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Public health reform: a whole-government priority?


‘Health will no longer only be the business of the DHSC, but a core priority for the whole of government’?

The quote above is from the new policy paper ‘Transforming the public health system: reforming the public health system for the challenges of our times’, published on 29 of March; although the question mark is mine. This paper puts some more flesh on the bones of the announcement of the UK Health Security Agency and the more recently announced Office for Health Promotion, and also connects them to ambitions for the future of integrated care, as set out in the new White Paper. So what to make of it?

Although perhaps obvious, the government does see these three elements as a triumvirate which should be seen together, and that together they will transform population health. This is a noble aim, but one of the challenges in setting up two bits of new infrastructure (effectively splitting Public Health England) and establishing the future of integrated care will be to ensure that, well, it’s integrated. That needs to happen at national, regional and local level. I will come back to that.

'One of the challenges in setting up two bits of new infrastructure (effectively splitting Public Health England) and establishing the future of integrated care will be to ensure that, well, it’s integrated.'

But first, a little on the newest creation, the Office for Health Promotion. This development essentially sees most of the functions of Public Health England except health protection (with some embedded Public Health England roles in NHS England and NHS Improvement being formally transferred) moving back into the Department of Health and Social Care ‘proper’. Cynics could argue what’s the change here, given that Public Health England staff are currently civil servants, working in an executive agency of the Department, so isn’t this just taking one sticker off, and putting the former one back on? However, in my view, Public Health England has developed, built and brought together expertise as an executive agency in its short life. What is going back into the Department core, therefore, is much stronger and more coherent than what left it in 2013.

The potential impact of that expertise is huge, if it can be mobilised across government policy. That relies, a lot it seems, on the role of the Chief Medical Officer and their leadership and a new cross-government ministerial board for prevention. The trick will be how to show other government departments – that in many cases have been starved of funds while the NHS has been protected – that working more closely with the Department of Health and Social Care is in their interests too. That requires humility, the sharing of expertise (advice and support, secondments and the like) and a spirit of ‘win-wins’. The ministerial board will have to have some form of teeth. Certainly its useful to have conversations around a table about alignment of priorities, but what really matters is that the ministerial board has the power to take decisions about cross-government policies that matter for health and this is accompanied by clear accountability for the wider determinants of health. The paper says there will be such accountability, but we need to see how.

The paper also reinforces what the Secretary of State for Health and Social Care said very boldly at the recent Local Government Association/Association of Directors of Public Health Annual Public Health Conference: that he sees the recent White Paper as the mechanism for the NHS to bring all its resources and capability to the prevention agenda. This, in my view, will require stronger direction, some clearer goals (perhaps even targets) and a change in culture and incentives. This is not because those in the NHS, and leaders of emerging integrated care systems (ICSs) don’t want to do more prevention but that all the public attention, political focus, cash and funding mechanisms are still more focused on the immediate issues of acute care. Finding the bandwidth and space to move upstream and do more prevention when waiting times and care backlogs are mounting, and to do that more closely with partners including local government and the voluntary and community sector will be hard, and will need strong support from ministers. To put more flesh on the laudable ambition, more work is therefore needed, building on previous thinking, whose time has now come.

It is also important to consider what the government is intending not to change, and that includes the fundamental role for local government in public health. As we have said, the recognition of this role and the transfer of directors of public health and their teams was perhaps one of the few long-term successes of the 2012 health reforms. This paper makes clear there will be no changes to the functions of local government – that will be a relief to many. But, the corollary of this is that the government needs to fund this function well. While local government has received significant funds to tackle Covid-19, which has boosted directors of public health’s teams, the latest announcement of the baseline grant for core public health was more thin gruel, a small cash increase, running just below inflation. This was supplemented by specific funds for weight management and for drug services – welcome but non-recurrent and ring-fenced for specific purposes. The upshot is that coming out of the pandemic, local government’s core public health grant, over which it has flexibility, is still almost a quarter per capita lower in real terms than in mid 2015/16.

This is ever more important, since it’s clear that directors of public health and their teams will need to be at the heart of the future public health system. Emerging findings from our work tracking their experience during the pandemic in depth, has shown just how critical they have been, and the deep respect in which they are held. Their role seems set to be both more important and more complex. They will be at the centre of the web making these recently announced reforms work on the ground and navigating the relationship between: national, regional and local roles (at the regional level the paper signals a stronger regional public health presence, yet to be defined, but which is welcome); health promotion and health security; and integrated care systems and population health. To do that they require more funding, but also more authority and stronger teams.

'There is actually much in this paper to welcome, some things to question, and much more flesh on the bones that we still need to wait for.'

So, overall, and putting to one side the poor timing of the original announcement of these reforms, there is actually much in this paper to welcome, some things to question, and much more flesh on the bones that we still need to wait for. The government expects the formal transition of Public Health England’s functions to be complete by ‘the Autumn’. We look forward to hearing more on the issues above, and others, by then.