The mistake we don't have to repeat from the 2013 NHS reforms

England lost public health from the NHS in 2013 through misjudgement and poor specification. The next generation of NHS architecture is being designed now. We don't have to make the same mistake again. 

Ask anyone who lived through the 2013 NHS reforms what changed. Most start with the structural list: the introduction of the Health and Social Care Act, the dissolution of primary care trusts, the creation of clinical commissioning groups, and the movement of public health out of the NHS and into local authorities. But, however well intentioned, they triggered a quieter shift. Moving public health functions to local government shouldn't have stripped the NHS of its population health expertise; yet it did. Crucially, that loss was a serious misjudgement, compounded by poor specification: the function was never named, so it was never protected. 

The transfer worked for local government. Public health teams there have built something durable and locally accountable, doing work nobody else does. Inside the NHS, though, an entire layer of specialist expertise quietly faded. The ‘core offer’ – a requirement for local authority directors of public health to provide advice to NHS organisations – was designed to bridge that gap, and where it works, it works well. But the conditions it was built for have shifted. Local authority budgets have been squeezed, and the number of NHS organisations doing the asking keep multiplying. 

Thirteen years later, NHS policy is full of population health language: ‘prevention’ is in the 10 Year Health Plan. ‘Inequalities’ are in the Model ICB Blueprint. ‘Neighbourhood health’ shifts care closer to home. Our new report commissioned by the Faculty of Public Health and the Association of Directors of Public Health, reviewed 21 of the most important current operational and structural documents. None of them specifies that accredited public health specialists should be doing this work.

The NHS doesn't expect surgical outcomes from a generically trained workforce. It expects named, regulated professionals. Population health is no different. Where accredited expertise is in the room, the system makes better calls about pathway design, prioritisation and resource allocation. Where it isn't, the cost lands on patients. We saw that cost in the pandemic: with public health cut off from the full resources of the NHS, unlike in 2009, the early Covid-19 response was confused and missing capacity. 

Why this isn't the NHS 2013 reforms in reverse 

It would be easy to read what we're saying as a call to undo the 2013 reforms. It isn't. Directors of public health should remain the statutory leadership anchor at place; their teams are essential and stretched. The argument we're making is the opposite of substitution. The NHS needs its own complementary capability working alongside local government, not extracted from it. Reciprocity, not handoff. 

Some systems already do this. Our report found integrated care boards (ICBs) are co-funding consultant posts with local authorities, providers are embedding accredited consultants into inclusion health and elective recovery, and combined authorities are running hybrid roles across NHS and council settings. None of this is easy, but done right, it can support integration of functions and services. 

The mistake we keep close to repeating 

The pattern of 2013 wasn't deliberate. Nobody set out to weaken public health inside the NHS. What happened was structural: functions that needed naming, governing and funding weren't. The workforce dispersed. Some moved to the local authority, some were reassigned, and others quietly took on broader roles. That kind of loss is hard to see at the time, and it shows up only in hindsight. 

We risk repeating it now because architecture designed under pressure defaults to what is specified. This time, we can specify it.

Three things to do next

First, the accredited public health workforce must be explicitly embedded within NHS decision-making. These specialists, who are directly accountable for population outcomes, need a seat at the table across England’s major healthcare structures, from ICB executive teams to newly forming integrated health organisations and in the design of neighbourhood health. 

Second, build on the core offer as a partnership model. It was designed to be more than transactional and treating it as a basis for reciprocity is the next step we can take together. 

Third, adopt the Faculty of Public Health's March 2026 statement on professional standards as the benchmark for senior public health appointments across the NHS, local government and combined authorities.

Not by chance 

If we want the next NHS to deliver on population health, we need to be clearer about who actually does that work. 

By design, not by chance. 

The 2013 lesson is visible now, and just as easy to miss again as the system rewrites itself under strain. The next 12 months are our shared chance to match the language of population health with the workforce designed to deliver it.