The recipe for success at the Office for Health Improvement and Disparities: tackling the wider determinants of health

More than a year after staff were told of its demise via a leak to the press on a Saturday night, Public Health England has now finally closed. Its functions and staff are now homed in the UK Health Security Agency, NHS England, NHS Digital and the Office for Health Improvement and Disparities (OHID) in the Department for Health and Social Care. With health inequalities already widening before the Covid-19 pandemic, and the unequal impact of the pandemic across society, the task ahead of the new OHID is considerable. What are its chances of success?

One thing is clear - the new OHID can't succeed by itself. Improving health and reducing health inequalities requires action across the wider determinants of health which means action across Whitehall, and beyond. As Jill Rutter, long-time Whitehall expert and commentator, has said the 'track record suggests that in the not-exactly-collegiate environment of Westminster, it is very hard to drive a cross- cutting agenda from a Department'. This suggests there is a steep hill for the OHID to climb if it wants to lead a genuinely transformational agenda across the wider determinants of health that recognises the role education, housing, work, clean air, open spaces and much more play in our individual and collective health and wellbeing.

Let's just briefly compare how the government is approaching health inequalities with its approach to levelling up. Far from relying on the normal Whitehall machinery, levelling up has a new (albeit temporary) Permanent Secretary reporting jointly to Michael Gove (Secretary of State for Levelling Up, Housing and Communities) and the Prime Minister and a taskforce (as opposed to the usual Cabinet Committee). Health improvement and inequalities on the other hand is firmly placed in the Department of Health and Social Care box with a ministerial board.

So, if the odds are stacked against it, how could the new OHID team better its chances of success?

Cross-government working

OHID needs a clear Whitehall engagement strategy to help other Departments see the win/win in the health improvement agenda. There are good examples in the recent past of successfully aligning the health improvement agenda to another Department’s priorities unlocking radical thinking and policy. The joint work between the Department for Environment, Farming and Rural Affairs, Public Health England and the Department of Health and Social Care on air quality is an obvious example, the Department for Transport’s efforts on active travel another. But this doesn’t happen by accident, it takes work to build the relationships, to build the capability and confidence of other Departments to understand how their policies link to health (there are not many health economists in Whitehall outside of the Department of Health and Social Care). If I add a brief note of optimism, the new Secretary of State is a seasoned Whitehall operator, having run five Departments. He knows the limits of what a single Department can deliver on its own and is looking across Whitehall – that could help set up the approach that OHID needs. And linking health improvement and health inequalities into the wider ambitions on levelling up is another chance to combine agendas to achieve impact.

Transparency and voice

Public Health England was seemingly both part of Whitehall and not part of Whitehall. That meant at times it could provide the independence and transparency of the evidence base and clarity on the action needed, and at other times it couldn’t. Straddling the dual role of being part of the machine but being seen as the independent voice for public health was not always an easy position. With OHID there is no pretence that it is independent. This brings important questions about how OHID will ensure appropriate transparency of the evidence base and a strong voice, even when what it is saying may not be welcomed by all. While this remains important for national decision-making, it is also key for supporting local decision-making. A good starting point would be to keep saying the word ‘inequalities’ and not shift to the more comfortable language of ‘disparities’, whatever its organisational title may be.

Joined-up thinking on public health

The OHID leadership team needs to learn to look up and look out at the same time – both influencing across Whitehall but also looking to regions and local areas as the leaders on the many wider determinants of health. Here, OHID has made a positive first step, with the appointment of Jeanelle de Gruchy as the Deputy Chief Medical Officer co-leading the new Office. This is a good foundation to ensure local government feels part of this agenda and is particularly critical not only because of the core role of directors of public health (DsPH) locally but also given the clear mistrust caused by an overly centralised approach to aspects of the pandemic response, which left DsPH frustrated and feeling that their role and expertise was overlooked. The experience of the past 18 months shows that DsPH can and should have a much more pivotal role post-Covid across health and care. There is also an important task for the OHID team to work with UK Health Security Agency, NHS England and NHS Digital to ensure that there is coherence and alignment across the different public health functions that have now been thrown to four different corners of the health and care system, and to support that coherence nationally, regionally and locally. Fragmented effort will make the already difficult task ahead even tougher.

Growing the workforce

A final area for focus is the workforce who will make change happen. There is a limited pool of public health consultants and directors of public health, so there is a need to determine the workforce model. How should OHID and the wider public health system use the limited expertise available now, and grow that expert pool over time? Alongside the professional expertise in public health, there is a much wider workforce available that can support local change as their roles can have a wider impact on health. The King’s Fund Leading for Population Health course has started to tap into a wide pool of people without public health in their job title, but with an enthusiasm for population health and the ability to make things better locally through their roles. To succeed, OHID must both grow the expert public health workforce and support transfer of skills to and contribution of the much wider workforce to improve population health.

The new OHID has daunting task ahead. Previous attempts at genuine cross-government working suggests it has a tough time ahead if it’s really to break out from 39 Victoria Street and make tackling health inequalities a genuinely cross-government task.