Moving into the public health system of the future while learning from the past: lessons from London

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London is a diverse, dynamic and truly global city. Before the Covid-19 pandemic, work was already under way to improve the population’s health and address health inequalities, including through the mayor’s statutory health inequalities strategy. Despite this work, the Covid-19 pandemic struck London hard, and health and care organisations and services had to quickly adapt to work more closely together, collaborating across sectors, disciplines and areas in a way that they had not done before.  

Between October 2021 and February 2022, London’s public health ‘family’ – senior representatives from the Office of Health Improvement and Disparities, UK Health Security Agency, Greater London Authority, NHS London, Local Authorities, ADPH London, ICSs and academia – and its key partners, supported by The King’s Fund, undertook work to learn from the experiences of the Covid-19 pandemic. The aim was to apply this learning to addressing the long-term impact of Covid-19; tackling health inequalities; and building readiness for future health threats. This work was undertaken with the acknowledgement that it needs to take place in a complex and evolving context; the public health system has undergone major structural change with the creation of the Office for Health Inequalities and Disparities and the UK Health Security Agency.

So what has been learned through this process in London? And what could be relevant to other systems and parts of the country reflecting on Covid-19 and facing the same organisational changes? 

Success is driven by common goals and shared understanding, more than governance or technical solutions...

First, is that success is driven by common goals and shared understanding, more than governance or technical solutions, such as streamlined data sharing arrangements. London developed a set of shared leadership principles that were explicitly co-produced, named and agreed by leaders. These centred around 15 agreed ‘I will’ behaviours and principles relating to individual roles (eg, … use my unique position, power and influence for city-wide objectives), their organisation (eg, ... help my organisation to work more with communities and through equality, diversity and inclusion) and work with partners (eg, ... work with the public health family to promote a system mindset and to relentlessly focus on health inequalities at all levels), with a commitment to sustaining them over time (eg, ... by helping power flow to where it’s most needed, working with communities, speaking up about equality, diversity and inclusion).     

Second, to make real progress on inequalities there needs to be a relationship between the public health family and local communities. In London, there was an understandable worry among communities and the leaders we worked with that public sector bodies would not maintain a community focus. Local partnerships will need to address this if impetus and trust are not to be lost. 

Third, was how the Office for Health Improvement and Disparities will take up its role and how this relates to the rest of the system. The role of the regional and sub-regional bodies will be even more important in the new health and care system, as integrated care systems (ICSs) take shape. London leaders spent time developing consensus on what the system wanted from the Office for Health Improvement and Disparities in London, particularly given its unique role in sharing insight, supporting best practice, and managing data and intelligence flows between bodies and sectors. 

Fourth, public health expertise is scarce, in London and elsewhere. This means that expertise needs to be applied creatively for the benefit of the wider system, wherever it happens to sit in terms of organisational ownership (be that at regional level, sub-regionally, at ICS level or within local authority footprints). Developing the right behaviours and principles is a way to identify how to use this resource effectively but only if they are adhered to as systems change.   

Being part of the public health family, recognising common bonds and shared purpose, shared expertise and joint effort was critical to the response to the Covid-19 pandemic.

Fifth, the metaphor and language of ‘family’ was seen as really important, particularly in an ever-changing, complex system, where people are the constant but roles, organisations and boundaries shift. Being part of the public health family, recognising common bonds and shared purpose, shared expertise and joint effort was critical to the response to the Covid-19 pandemic. But these will also be crucial in facing the challenges of the future, in a way that creates belonging and transcends the language of place, organisation and system. 

This work is only the start of the process. In London, there will be wider engagement and ongoing conversations across and within the public health family and its partners. Similar conversations will be happening in health and care system across the country as structures change and services emerge from the Covid-19 pandemic to face new challenges. The experience and approach in London is not a template to follow but may provide insight for others to learn from. 

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