On the eve of Covid-19, the landscape for public health (including its relationship with the NHS) had been set by the public health (and NHS) reforms implemented in 2013. These reforms had taken directors of public health (DsPH), their teams and most public health funding out of the NHS and into local government. The King’s Fund’s assessment was that this had been the right step, as these changes placed public health teams where they could best influence the wider determinants of health, which are the real key to improving outcomes. Even before the Covid-19 pandemic, there were many areas of England where local government public health teams, and regional Public Health England teams, worked well with the NHS and the wider functions of local government within which they are based. However, one unintended consequence was that some interpreted this structure as meaning that the NHS should focus primarily on ‘treatment’ and some specific aspects of prevention (particularly services such as screening and vaccination, and those funded specifically under the section 7A grant), and that wider prevention and public health were now for ‘someone else’.
Among other things, this apparent separation led to high-profile battles over who paid for prevention. Perhaps the most notable example of this was the use of pre-exposure prophylaxis (PReP) to prevent people at risk of becoming infected with HIV. NHS England argued in court that it had 'no power' to offer preventative treatment due to reforms, but lost its case. Even as regional directors of public health joined NHS England and NHS Improvement’s regional teams, as late as the NHS Long Term Plan in 2019, the NHS contribution to public health was still primarily focused on secondary prevention and was light on primary prevention and the NHS’ contribution to broader public health aims. This separation was clear at national level, with NHS England and NHS Improvement (and other NHS national bodies) focusing on the NHS role, while Public Health England led on health protection, prevention, evidence development and supporting local government’s role.
Into this context came sustainability and transformation partnerships (STPs), created partly with the intention of bringing together the range of health and care stakeholders (including public health). However, at their outset, STPs were primarily NHS led and, despite warm words, focused on the core busines of treatment pathways and played down prevention (particularly in terms of any concrete actions) and the connection to public health. One exception to this has been the experience of Greater Manchester, through its special status as a result of its early public service devolution programme, which has included a strong focus on prevention and population health. Despite this initially troubled start, the evolution from STPs to integrated care systems (ICSs) has led them towards more genuine partnerships and a clearer objective to bring together all aspects of the wider health and care system in order to focus on improving population health. West Yorkshire and Harrogate ICS has been very active in this space, including through the launch of a health inequalities academy.
In practice, and often less visibly, many of the strongest links between public health and the NHS have been below regions and the sub-regional level of STPs and ICSs at ‘place’ level, usually based on a local government footprint. For many areas this also meant a clinical commissioning group footprint (before the wave of mergers among NHS commissioners). For many services, place level is a natural home: it brings together local government’s responsibility for social care and its influence over the wider determinants of health, and to perhaps state the obvious, it’s also where the DsPH and their teams sit and there can be no population health without public health. For the NHS, as place is much closer to local communities than the larger and more distant ICS, it is also a better planning unit for community and primary care services and indeed, some hospital services. Clearly, the public health system could and should play a key role in this evolution as it is (obviously) an essential part of improving population health.
The experience of the Covid-19 pandemic has affirmed how important the local public health system is in protecting and improving the health of the population. This central role of public health teams and of DsPH was underlined by the pandemic as local areas mobilised to control infection, reassure and support communities, and to maximise vaccination uptake, alongside NHS colleagues. This may have only been recognised by the centre after some delay, but recognised it was. Many geographies are also experiencing a step change in the depth and range of collaboration across the system as part of moving towards ICSs. It is within this more positive context for system working – however dearly brought about by the experiences of Covid-19 – that the current changes take place.
The reformed system
The reformed system is still taking shape, and it will need to work at local, regional and national level – and at the joins between the NHS and public health.
