Integrated care systems (ICSs) were established to create partnerships for population health, not simply to better manage existing patterns of NHS care. In many systems, statutory status has been accompanied by the creation of director, or similar, roles with titles that include population health.
Roles intended sometimes to stimulate a reframing of work across the whole leadership team but elsewhere simply leading a standalone programme of work, often primarily analytical. How these emergent roles develop matters.
Since 2012, most public health functions have been based within local government. Directors of public health and their teams play a central role in care delivery, exert considerable influence over wider policies for health, and have a health protection role. Beyond local government, existing public health expertise sits across the system in regional UK Health Security Agency (UKHSA), and NHS and Office for Health Improvement and Disparities (OHID) teams, ICSs and local trusts and organisations. Reorganisation amid the Covid-19 pandemic has not overshadowed the outstanding community leadership public health teams have curated.
'There should be strength and mutuality in these varied roles and traditions, with new leaders for population health working alongside their peers in public health. Yet there is also the possibility of confusion, competition and disagreement on roles and expertise.'
There should be strength and mutuality in these varied roles and traditions, with new leaders for population health working alongside their peers in public health. Yet there is also the possibility of confusion, competition and disagreement on roles and expertise. The integrative thinking population health demands, and public health is founded on, will not be served by competing narratives nor an artificial division of labour where population health leaders simply work on better NHS healthcare rather than the roots of wellbeing and healthier lives.
So, if both roles are increasingly now in place, how can this synergy be achieved? It starts with simple acknowledgement of one another’s contribution, and recognition of a risk of discord. But it needs too some behavioural exchange – what each can contribute to one another.
Three specifics will help.
here is a pervasive risk that new roles and new people want to begin at the beginning. Health inequalities are longstanding but can be seen as a new focus, especially inside the NHS – to the chagrin of local government. Much is known already about interventions (for example, through NICE’s guidelines on public health), and wider practice and policy on health inequalities and population health which needs to be as prominent as NHS England’s support for population health management and core20plus5 approach to health care inequalities. That knowledge and insight is often held by public health specialists, and sharing that requires both generosity, and humility. We have been fortunate in recent months to work with systems that have been upfront and explicit about the principles and behaviours for engagement, for example, in the Midlands, Cheshire and Merseyside, London and in North-East and North Cumbria, including, in the latter, on where directors of population health and directors of public health each lead, collaborate, inform and advocate for the other.
A decade of austerity has starved local government of funding and the public health grant’s spending power has fallen. Though there are calls for more NHS funding, justified against peer comparisons and a post-covid surge of need, the NHS already holds much of the local public service resource. Population health leaders in the NHS have to become lead actors in bringing health care expenditure into play beyond the narrow confines of health care delivery, to realise the benefits of a population health approach. There is a pressing need to break the cycle of under-investing in prevention, when it is a cost-effective investment in population health. In March 2022, Sajid Javid made a commitment to at least measure prevention spend in the NHS for the first time, this idea must not be lost, and the upcoming Hewitt Review needs to give it prominence as a start in a bigger journey of change. There is clearly more to do, and a mixed picture in how integrated care board health inequalities budgets are being deployed.
Health and care integration is only one pillar of population health and there needs to be simultaneous action on the others – healthier communities, good health behaviours, and tackling wider determinants. We need concurrent creation of better health and constructive disruption. Integrated care partnerships, and their five-year strategies, may bring alignment in time. But surely we know it is relationships that make the culture that eats that strategy with ease. Mindful of that, public health expertise has to open the room to the wider local government talents of their peers and connect via population health leaders to the anchoring powers of the NHS. This is tentatively starting to happen in some areas, with a focus on poverty, exclusion and behaviour change but needs accelerating to make the most of the joint capability that exists at local and regional scale. Supporting these new collaborations needs profile and support – an ICP strategy alone is not a substitute for structured mutual learning. Public health has to evolve from the ‘doing’ of the pandemic to the capability building needed to address structural inequality.
The scale of inequalities, the significance of an ageing unhealthy population, and the need to connect health creation and wealth generation require the efforts of all in local and regional systems. Public health and population health practitioners sharing expertise, funding and adopting match-making roles can help. Though this is a local endeavour, it needs to be mirrored nationally – learning from some regional examples that have acknowledged the risk of division and want to seize the opportunity to be more than the sum of professional parts.