaborate closely with him both in releasing staff needed at local level, for example for contact tracing, and in sharing information seamlessly. The confusion and apparent indecision resulting from the plurality of leadership figures, and the multiplicity of strands of apparently separate activity need now to be addressed. 

The proximate cause and focus of the Griffiths Enquiry into the management of the NHS in 1983 were very different  to our current situation,  but its conclusions have a forceful resonance: ‘‘…if Florence Nightingale were carrying her lamp through the corridors of the NHS today she would almost certainly be searching for the people in charge….Units… are swamped with directives without being given direction….. devolution of responsibility is far too slow because the necessary direction and dynamic to achieve this is currently lacking.” 

Before the Health and Social Care Act was passed in 2012, Lansley said in 2010, “My vision is for a new public health service which rebalances our approach to health, and draws together a national strategy and leadership, alongside local leadership and delivery and, above all, a new sense of community and social responsibility”. That vision has shown itself unrealised.  As ever this government has reacted to a crisis with an essentially paternalistic form of policy making. Both the AIDS and BSE crises are examples exposing the vital role of the CMO in the interpretation and management of significant new health risks. This one has done the same.

David Nicholson when Chief Executive of the NHS famously said the Lansley reforms demanded “such a big change management, you could probably see it from space.” The same can now be said of the flaws in the organisational arrangements which resulted. The Covid crisis has cruelly and publicly exposed them. The intention here is to propose an expedient approach to restoring coherence, and hopefully, public trust.

Mike Gill, former South East Regional Director of Public Health. (London)

Competing interests: None declared