Were Hospital Listeria Deaths Due to Public Health 'Chaos'? 

Tim Locke

August 23, 2019

Eighteen deaths from listeria and streptococcus outbreaks could have been due to 'systematic failures' in England's public health system, according to a former health chief.

The cases relate to listeria linked to an external catering company's hospital sandwiches and, separately, the spread of group A streptococcus in mid-Essex.

Public Health England (PHE) has refuted the claims by independent public health consultant Prof John Ashton, published today in the Journal of the Royal Society of Medicine .

The Department for Health and Social Care (DHSC) hasn’t responded directly to criticisms of the structure of the public health system in England, but it has announced a review of hospital food safety and quality.

Were Structural Changes to Blame?

Prof Ashton used to be in charge of public health for the North West of England. He argues that reorganisation of public health 6 years ago at national and local levels allowed a confused picture to develop as listeria cases began to be reported.

He believes that lessons have not been learned from two major outbreaks of salmonella and legionella in the mid-1980s that also resulted in multiple deaths.

Prof Ashton told Medscape News UK the public health changes were not evaluated before they were implemented: "Not at all. It was chaotic. It was part of an overall chaotic set of measures from [former Health Secretary] Andrew Lansley.

"None of it was thought through properly and the arrangements of public health in England were very chaotic."

Before the reorganisation, he said: "We had a system that had national, regional, and local dimensions to it. There's been a centralisation of function.

"The situation that had existed since the Second World War had a very strong regional structure based on the civil defence regions, the same footprint the NHS was established on – and it worked."

Prof Ashton described how he would have had trouble doing his old job under the new system: "I was a regional director for 13 years for the North West of England. And we provided local leadership to the districts and to the citizens. They scrapped all that. What you've got now is four so-called regional directors, who are really civil servants, and whose primary loyalty is to ministers rather than to the populations that they serve. So inward looking rather than outward looking.

"The resources have been whittled away locally, and they have been centralising them into London and the South East."

He is critical of the shift away from local accountability: "There's a vanity project going on, which the general public doesn't know about, which is to build this big national centre at Harlow [Essex].

"That's likely to suck-in all the specialist expertise from around the country. I think that will undermine resilience even further, because having strong specialist expertise in each of the original regions gives you a resilience if you've got problems.

"We've now got this sort of parallel structure where you've got Public Health England, which employs people on a national footprint, and then you've got the local authority public health departments."

The new structures, he said, can make public health officials powerless to carry out their jobs: "In quite a large number of places the director of public health is actually line managed by the director of adult social care, which is bizarre. Public health involves just about everything that goes on in a community and the director of public health needs to influence policies in all areas: education, schools, economics, community, community development, as well as the clinical side.

"They've created a situation where the independence of the local director of public health has been compromised. They don't have access to the media to talk about things the way I did when I was a local director of public health. And the independence of the annual report of the director of public health is itself being called into question. They're often regarded as producing a report which is a corporate report, rather than an independent report on the state of public health in the district, and being unable to report on uncomfortable truths."

Non-Medical Workforce

Prof Ashton also described dilution of clinical expertise in public health: "We have a multi-disciplinary workforce in public health. To be a director of public health now, you don't have to be a doctor, but you have to have completed a 5 year postgraduate training, which is the same for medics and non-medics. But the salary structure is completely different. If you're doing the same job, if you haven't got a medical degree, you can be earning £30-40,000 less than if you've got a medical degree.

"The medics have been drifting away from local governments, because the local authorities are not willing to pay clinically-related salaries. So you've got a non-medical workforce, predominantly, in local authority public health departments.

"The clinical expertise has been shifting over to Public Health England, and the linkages between local public health and the National Health Service have become really weak."

He's also concerned about territorial issues: "Over the last 30 years, a number of functions have been nationalised, if you will. Food hygiene is another example of that. There's a national Food Standards Agency now, whereas food standards would have been managed in the past by local authorities.

"In a sense, the national public health bodies: Public Health England itself, the food hygiene people, and others, have claimed territory they can't occupy because they're not close enough to the ground.

"The local level isn't integrated the way it was until 2013. So it's a mess basically."

Prof Ashton believes a lack of independence in public health has interfered with public health messages: "They made decisions and policy pronouncements on a number of things which would be highly controversial among public health specialists. The report they produced on e-cigarettes claimed that e-cigarettes are 95% safer than cigarettes, which is a degree of certainty that is difficult to support scientifically.

"The advice they gave on food, with regard to sugary drinks at first, was very wishy-washy and very much seemed to be in the hands of the drink manufacturers. They prefer to go down this voluntary route of the so-called Responsibility Deal, which hasn't worked. We were telling them that.

