As ICSs bed in, how are public health and population health leadership collaborating?

One of the core strategic aims of Integrated care systems (ICSs) is to ‘improve outcomes in population health and health care’. To support that aim, new leaders are emerging within ICSs. Job titles vary; integrated care boards (ICBs) are establishing new roles such as director of population health or director of population health management, sometimes with ‘and health inequalities’ appended. Comparable roles, such as health inequality leads, are emerging at place level.

It is vital that systems work out how new population health leaders can work effectively alongside directors of public health and others in local government. But to ensure this happens, population health and public health leaders (alongside wider invested parties) need to tackle questions about how they can work together to improve services rather than duplicate each other’s work, and how leaders, and associated workforces, negotiate the imprecise boundaries between roles and responsibilities.

In work currently under way at The King’s Fund, supported by the Health Foundation, we are hearing very different views on whether or not the emergence of population health leadership, in whatever guise, represents a positive opportunity. We have been discussing this with groups of population health and public health leaders, as well as hearing from leaders collaborating across functions at different scales (region, ICS and local authority) about how it is working in practice.

Some people we’ve talked to see the opportunity for collaboration and working towards common goals, whereas, for others, the introduction of ‘population health’ is a direct challenge to established public health systems that have proven their effectiveness. Still others focus on the novel contribution that population health approaches can bring: for example, the intensive data-led approaches of population health management, or the capacity to bridge the gap between NHS and local government systems.

'New population health leaders have a nuanced understanding of their roles and how they fit within local structures and so are seeking to complement rather than substitute or duplicate the work of public health leaders'

When we’ve talked about how different roles and responsibilities should be organised, people have tended to foreground tensions and potential pitfalls over more-optimistic visions of co-operation and collaboration. However, where discussion has been about the operation of a specific system or place, people have focused almost exclusively on how population health and public health are working together effectively for mutual benefit. New population health leaders have a nuanced understanding of their roles and how they fit within local structures and so are seeking to complement rather than substitute or duplicate the work of public health leaders, often acting as a bridge between ICS partners that are working to improve the health of the public.

But roles and relationships are still evolving and participants raised some issues they are experiencing. First, there are considerable public health workforce shortages. While a new population health workforce might alleviate the consequences of some of those shortages, it also creates competition for staff among existing leaders and in the public health training pipeline.

Second, directors of public health can see tying their statutory responsibility for delivering public health services for their populations to the NHS focus on population health, which some fear may be a transitory and passing interest, as risky. As such, it is not surprising to see them express some caution regarding change and rebalancing of powers and responsibilities. Third, notwithstanding this ‘risk’, there is still much for population health and public health workforces to do to understand the scope and mapping of functions, roles and capabilities between an ICS focus on population health and a local government-led focus on public health. For example, how population health management and its data-driven identification of specific population targets for intervention connects with the intelligence and insight from joint strategic needs assessments; and where the NHS’s greater interest in communities and health meets local government’s insight into and knowledge of local communities.

Even where leaders have negotiated this sort of systemic issue and population health and public health collaboration is working in practice, leaders and associated workforces still need to work through apparently obvious practical matters related to definitions, approaches and responsibilities to avoid confusion and duplication. For example, we heard different applications of the term ‘population health’, which often underpinned the disagreements about how population health and public health functions fit together. And population health leaders, particularly, reflected on being brought into matters and asked to attend meetings outside their remit.

'As time progresses, public health and population health leaders need to develop trusted relationships and common understandings to improve ways of working, to reduce any duplication or confusion over roles and priorities.'

Doing ‘the mapping’ is therefore a key activity for public health and population health leaders; some areas have done this very explicitly and it is serving them well. As time progresses, public health and population health leaders need to develop trusted relationships and common understandings to improve ways of working, to reduce any duplication or confusion over roles and priorities.

It remains to be seen whether these issues are simply the teething problems of ICSs grappling with new roles and seeking to develop the leadership to take their population health principles seriously, or whether they will have more fundamental impacts on the organisation of population health and public health. We will have more to say on this as our project unfolds.

However, it is already clear that the future for public and population health leadership is there to be shaped, even if it is less clear how roles will develop and functions will fit together. At a time when cost-of-living pressures are worsening health inequalities, and financial pressures are making it harder for the health and care system to respond to growing need, it is more vital than ever that there is a strong and effective public health and population health system, with a cohesive approach where engaged and effective public health and population health leaders work together.