How influential is public health within local health systems?

The 2020s have been a tumultuous decade for public health so far.

The Covid-19 pandemic generated a huge amount of interest in public health, both across society and within the NHS and local government. Besides being an incredibly intense period for directors of public health (DPHs), it was also one that saw a marked increase in their influence as leaders within local authorities and the NHS. Indeed, many DPHs interviewed by The King’s Fund at the time reported that the role they played in guiding and shaping local responses, and the new relationships they had formed both inside local government and beyond, had given them a new profile as a group coming out of the crisis.

This upsurge of interest in public health was further cemented by the creation of integrated care systems (ICSs). Upon their creation as statutory bodies in 2022, these new bodies were given the task of tackling inequalities in health outcomes, experience and access, and have a duty to consider the effects of all their decisions against this. This focus on health inequalities created an opportunity for public health – and the proliferation of roles in population health within these new ICSs has only strengthened this.

The extent to which public and population health are similar as concepts – in practice and in terms of the skills of who ‘does them’ – is contested. Some view them as essentially synonymous, while others emphasise the differences that exist, both in the goals and methods, between these two professional groups. What is clear is that, at least in theory, ICSs should have been systems that built on that uptick in interest in public health that came out of the pandemic.

But how has that played out in practice?

Some answers are emerging in a new project from The King’s Fund, supported by The Health Foundation, that is exploring the state of public health and population health leadership, the challenges being faced, and the potential for improvement in the coming years.

The interviews we are conducting with DPHs and other leaders across local government and the NHS are presenting a complicated picture. In local government, that initial surge of influence that most DPHs experienced has now evolved very differently from place to place. In some councils, their influence has been retained and DPHs are enjoying a permanent shift in their status. In other areas, the exceptional period of the pandemic has receded, and DPHs are now back to where they were before, as crises around children and adult social care get more attention. In a few further instances, perhaps more worryingly, DPHs report being pigeonholed into a role of someone you turn to in a crisis (as with Covid), whose influence is therefore more limited during ‘normal’ times.

These varied experiences for public health leaders are mirrored within ICSs. ICSs are trying to give their duties around population health and health inequalities the time and attention they deserve. However, their ability to do this in practice faces some significant challenges that are acting as a stall on progress in many areas.

Integrated care board (ICB) leaders we’ve spoken to report that the various, overlapping crises that the NHS is experiencing mean that the pressures they experience from national bodies and accountability structures push them to put issues of acute care and finances first. Couple this with the context of ICBs having to make significant cuts to staffing budgets and it is becoming hard for public health and population health to achieve the prominence on ICS agendas that was envisioned when integrated care was first conceived.

Where we go from here remains up for debate . The increase in capacity – and potentially complementary capability and leadership influence – that the creation of new roles in population health has created for public and population health agendas means that there is potential for transformational work to be done over the rest of this decade. Add in the fact that according to our interviews with people in local government, many people working in areas related to the wider determinants of health (such as housing, the environment and employment) are now more aware of the health impacts of their roles since Covid-19, and the future could be incredibly bright.

However, for that positive vision to be realised, both ICSs and local government need to be given the bandwidth and resources to put public health and population health centre stage.