Thread by @petermbenglish

1/ Yesterday my friends @DrSelvarajah posed the question "When did #PublicHealth become a political and populist tool?".

https://twitter.com/DrSelvarajah/status/1452006942747017216

My friend @awoodall suggested that now I've retired I might be able to answer.

2/ (My responses will refer primarily to public health in England.)

tl:dr version: public health is funded by public money. Politicians control public money; and use this control to bully publicly funded public health bodies not to disagree with ministers.

3/ This has always been so, but, since the turn of the millennium (if not before) government has progressively brought public health bodies closer to government, allowing closer ministerial control.

I was a GP in the 1990s before training in public health.

4/ When I trained - in the then Trent NHS region, initially under Director of Public Health (DPH) @MorganSagartia.

Public health professionals were then located in health authorities (HAs).

5/ HAs had a lot of independence from the Department of Health; and the DPH produced an annual, independent, annual report.

Upper level Local Authorities (LAs) eg County Councils also employed health promotion staff. There was some overlap.

6/ LAs and HAs were often at least roughly coterminous (covered the same geographical patch), and they generally worked closely together - although staff were on different salary scales, which occasionally caused tensions.

7/ The roles of public health in health authorities included health policy, and a lot of support to the commissioning of health services. Arguably, too much of our time was spent on the latter, and too little on the wider determinants of health.

8/ HAs were not best placed to influence the wider determinants of health; but public health staff did work closely with LAs, inputting into policy documents; and the LA had a level of ownership of the DPH annual report.

9/ Public health doctors, after training, would become Consultants in Public Health - and possibly thereafter Directors of Public Health; or Consultants in Communicable Disease Control (CCDC/CsCDC).

10/ CsCDC could also be appointed from infectious disease or microbiology backgrounds. At the time, all the consultants and trainees were medically qualified.

11/ I rotated to Southern Derbyshire HA as a senior registrar, where the redoubtable CCDC, Dr Mary Newlands aimed to be mentioned in the (daily) local paper once a week if possible.

12/ (A digression - in Leicester and Derby back then - the 1990s were county towns, with BBC and independent radio and TV stations, and a strong, widely-read daily paper.

13/ When I became a consultant in Surrey I had to adapt to a very different media setup - Surrey is on the border of various areas, and has no strong sense of County.)

HAs were very independent - which was good and bad.

14/ Each HA had to develop its own policies on many issues - there were many fewer national policies.

15/ There was a national infectious disease body - Communicable Disease Surveillance Service (CDSC), a sub-body of the Public Health Laboratory Service (PHLS) (so sometimes referred to as PHLS CDSC).

16/ After an enjoyable six-month senior registrar attachment at CDSC's centre in Colindale, North London, I completed my training in Southern Derbyshire.

17/ Things that stand out from this period include the growing number of cases of meningococcal disease - group C disease in particular - and the implementation of an effective vaccine.

This vaccine became available a year earlier than anticipated.

18/ With cases rising, and a lot of media concern about the disease, the government agreed to implement a vaccine programme immediately - even though the vaccine was not available in quantity and would have to be used as fast as it could be produced.

19/ This inevitably meant some glitches as batches were delayed, but it was ultimately very successful.

20/ Inevitably, there were complaints from people whose children got ill or died, when their children were in the second risk category, and not included in the first round of vaccines.

21/ This was very sad; but had we not prioritised the most vulnerable age-groups, there would have been even more such cases in the highest priority groups.

22/ There were a lot of lessons to be learned from this MenC vaccination programme that are relevant to - and no doubt influenced - decisions about the Covid-19 vaccination campaigns.

23/ One difference is that (at least in people aged 2 years or more) a single dose of MenC vaccine seems to give very long-term, high quality immunity. Second, third, or booster doses were not needed.

A serious incident related to a hepatitis C lookback.

24/ A healthcare worker (HCW) had infected at least one patient (whom I'll call the index patient), who had an acute illness and was admitted with jaundice.

25/ The HCW was a carrier of the disease; and any patient on whom they performed an "exposure-prone procedure" (EPP) was at risk of being infected.

We did an extensive lookback, working with the hospitals and the other HA where the HCW had been employed.

26/ Representatives of the DH (at that time, from the "regional outpost" of DH, which had replaced the regional health authority) attended the meetings.

