The knives were already out for Public Health England

When the UK Government finally got around to publishing its Covid exit strategy in May, one paragraph above all others signalled radical change for Britain’s public health establishment.

Under the heading “Sustainable government structures”, the authors noted that as the Government fought Covid-19 it would “learn the right lessons from this crisis and act now to ensure that governmental structures are fit to cope with a future epidemic”.

It said: “This will require a rapid re-engineering of government’s structures and institutions to deal with this historic emergency and also build new long-term foundations for the UK.”

Three months later and the game to determine the future shape of Whitehall is in full swing. Mark Sedwill, Cabinet secretary and Britain’s most senior civil servant, has been dismissed for a duck, clearing the way for those Conservative ministers, MPs and aides best known for their “strategic vision” to step up to the crease.

Meanwhile, permanent secretaries and assorted mandarins play their usual long game (“management and efficiency” tweaks) rather than anything resembling the last great structural shake-up of the Civil Service that followed the First World War and the Spanish flu pandemic of 1918.

Those reforms, which among other things ushered in the first dedicated UK ministry of health in 1919, were also prompted by “obscurity and confusion” in the functions of Whitehall.

So what are the lessons of this crisis and what reforms might be expected?

While virtually all independent experts say it will take years for the dust to settle, the knives are already out for Public Health England, the executive agency of the Department of Health and Social Care.

It is accused of being slow off the mark – “sluggish”, as the Prime Minister put it – when the pandemic first broke in January. Specifically, it is blamed for not having in place the testing capacity to track the initial wave of the virus, nor the contact tracers needed to stem its spread.

Poor data provision is said to have hampered No10’s ability to respond promptly to local outbreaks.

In its defence, Duncan Selbie, PHE’s chief executive, said “the Department of Health and Social Care leads on all aspects of pandemic planning and preparedness, not Public Health England”.

He added it was “never at any stage our role to set the national testing strategy for the pandemic. This responsibility [also] rested with DHSC. Any suggestion that PHE monopolised, centralised and controlled pandemic testing, and even stopped others from developing tests or conducting them is not true.”

Iain Duncan Smith MP, the former Conservative Party leader and the brains behind Universal Credit, has said he would “abolish PHE tomorrow” if he was in charge, accusing the agency of “arrogance laced with incompetence”. Others also think the agency’s responsibilities are too broad, covering everything from infectious diseases to sexual health.

Matthew Lesh, head of research at the Adam Smith Institute, is one of several calling for PHE’s responsibilities in the area of infectious diseases to be hived off into a dedicated agency.

Mr Lesh said: “I think the first step would be to split infectious diseases out, and create properly devolved centres for disease control.”

Nick Davies, programme director at the Institute of Government, agreed PHE’s duties may be too broad.

“I guess there are reasonable questions about whether campaigns to reduce smoking should sit with infectious disease control,” he said.

Whitehall will be delighted if reform is limited to the splitting of PHE. As Mr Davies says, it was the Cameron government that “bundled” it up with the Health Protection Agency in 2012, against the advice of civil servants.

Mr Davies said it was “a nonsense” to say PHE was beyond the control of ministers. As an executive agency of the DHSC, it has “direct accountability to Matt Hancock,” he said. “I think it’s fair to say the crisis hasn’t exactly been a good advert for what happens for services directly under government control,” he added. “If you look at, for example, NHS test and trace – directly under the control of ministers – that’s clearly been a bit of a disaster.”

Michael Gove is another key player in the bid to reform Whitehall. As education secretary, he and his then aide, Dominic Cummings, took on the education establishment and scrapped continuous assessment in almost all GCSE and A-level courses. Now Cabinet Office minister, he has recently made clear he aims to tackle “group think” in Whitehall.

There can be little doubt Britain’s poor response to the pandemic will ultimately be explained by group think.

Today it is best seen in the excuse proffered by almost any minister, civil servant or government scientist you challenge about Britain’s response to the pandemic: that all would be have been well had we been hit by pandemic flu rather than a coronavirus.

Britain had a first-class influenza pandemic strategy – second in the world after the US for its preparedness – and would have performed well had it been another Spanish flu, so the argument goes. There would have been no demand for masks, visors or droplet repellent PPE. Mass testing and track and trace systems would have been next to useless. And there would have been no need for lockdown. Why? Because an influenza pandemic would have been unstoppable. Many tens of thousands would have died but there would have been nothing much to do, other than bury the dead.

This is the narrative pushed out by Jeremy Hunt, the former health secretary, and Sally Davies, the former chief medical officer, who were responsible for Britain’s pandemic strategy, but it would never survive a public inquiry.

Past pandemic strains of influenza and SARS-CoV-2 are extraordinarily similar. Both are droplet spread, cause asymptomatic infections and have similar infection fatality rates. Mr Lesh says the real problem in Whitehall was “failure of imagination” and a misjudgment about society’s modernday tolerance for risk.

He said: “They thought people’s tolerance for risk was higher, and that people would also be far less tolerant of social distancing measures.”

Group think and western exceptionalism were certainly part of the problem but, as Mr Davies, points out it was money too.

The Institute of Government’s report on the pandemic finds that “funding cuts meant public services were not well prepared to handle the coronavirus crisis”. Years of austerity overseen by former chancellor George Osborne saw the NHS protected but the capacity of its sister public health services dramatically cut.

“The Treasury is very effective at controlling spending but has historically been less good at understanding what it is getting for its money”, said Mr Davies.

“Also, the priority of governments since 2010 has been tax as low as they can and within public spending, and focus on efficiency over resilience. Those are perfectly reasonable political judgments to make, but clearly that has come back to bite us.”

‘It is accused of being slow off the mark – “sluggish”, as the Prime Minister put it – when the pandemic first broke in January’

‘I think the first step would be to split infectious diseases out, and create devolved centres for disease control’