Ebola exercise, Public Health England

It may surprise you to know that Ebola virus is difficult to catch. Ebola is not spread through airborne droplets like flu virus, but instead by direct person-to-person contact with a sick patient or dead body. Once someone is infected the biggest problem is that there is a long incubation period of up to three weeks during which time the infected person can pass it to other people, but may not be showing symptoms. This means that close family members and healthcare workers are most at risk. Once infected the death rate form the virus is high, probably somewhere between 50 and 90 per cent.

Ultimately every case of Ebola is preventable with early and thorough public health action. There should be high suspicion for people who meet the criteria for being at risk and early identification through testing. Strict control measures should then be put in place for both patients and their close contacts to prevent secondary cases and further spread. Control measures include isolating infected patients, conducting medical care through appropriate protective equipment and detailed contact tracing – identifying people at risk and monitoring and isolating them as required.

Given that we know this about Ebola, what has gone so terribly wrong that the outbreak in West Africa has reached such dire levels and that we have seen person-to-person transmission in America and Spain? What kind of health system would have served people better?

In West Africa the problems are clear — lack of funding for health systems, including building hospitals, labs and clinics and few trained doctors and nurses means that there is little ability for countries to have prevented or controlled the outbreak. Despite billions of dollars of international funding, charities and NGOs ultimately have their single areas of interest, which has meant funding that could have been used to develop good public health systems has instead been used to develop programmes for specific diseases. In the early stages of the outbreak there was a lack of culturally relevant educational material and good communication to local people, causing confusion and resulting in the outbreak spreading further. The international response was late, weak and uncoordinated. 

So what has gone wrong in rich countries in the developed world? The situation in Spain where Teresa Romeo contracted Ebola after nursing a missionary who had returned from West Africa seems to be a case of an individual failure of infection control procedure. The Spanish authorities have quarantined any contacts they deem at risk.

In the US the situation seems more worrying. Not only are there reports that there was a delayed diagnosis of Thomas Eric Duncan following a low index of suspicion of Ebola, but that once diagnosed the two nurses who subsequently contracted the virus had improvised infection control procedures. It appears that the Centre for Disease Control (CDC), the US Federal public health agency, was involved in providing advice, but it took little action to identify, quarantine or trace potential contacts. The CDC even advised that Amber Vinson could board a commercial flight with a low-grade fever, having been a high-risk contact of Mr Duncan.

Part of the problem is related to the healthcare system in the US. Contact tracing and isolating people is time consuming and challenging to undertake, yet is initiated on a local hospital level, where busy doctors and nurses are also responsible for trying to chase down family, friends and other people at risk. The Centre for Disease Control usually only provides advice and guidance to healthcare staff in this situation. If an outbreak becomes sufficiently severe or is considered a federal matter then it becomes more actively involved.

The US system is highly fragmented, with little joined-up oversight for public health matters. It is clear that issuing guidance is insufficient in these matters and waiting for a full outbreak of Ebola to occur is an extremely dangerous outcome. There is much uncertainty of the legal role of the CDC in isolating and quarantining people at risk of spreading disease on a local state or hospital level. Tackling Ebola requires certainty, not indecision. It would be a tragedy for the US to have to suffer a full-scale outbreak to clarify the role and responsibilities of its public health bodies.

Historically the UK has had a strong public health system and good procedures in place between the government, NHS and other public health bodies to effectively manage disease outbreaks. The Health Protection Agency (HPA) was previously responsible for controlling infectious diseases. Under health protection legislation, regional Health Protection Teams undertook contact tracing for notifiable infections diseases (including Ebola), providing advice direct to hospitals and coordinating action with local authorities on the exclusion and isolation of patients and their contacts. There were clear lines of decision making, shared protocols and agreed ways of working across 3 organisations: national government, local government and the NHS. It was efficient, effective and robust.

However, two recent changes are putting this protection seriously at risk. Both are related to the Health and Social Care Act (HSCA) 2012.

Last year the Health Protection Agency was reformed into a new organisation called Public Health England (PHE). Having then spent 18 months stabilising after the massive disruption caused by the NHS reforms, the coalition Government has decided to cut the Public Health England budget by 16 per cent next year, shaving a staggering £65 million from a budget of £400 million.

This will inevitably reduce the level of service Public Health England is able to provide and is likely to result in the loss of a large number of expert staff. This also risks losing the priceless knowledge of personal contacts and professional networks across an increasingly complex health system. There have been no detailed plans of how these savings will be made, but with such large cuts required, it’s likely to be highly damaging to the organisation.

The second is the increase in the role of market forces in determining what health services are available in England, which was enshrined in the Health and Social Care Act. In order to package off chunks of NHS services to be tendered out through the process of commissioning, the number of organisations, both public and private, operating within the NHS is increasing substantially.

With NHS 111 services being run by Harmoni, GP Services by The Practice PLC, local out of hours services by Serco, Urgent Care Centres by Virgin or Hospitals being run by Circle, this fragmentation inevitably weakens the public health system. The more provider organisations there are, the more difficult it is to control the spread of infectious disease, as evidenced by the difficulties faces in the US. This is particularly true where private sector groups take over providing NHS services. With a focus on profit, they are more likely to only be providing one specific service and less concerned with system-wide problems, like unexpected outbreaks of communicable disease. It is unclear what role Public Health England will have in interacting with private sector organisations and whether the lines of reporting and disease control will remain in their current form.

Cutting Public Health England while it is trying to get to grips with interacting across an ever-increasing number of organisations is a dangerous backward step. There must be a clear line of sight and procedure of command to tackle a threat like Ebola – confusion and uncertainty results in the situation we have seen this week in the US. The UK Government would be mindful to learn from this example and reverse its damaging decision to cut and fragment the public health system, which puts the health of the British population at risk.