27/ A huge amount of work was done to identify other patients identified as possibly having undergone an EPP at the hands of the HCW (and thus at risk of infection).

28/ A lot of work was then done to set up a media campaign and clinics to which such patients would be invited for counselling and testing.

Dates were set, staff training was arranged, and letters were about to be sent out to patients.

29/ At the last moment, I received a phone call from somebody senior in DH ordering me to call off the clinics for unspecified but allegedly very important reasons.

30/ I have always regretted agreeing to do so; or agreeing to do so without a written instruction detailing the reasons.

31/ What happened was that the index patient (as we knew they would) went to the press, and the carefully planned process had to be undertaken in haste and relative chaos.

32/ It turned out that the actual reason was that an election was coming up, and ministers didn't want this done until after the election.

(It was, of course, as the press didn't worry about that when reporting on the index case, and demanding action from the HAs.)

33/ I subsequently gave a paper on this - reminding CsCDC and HAs that they were the responsible bodies, and advising that they treat any such instructions from DH as (as, strictly, they were) purely advisory.

34/ The then Deputy CMO responsible for infectious disease issues (Mary O'Mahoney) was in the audience. She approached me afterwards, and told me that the reason for the delay was that the other hospital and HA "wasn't ready".

This was news to them.

35/ In fact, it was a complete lie. It was clear that civil servants had lied to the deputy CMO about the reason for the delay. Quite who briefed the person who called me, I have never established.

But it severely undermined my trust in government and DH.

36/ It became clear that politics was far more important than public health.

Another issue that took up an extraordinary amount of our time around the turn of the millenium was head lice.

Head lice are distasteful. But they are not associated with other diseases.

37/ They do not appear to be vectors for viral or bacterial disease. And they are not a disease of squalor, as many people thought.

38/ Memories of "Nitty Norah the Nit Nurse" were prevalent, and people would complain vociferously to local CsCDC about dirty children who infected their own nice children, and would demand that Something Must Be Done.

39/ Eventually a self-organised group of CsCDC and Environmental Health Officers (EHOs - very close colleagues of the CsCDC, employed by LAs) - the Public Health Medicine Environment Group - wrote some guidance.

40/ Led by a CCDC and steering group who consulted closely with the profession, the guidance made quite a difference - if only because we could refer members of the public and schools to the relevant sections.

41/ Indeed, I would refuse to take calls on the subject of head lice unless the caller told my secretary that they had read the relevant section.

42/ (In practice, they'd be told that I would speak to them AFTER they had read it - and my staff would tell them how to find a copy on the internet, or post or email a copy.

Some of the guidance produced by CDSC was excellent - the food poisoning guidance, for example.

43/ Some of it, however, was less well received, perceived as "ivory tower" guidance, by people with little or no experience of implementation such guidance.

In 1997 I set up an email discussion group for CsCDC and those with whom we had close working relationships.

44/ It rapidly became very successful. People needing a policy on a particular topic could rapidly identify policies written by CsCDC working in other HAs on the same topic, saving a lot of time in writing one from scratch.

45/ I like to think that, as well as saving a lot of effort, this process improved policies considerably.

46/ A CCDC might write a policy for their HA; and then somebody else, in adapting it for their own HA, might improve on it; and discussion about the versions of the policy on the group added a level of informal feedback.

47/ On 1 Feb 1998 I became a CCDC in the Surrey Health Authorities. The two HAs - East Surrey HA and West Surrey HA - were expected to merge within the next year or so.

48/ They had innovated by setting up the Surrey Disease Control Service - effectively merging the CCDC services in the two HAs which, between them, were coterminous with the county of Surrey.

49/ (The DsPH of the two HAs still expected to have their "own" CCDC, and fairly close control. I was the CCDC for East Surrey HA, based in the ESHA offices - although I had weekly meetings with colleagues in WSHA, and we shared the on-call and training arrangements.)

50/ The NHS consultant contract has, since well before I became a consultant, included (Schedule 12, para 7):

51/ "A consultant shall be free, without prior consent of the employing organisation, to publish books articles, etc and to deliver any lecture or speak, whether on matters arising out of his or her NHS service or not."