"The report they published on fracking was very much leaning towards the position that the Government wanted it to take."

He cites the need for changes in NHS health checks as an example of where public health expertise was ignored: "For 6 years, we public health specialists have been telling them that this is a waste of money to do health checks, that you're better off using resources in other ways.

"They don't have independence from Government. They're neither fish nor fowl; they're too close to Government, and so they tend to say things that are comfortable to Government. But they've left [the] Government exposed in this particular set of circumstances, with the food [poisoning] and the wound infections, the Government's not being well served by them.

"But [it's] at the same time as them being too close to Government, so neither one thing or the other, really."

Unintended Consequences or Predictable Problems?

"I think quite a lot of it was predictable," Prof Ashton told us. "Quite a few of us were saying these things from the beginning. When I was president of the UK Faculty of Public Health, I was saying some of these things, and I made myself very unpopular with Public Health England for saying them, and criticising them for not supporting adequately local public health directors.

"I think we anticipated some of this. But it's when you get these very specific examples, resulting in the deaths of these people, that you can see the system hasn't worked the way it should have done.

"It's ironic because it's full circle, 31 years after Donald Acheson [the former chief medical officer] had to review similar weaknesses from the previous large scale reorganisation that took place in 1974."

What Would It Take to Put Things Right? 

"We should have learned by now just throwing all the cards up in the air isn't a good thing," he said.

 "You lose lots of corporate memory. The best people tend to take retirement packages and then get a job again somewhere else. It's a mess when you do that. We've got to reshape it and strengthen it.

"Some of this is about the way in which Public Health England is set up nationally. I think it needs a proper robust board. It is like a 'reference board' rather than a proper management board.

"It's silent. You'd be hard pressed to find any reportage of what the board of Public Health England has ever said, or done, or advised.

"The appointments of local directors of public health, they need to be joint appointments with Public Health England, instead of having these two parallel structures.

"There needs to be proper accountability to parliament. The health Select Committee did have a look at Public Health England a couple of years after 2013 and was critical, and said that really they had the scope to be more of an independent body and they hadn't used the powers that were written into their constitution. Those things need to be drawn to attention.

"But the issue of local resources is important because the public health budgets have been whittled down and also raided by local authorities."

Vaccination and Screening

The UK has just lost its measles-free status, and Prof Ashton said vaccination issues are also rooted in public health issues: "Deterioration in vaccination coverage, deterioration in screening programmes, these are because local authorities haven't given the local directors sufficient authority and sufficient resource to be able to do what they should be doing.

"In 2010, the Health Protection Agency [that preceded PHE] published a document which spelled out greater freedom and independence for local directors of public health. But it's not been implemented. It needs to be strengthened again. They should have direct access to the leader of the city or borough council. And they should have direct access to the chief executive, which they don't in many cases. They have to go through a director of adult social care, as a second or third tier officer.

"Their role, and status, and influence, has been greatly watered down. The tradition of public health in England, going back to the 1840s, was these figures who had a great deal of authority and influence over what went on across the borough.

"It's been described as public health being reduced to a box in the town hall cellar."

Prof Ashton recalls getting safety measures implemented sooner in the Mersey Tunnel, and holding a water company to account over cases of cryptosporidium: "When I was a director, I was proactive, keeping ahead of the game, and holding people to account when they were doing things that would threaten the public health.

"A lot of directors of public health just aren't allowed to do the sort of thing I did then. They've become local bureaucrats."

Genome Sequencing, Better Hospital Food

PHE countered Prof Ashton's criticism, saying its technology and expertise helped save lives.

Dr Nick Phin, deputy director, national infections service, said in a statement: "PHE rapidly identified the extent and source of the recent listeria outbreak, using whole genome sequencing, which undoubtedly saved lives. The public health system works 24/7 to keep the country safe from infectious disease and other hazards to health."

Medscape News UK asked DHSC to comment on the reorganisation and structural issues raised but no comment had been received at the time of publication.

Whether by coincidence or planning, today a review of hospital food was announced by DHSC. This will address nutritional standards as well as food safety concerns.

DHSC said in a statement: "The review follows the deaths of six people linked to an outbreak of listeria in contaminated food earlier this year. It aims to improve public confidence in hospital food by setting out clear ambitions for delivering high-quality food to patients and the public."

One outcome could be more food produced in hospitals' own kitchens for patients and staff rather than being bought-in. Great British Bake Off judge Prue Leith will act as a high profile advisor to the review.

Hospital and community deaths from listeria and streptococcus reveal weaknesses in public health – here we go again! ( DOI: 10.1177/0141076819866087 ) Friday 23rd August 2019.

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