Hospital and community deaths from listeria and streptococcus reveal weaknesses in public health

So far this year there have been two more serious failures of the public health system in England. In June, Public Health England announced that listeria had appeared in six seriously ill in-patients, three of whom had since died and later the same month it transpired that 12 people had died and 20 more had been infected from the spread of group ‘A’ streptococcus in care homes and in their own homes in mid-Essex.

Initially there was a confused picture of what was happening with Public Health England apparently reluctant to divulge the full story. Not for the first time the communications function at Public Health England seemed to be not up to the job. As the full picture emerged about listeria, the finger was pointed at sandwiches supplied to NHS Hospital Trusts across England by the Good Food Chain from Staffordshire which soon went into liquidation.

By the time the incident subsided, 5 patients had died with others affected across the country. Public Health England saw fit to claim that the risk to the public was low. The affair had quickly become political with questions being asked in the House of Commons and the Secretary for Health, Matt Hancock announcing a root and branch review of hospital food. The Health Select Committee announced that they would call Public Health England Chief Executive, Duncan Selbie to ‘explain how dozens of NHS hospitals were supplied with sandwiches potentially contaminated with lethal listeria’ and former health minister MP Ben Bradshaw criticised Mr Selbie for leaving the crisis in the hands of his deputies.

With the row over listeria still bubbling away it emerged that there had been a number of streptococcal-related deaths among patients in Essex involving 32 elderly people receiving community treatment for wounds where most care was being delivered by a ‘Community Interest Company’. The director of nursing quality at the clinical commissioning group responsible for overseeing the provision of care in mid-Essex is quoted as saying that “Our thoughts are with the families of those patients who have died … The risk of contracting (Invasive Group A streptococcus) is very low for the vast majority of people and treatment with antibiotics is very effective if started early … ”.

It is now time to digest these latest failings of a public health system that was only put in place 6 years ago as part of Andrew Lansley’s structural changes to the NHS and for public health. In doing so we should reflect that we have been here before.

In 1974, radical changes to local government unravelled a public health system that had evolved over 130 years. In this the NHS had consisted of three complementary parts – the hospital services, the family practitioner and related community health services, and the public health services under the direction of the Medical Officer of Health. Environmental health, food hygiene, water, housing, maternal and child health clinics, social work and health visiting, were all parts of an integrated approach to public health. At a stroke this was taken apart with the position of Medical Officer of Health disappearing and being replaced by the short lived ‘community physician’ based in the local health authority.

This new role was largely an administrative one and a shadow of the one it replaced. Its weaknesses soon showed. Two serious clinical service failures occurred in the mid-1980s that brought urgent action. First, in August 1984, an outbreak of salmonella food poisoning at the Stanley Royds psychiatric hospital in Yorkshire led to the deaths of 19 elderly patients, and then in April 1985 there was an outbreak of legionella at Stafford District General Hospital affecting 68 patients, of whom 22 died. As a result of these two major clinical incidents, Chief Medical Officer, Sir Donald Acheson, carried out his 1988 enquiry into public health in England which led to steps being taken to rectify the weaknesses that had become apparent in the new system. Central to both events was deemed to be a lack of effective local environmental and communicable disease control since 1974. The Acheson review led to the recruitment of a new cohort of public health physicians and the establishment of positions of Consultant in Communicable Disease Control, working across the boundaries between the NHS and the local authorities.

The situation in 2019 is different but has similarities. Since 1988, public health in England had evolved into an effective system, led by the Chief Medical Officer and Regional Directors of Public Health together with local Directors based in Health Authorities and latterly Primary Care Trusts. This regional structure was supported by the Public Health Laboratory Service with its regional laboratories and clinical facilities and a distribution of expertise balanced between the centre at Colindale in north London, the defence orientated research facility at Porton Down, and academic regional centres based in NHS hospitals. After the loss of staff and funding following the 1974 changes, public health leaders at local and regional level had steadily built up credibility and resources, supported by successive governments’ priority to public health and prevention.

Alongside this there had existed successively the Health Education Council and the Health Education Authority with remits to develop an educationally-based preventive agenda. There was tension between government and these bodies because of disagreement over tackling anti-health forces, including the tobacco and alcohol industries. Consequently, neither of them had a long life and following the terrorist atrocities in New York on September 11th, 2001, the Health Education Authority was transmogrified into the Health Protection Agency bringing together the biological and chemical underpinnings of public health with the wider prevention agenda. In reality, this led to a takeover of the preventive wing of public health by a biologically (and largely microbiologically) driven emphasis rooted in the laboratories of Porton Down and Colindale.

The Health Protection Agency itself failed to live up to expectations and was replaced by Public Health England in 2013 where it was caught up in the Lansley reorganisation of the NHS with its subsequent simultaneous fragmentation and centralisation of the NHS. The dominant influence on the structure of the new body came from the United States in the form of the Centres for Disease Control based in Atlanta, Georgia. Public Health England was to be centred in London and the South-East, weakening an approach which had endured for almost 70 years. The nine regional Directors of Public Health with their local focus were replaced by four civil servants whose loyalties were primarily to a national body based in London.

Although many voices had called for a return of the public health function to local government, when it came in 2013, its form took many by surprise. Many of the Directors of Public Health were placed in structures in which they are line managed by Directors of Adult Social Care, with restrictions placed on their scope for action and freedom of expression, something that was at the heart of the work of Medical Officers of Health.

Since 2013 local authority public health establishments have been whittled away, budgets cut dramatically along with salaries that were previously tethered to clinical salaries in the NHS. There has been a flight by public health consultants with a clinical background to jobs with Public Health England, where clinical salaries are still maintained. This has led to a schism in which the clinical perspective in local government has been disappearing and the links between local authorities and the NHS have become ever more dysfunctional. This has been reflected in the deterioration in performance in areas that include sexual health, immunisation and vaccination and screening programmes. To add to the agony, ten years of austerity and massive cuts to local authority budgets have resulted in attrition of environmental health departments which no longer have the capacity to keep ahead of the threats to human health despite their best efforts. Nevertheless some local public health teams have been achieving remarkable results, often at a personal price with deteriorating morale and co-ordinated anticipatory partnership work has suffered.

So in 2019, just 6 years after the pack of cards was thrown up in the air and public health rearranged in an NHS-style top-down reorganisation we have a systemic problem resulting in the deaths of 17 elderly citizens who deserved better. Surely it can’t be long before there is a full review of the arrangements for public health in England! It is now 31 years since Sir Donald Acheson carried out his review into the dog’s breakfast created by the 1974 local government reorganisation. The lesson from history is that we should not embark on another reorganisational folly but rather find ways to strengthen what we now have and support its evolution into something fit for purpose. An important task beckons for the incoming Chief Medical Officer, Chris Whitty.