52/ It's still there in the current version: nhsemployers.org/sites/default/…

When I became a consultant, the Royal College for public health was the Faculty of Public Health Medicine, a faculty of the Royal College of Physicians.

53/ Early in the 2000s it decided to become a non-medical body, and to admit non-medics.

54/ The idea was (and remains) that "public health is a medical speciality with a non-medical route of entry"; and that people who had undergone the full training and were accredited as Public Health Specialists were equivalent in competence to public health physicians with a…

55/ …medical qualification.

Whether or not this is true (and there are some brilliant public health specialists who are not medically qualified), employers have always treated non-medically qualified specialists differently.

56/ I have long argued that the specialists should be treated exactly the same as doctors* (registered medical practitioners), put on the NHS medical contract, and on the same pay scales. And, once this was true, they should be eligible for @TheBMA membership.

57/ (*In this thread I shall use "doctor" to refer to "registered medical practitioner" (RMP) for the sake of brevity. No disrespect to non-RMP PhD doctors is intended.)

58/ Of course, some employers saw an opportunity to create posts on much lower pay scales; and because they were not on the same terms and conditions; and the BMA - a trade union and professional body for doctors - has not represented them.

59/ I suspect that non-medics on "consultant" appointments may not have this clause in their contracts.

60/ To return (after all this background!) to @DrSelvarajah's question, it wasn't very long after I became a consultant that I learned that our freedom to speak and to publish was not quite what our contract said it was.

61/ In early 2000s there was a lot of concern about influenza; and about the failure of more healthcare workers (HCWs) to get vaccinated,

As ever, much of the problem was accessibility. Getting time to go to occupational health when it was busy on the ward.

62/ And, as usual, the HCWs were blamed for vaccine refusal.

There was some truth in this. Myths about flu vaccine ("it gives you flu-like symptoms; it may not be safe" abounded.

63/ Mark Crislip used, annually, to produce an amusing rebuttal: boards.medscape.com/forums/?128@@.… (sorry if you have to register - perhaps this will work better: skepticalraptor.com/skepticalrapto… )

64/ But there was a lot of pressure from the Department of Health (DH) (it wasn't called Department of Health and Social Care (DHSC) back then) to increase HCW vaccine uptake.

65/ There was a considerable amount of bullying from DH, which HAs and hospital managements were expected to pass on.

At the time, the evidence-base for vaccinating HCWs was much poorer; and I wrote an article in the BMA News Review questioning the pressure.

66/ When it appeared in print, I was summoned into my (ESHA) DPH's office and given a reprimand. "How do you think it makes me feel, having a CCDC I manage criticising DH policy like that?"

It was a legitimate professional discussion, written politely, in a journal for doctors.

67/ It was completely within my contractual rights under S12 (7). And yet it was made very clear to me that questioning DH was unacceptable.

68/ I continued to feel strongly, however, that it was a professional duty to call out bad practice and bad policy where I saw it, and for the profession to work together towards best practice - not to accept the implementation of bad policy from DH or politicians.

69/ Things only got worse after HAs were abolished and general public health moved into PCTs, and CsCDC (a year later) joined the Health Protection Agency - a highly defensive, almost paranoid body, highly dependant on DH and ministerial approval.

70/ One of the consequences was that, rather than professionals like CsCDC being able to call upon press officers to help them with messaging, they were actually frozen out of media work.

71/ Nearly all interviews and statements were made by senior managers, who often had no professional knowledge or experience of what they were talking about. Presumably, only they could be trusted to keep to the DH script.

72/ Sometimes I "got away with it" - mutterings, but no formal action, for example when I pointed out that the ministerial diktat that everybody with flu symptoms in the early moths of the flu pandemic MUST be given antivirals was counterproductive.

73/ This followed being asked to implement this in Birmingham, where I discovered that there was no infrastructure to do it.

74/ The consequence was that everybody identified as having flu symptoms had to be given antivirals; but they wouldn't get them until 8 days or longer after the onset of symptoms.

75/ We knew, at the time, that antivirals made little difference to clinical outcomes; but if they were to be effective, they had to be given within 48 hours of symptom onset. Leaving it until a week or more provided no benefit.

76/ But it did cause harm through side-effects and potentially by driving antiviral resistance.

Worse, it meant that we were explicitly forbidden to prioritise people at higher risk of severe influenza.

