{"id":48661,"date":"2020-09-28T18:27:45","date_gmt":"2020-09-28T17:27:45","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=48661"},"modified":"2020-09-30T11:24:11","modified_gmt":"2020-09-30T10:24:11","slug":"building-back-better-for-population-health-and-wellbeing","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2020\/09\/28\/building-back-better-for-population-health-and-wellbeing\/","title":{"rendered":"Building back better for population health and wellbeing"},"content":{"rendered":"

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<\/p>\n

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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 <\/span>scrutiny<\/span><\/a>. 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.\u00a0<\/span><\/p>\n

We have some differing views on the place of public health, but all agree that “function”\u2014improving population health and wellbeing, reducing inequalities, and integrating community and health and social care services\u2014should drive structure. And we all agree that public health is reaping what was sown in earlier decades.\u00a0<\/span><\/p>\n

How did we get to a position of fragmented and dysfunctional systems for health and social care?\u00a0\u00a0\u00a0\u00a0<\/span><\/p>\n

The NHS\u2014and until 2012 public health within it\u2014has not escaped the extraordinary British infrastructure reorganisation “disease”, described as <\/span>multiple re-(dis)organisations<\/span><\/a>. It happened again in August 2020, with the sudden replacement of Public Health England by the new National Institute for Health Protection.\u00a0<\/span><\/p>\n

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 <\/span>focal point<\/span><\/a> for health in a population. The public health discipline and training provided the backbone for the NHS from this point\u2014to 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.\u00a0<\/span><\/p>\n

As re-disorganisations moved public health successively into new homes, its leadership roles, power and voice became weaker and weaker. And with public health\u2019s 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 <\/span>ignored<\/span><\/a>. The NHS now lacked the very profession and skills whose purpose is the “organised efforts of society to improve health.”\u00a0\u00a0<\/span><\/p>\n

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\u2014with current discussions and any new proposals welcome\u2014should follow the guiding principle of structures following function.\u00a0<\/span><\/p>\n

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.\u00a0<\/span><\/p>\n

The re-(dis)organisation of NHS and public health services has created many examples of chaotic fragmentation.<\/span><\/p>\n