What we think
Although before the pandemic most people were living longer than ever before, England faced significant public health challenges. Improvements in life expectancy were stalling, health inequalities had widened and we compared poorly with other countries on many key health outcomes.
Government funding for local authority public health budgets has been substantially cut since 2015/16. Even with more recent uplifts in cash terms, the public health grant in 2021/22 was 24 per cent, or £1 billion, lower per head in real terms compared to 2015/16. This has led to reductions in vital services such as health visiting, stop smoking support and sexual health clinics, putting people at risk of poorer health and storing up problems for the future. This is reflected in performance against some key public health indicators. For example, in recent years, cases of some sexually transmitted infections have risen and the number of drug-related deaths has increased significantly.
A much higher priority should be given to promoting wellbeing and preventing ill health. A number of national government and NHS strategies have promised this over the years but all have fallen short of the scale and ambition needed. The current government's Build Back Better plan is the latest to promise this, stating that the 'long term priority remains shifting the NHS towards prevention'.
The development of integrated care systems is an opportunity to focus on improving population health by increasing partnership-working between the NHS, local authorities and the voluntary and community sector. As our research shows, directors of public health played a crucial role in leading the response to Covid-19 locally and could play a pivotal role in improving population health as the country emerges from the pandemic.
However, as with all parts of the health and care workforce, directors of public health and the wider public health workforce are in short supply and are exhausted from the pandemic response.
At the same time government’s decision to dismantle Public Health England and replace it with two new bodies, the United Kingdom Health Security Agency and the Office for Health Improvement and Disparities increases complexity locally and nationally; all agencies will need to work hard to collaborate and provide an integrated approach to public health.
The establishment of Office for Health Improvement and Disparities is an opportunity to bring a public health approach to wider government policy. To do so it will need to work hard to get traction with other government departments, bring a stronger accountability for the impact of cross-government policy on the public’s health and develop a cross-government health inequalities strategy. As part of this, the government should adopt a bolder approach to using tax and regulation, learning from successful interventions such as the measures taken to reduce smoking and from the Soft Drinks Industry Levy.
Rates of smoking remain high among some groups, levels of obesity are among the worst in western Europe and rates of harmful alcohol consumption, which were already high, have risen during the pandemic. Around 40 per cent of premature mortality in the UK is caused by preventable conditions such as cardiovascular disease, diabetes and cancer. We know that preventive public health services such as smoking cessation, weight management and sexual health services are essential to help avert the onset of disease, improve people’s quality of life and reduce health inequalities.
In 2013, local authorities were given new legal responsibilities for improving and protecting the health of their local population, moving responsibility and accountability for many public health services to local government, while Public Health England was created to support the public health system and protect the public against major health risks. Local authorities were given responsibility for ensuring provision of a range of public health services previously provided by the NHS, including most sexual health, smoking cessation and substance abuse services, as well as wider health protection work such as protection from outbreaks of infectious disease.
In August 2020 the government announced a major re-organisation of the public health system. The changes create two new bodies, the United Kingdom Health Security Agency which focuses on health protection, including responding to pandemics, and an Office for Health Improvement and Disparities which will have a cross-government remit for improving health and reducing health inequalities. As a result, Public Health England has been disbanded.
Under the changes, local authorities continue to remain primarily responsible for local public health services. The Department of Health and Social Care pays the public health grant to local authorities so that they can deliver these services. However, between 2015/16 and 2019/20 the grant was squeezed substantially, since then it has been maintained at the same level in real terms, and in 2021/22 the public health grant was 24 per cent lower in real terms compared to 2015/16. Wider reductions in local authority budgets since 2010/11 have also had an impact on services that support the health and wellbeing of the whole community - such as housing, transport, leisure centres and green spaces.
NHS England and NHS Improvement also receives a ringfenced budget of around £1.3 billion per year to commission public health services such as immunisation and screening, though the cost of the Covid-19 vaccination scheme has meant the ringfence has been temporarily lifted. In 2019/20 Public Health England had a budget of £900 million to fund their core public health responsibilities.