77/ A sensible policy would have been to prioritise those at highest risk and ensure they got antivirals very soon after symptom onset. But by being required to pursue an ideal - but impossible - policy, we were prevented from pursuing a sensible public health approach.

78/ Soon after HPA was abolished and re-emerged, phoenix-like from the ashes as Public Health England, I discovered that, in the process, PHE had taken over running "NHS Health Checks".

These: thetimes.co.uk/article/health…

thetimes.co.uk/tto/health/dr-…

gponline.com/Opinion/articl…

79/ gponline.com/Opinion/articl…

bmj.com/content/342/bm…

ncbi.nlm.nih.gov/pubmed/24089427

I tweeted a question along the lines of: "What is the evidence base for NHS health checks? Last I heard there wasn't any" - I cited a recent Cochrane review. bmj.com/content/345/bm…

80/ I was summoned to the PHE Medical Director's Office (Paul Cosford) and told I'd committed a disciplinary offence by questioning DH and PHE policy. People responsible for implementing the policy might be upset!

And using Twitter was an exacerbating factor.

81/ (At the time Twitter was a smaller space than it is now; and I followed and was followed by people in public health and primary care, both practitioners and academics, so it was an ideal place to have a profession-wide discussion).

82/ It turned out that the policy I had allegedly breached was a fiction: the threat of disciplinary action was based on lies. See academic.oup.com/eurpub/article… (scroll down past the article to the responses) for more details.

83/ I wrote to the then president of the Faculty of Public Health about this breach of contract and the consequences if the people who know most about the consequences of policies are forbidden from discussing them in public.

84/ The PHE Chief Executive (Duncan Selbie) then subsequently denied (despite the existence of the email from Paul Cosford with the threat of disciplinary action!) that the event had ever happened.

85/ He has also insisted that public health doctors can speak out; while punishing those that do so.

86/ British Medical Association. Freedom of speech promised for public health doctors. News 2013; Updated 7 January 2013; Accessed: 2015 (6 July): (bma.org.uk/news-views-ana…).

87/ I could enumerate many examples of punitive action taken by HPA and PHE against people who were awkward enough to question policy decisions. Frequently pretexts were made to take disciplinary action for other issues.

One such ended in an employment tribunal.

88/ minhalexander.com/2018/04/07/rac…

I'm not sure this was actually primarily race discrimination - similar actions were taken against others who questioned decisions. The tribunal report is well worth reading - PHE comes out of it extremely badly.

89/ (It is hard to find. I can only find the decision not to award costs to the plaintiff online: assets.publishing.service.gov.uk/media/5bdae80a… )

I have uploaded a copy here: drive.google.com/file/d/1IaM-Zb…

The PHE investigation was heavily criticised by the BMA. assets.publishing.service.gov.uk/government/upl…

90/ At some point, I will describe in detail my persecution - for happening to be a CCDC working in Surrey when there was a large outbreak of E coli O157 at a petting farm in Godstone. (The farm also suffered, grossly unfairly).

91/ As it happened, there were major errors made by PHE senior management (some of which I only found out about much later); and I was a convenient scapegoat. My line manager, in particular, cocked up and tried to throw me under the bus; but many others were complicit.

92/ (I have copious documentation.)

93/ So... Please excuse this long thread.

The fact is that public health is there for the public.

It is funded out of public finances.

Governments - and ministers - therefore approve its funding.

94/ This gives ministers and mandarins the power to threaten the people put in power to manage public health bodies.

Over time, politicians have moved public health bodies closer and closer to government.

95/ I retired before the United Kingdom Health Security Agency (UKHSA) was created.

96/ (As an aside - was Public Health Scotland also abolished to become part of UKHSA? If not - what's the UK bit about? UKHSA has absorbed much of PHE (England); but does it cover the devolved nations too? If not, why isn't it the English Health Security Agency?

97/ I'd guess, it's because the English government doesn't really acknowledge any devolved powers.)

I get the impression that UKHSA will be even more controlling of what its employees are permitted to say.

98/ @ThreadReader unroll

@ThreadReader unroll - this unroll hasn't dropped yet, I wonder why?

@ThreadReader I failed to type [at]threadreaderapp correctly - that was why.

D'Oh!