A call for a truly integrated public health function providing leadership and expertise nationally, regionally and locally within the NHS, local authorities, and local and national government
As the covid-19 pandemic continues to unfold globally, with its severe impact on all societies and particularly the most disadvantaged, public health systems and infrastructures are under scrutiny. We reflect on what direction public health should be taking in the UK and specifically England. The rhetoric used by current politicians about for the need for reform is not new and we urge them to learn from the past.
We have some differing views on the place of public health, but all agree that “function”—improving population health and wellbeing, reducing inequalities, and integrating community and health and social care services—should drive structure. And we all agree that public health is reaping what was sown in earlier decades.
How did we get to a position of fragmented and dysfunctional systems for health and social care?
The NHS—and until 2012 public health within it—has not escaped the extraordinary British infrastructure reorganisation “disease”, described as multiple re-(dis)organisations. It happened again in August 2020, with the sudden replacement of Public Health England by the new National Institute for Health Protection.
By the Health and Social Care Act, almost a decade ago, it was already apparent that the earlier leadership roles of public health within the NHS had changed profoundly. Sixty years ago, it was recognised that there should be one administrative focal point for health in a population. The public health discipline and training provided the backbone for the NHS from this point—to drive, argue for, assess, and evaluate the evidence to improve health, organise healthcare and “hold the ring” for local, regional, and national services and populations. This covered all aspects of “organised efforts to improve health,” from investigations of disease outbreaks, local disease, and health patterns to researching evidence and developing whole systems most appropriate to particular populations.
As re-disorganisations moved public health successively into new homes, its leadership roles, power and voice became weaker and weaker. And with public health’s final removal from the NHS through the Health and Social Care Act, warnings that this heralded a further damaging disintegration of the health service were too easily ignored. The NHS now lacked the very profession and skills whose purpose is the “organised efforts of society to improve health.”
The loss of public health expertise among NHS leadership, and a progressive disconnect between the NHS and social care, has created huge problems. Services that functioned well across these infrastructures were torn apart in ideological re-(dis)organisations. Bringing them back together—with current discussions and any new proposals welcome—should follow the guiding principle of structures following function.
Speaking truth to power has been seriously inhibited by the way in which public health now sits within the system. Its critical role of providing independent advice on the health of the population has been eroded, and its practitioners and leaders cannot speak out where it might not be in the political interest (national, regional or local) to do so.
The re-(dis)organisation of NHS and public health services has created many examples of chaotic fragmentation.
- Sexual health: fragmented structures over the past 15 years have made it impossible to develop coordinated services. This has adversely affected access to contraception, managing multi-drug resistant gonorrhoea and sexual health services for people with HIV or at risk of HIV. This culminated in a legal fight over which government body would be responsible for funding PreP (pre-exposure prophylaxis).
- Smoking: fragmented and patchy commissioning has reduced both access to community smoking cessation services and their effectiveness. There have been inconsistent, diverse policies and funding models, plus frequent changes in the role of community pharmacists.
- Liver disease: clinical services are siloed and lack integration with community services and hepatology on prevention of liver disease. An integrated approach needs to include health and social care, as well as policy development and behaviour change interventions to address key causes of liver disease (alcohol, obesity, viral hepatitis).
The shift of public health to local government is still supported by many, but the lack of adequate powers and investment has seriously inhibited the workforce’s ability to function and influence outcomes. Evidence over the years from the UK, and globally, confirms that public service infrastructures need to be enduring and led by people who are committed to them for the long term.
If we are to avoid repeating the past, we need a new and bold vision that extends beyond the National Institute of Health Protection (which is but one function of public health).
We must restore the public function of independent advice and recreate empowered leadership roles for public health within the NHS. These should work alongside similarly empowered and secure leadership roles in local authorities and intermediate structures serving larger populations. And public health leaders should be supported by appropriate skilled capacity for now and the future, with the right function in the right place. If this does not happen, we contend that the population, and taxpayers, will be continue to be short changed, getting less overall benefit, and indeed poor value, from major investments in healthcare and beyond.
As a result of the harsh realities exposed by the current pandemic for our national infrastructures we now have a clear opportunity to reshape how we organise public health, recognising its diversity. What would Big and Different look like? We call on this government, and its future incarnations, to move beyond the contract with the public for the NHS as an illness provider and security net to a partnership with the peoples of this country to sustain and improve our and future generations’ health. We argue for a contract that commits our political leaders to coming out of the pandemic with a long-term accountable eye to whole population health, wellbeing, and sustainability. We must seize this moment to create health and economic models that have the health and wellbeing of future populations at the heart of all policies.
Perhaps we can finally learn from the past, look at where we are and work towards a radical and bold approach that embeds research. Unlike the past, we can evaluate and test over the months and years to come working as a whole system. We urge those with power in the current reorganisations to heed our voices.
Carol Brayne, Professor of Public Health Medicine in the Department of Public Health and Primary Care in the University of Cambridge, UK.
Matt Hickman, Professor in Public Health and Epidemiology, University of Bristol, UK.
Competing interests: None declared.
Acknowledgements to SIPHIG members active contributions: Iain Buchan, Rona Campbell, Andrew Hayward, Irene Higginson, Debbie Lawlor, Susan Michie, Stephen Peckham, Rosalind Raine, Robert Stewart, William Rosenberg, Judith Stephenson, Helen Ward, Robert Walton, Richard Watts on behalf of the NIHR Senior Investigators Public Health Interest Group. This article represents the views of the authors, and not NIHR.