At national level, the legislation and wider policy decisions result in three separate bodies in terms of key public health service delivery: the UK Health Security Agency, the Office for Health Improvement and Disparities, and NHS England and NHS Improvement. The Department of Health and Social Care has set out where former core Public Health England functions have been distributed across these bodies. As expected UK Health Security Agency takes on health protection functions, the Office for Health Improvement and Disparities has responsibility for health improvement, wider determinants of health and inequalities, and NHS England and NHS Improvement looks after public health delivered by health care services (including vaccination, immunisation and screening). The King’s Fund has shared its views on the decision to abolish Pubic Health England but there is now a new and clear opportunity for the Office for Health Improvement and Disparities to influence other Whitehall departments on the wider determinants of health.
However, it is how this separation of public health roles and functions come together again below national level and then connect with the regional and local health and care system, including the new statutory ICSs from April 2022, that is the question most in need of answering. At region level in particular, the functions of both the NHS and public health are yet to be clearly defined. Given the importance of the regional tier to both, it will be important to ensure these are as aligned at regional level as they are at system and place. Although the detail will differ between different parts of England, what the regional tier is ‘for’ needs to be consistent, and we develop our views below.
There is some emerging clarity, but also complexity, below regional level. The clarity comes about through the alignment of local government and NHS boundaries at place for most geographies, and signals in the legislation about how public health, health and wellbeing boards and local government will relate to ICSs. This does not mean the relationship will be straightforward in all geographies, however, as the legislation leaves a lot of room for local discretion and variation.
The reforms explicitly aim to support and build on strong place-based partnerships, many of which already exist in some form. These will usually be based on a local government footprint thus enabling better integration with the range of local government services and powers, including those in public health and the role of the DPH. ICSs will have two main components: an integrated care board (ICB), and an integrated care partnership (ICP). In many geographies, NHS funding for much of primary care, community services and others best handled at place level will be delegated by the ICB (responsible for commissioning services for an ICS) to place to sit alongside local government funding. ICBs in turn will have a local authority representative on the board, and all constituent local authorities will be represented on the ICP, which will set the overarching integrated care strategy that ICBs will have to have regard to in fulfilling their role; this strategy will address health inequalities and the wider determinants that drive these inequalities. There will also be links between local plans and ICB/ICP plans and strategies. While it is still the case that much of the implementation and operation of this system is left to local leaders (whether at ICB and ICP level or at place), there should be a relatively clear connection between the public health and NHS systems at both levels, though in many cases this will be neatest at place.
National level: more players on the pitch but still the same game
The changes following the abolition of Public Health England and the creation of Office for Health Improvement and Disparities and the UK Health Security Agency leave one innovation from 2013 intact: a separation, at national level, of the bodies responsible for public health and the NHS. This is despite the clearer coming together of these functions both at place and at ICS level.
There are indeed clearly different roles for these bodies to play at national level. The Office for Health Improvement and Disparities will be looking across Whitehall to other government departments and the role they play in the wider determinants of health. The UK Health Security Agency will focus on the threats to the health of the population from future pandemics and other shocks. NHS England and NHS Improvement remains responsible for the finance and performance of the NHS. However, with this separation comes a risk: when thinking about the health of different communities, or of the key causes of death and ill health (cancer, mental health, cardiovascular disease), policy-makers should be considering all the tools in the health and care toolbox, from primary prevention to secondary prevention and treatment. It may be ironic that at ICS and place, this is exactly what local leaders will be doing as the full set of partners from the NHS, local government (including public health) and the voluntary, community and social enterprise sector should be at the table. Yet at national level, these players move back into their older, post-2013 separation.
The risks of this separation go beyond a degree of disintegration in national policy. ICBs will be in a clear accountability relationship with NHS England and NHS Improvement. Yet NHS England and NHS Improvement is not accountable for public health, except in the limited case where the NHS is the delivery arm. The Department of Health and Social Care and national leaders need to ensure that the oversight of this emerging system – both in accountability and governance and critically, the indicators and measures by which ICBs are assessed and performance managed – does not become NHS-centric and undermine the joint working at local level.
The regional tier: much unfinished business
While the Health and Care Bill sets out a clearer structure for ICBs and ICPs, it still leaves much room for local discretion and this is amplified at place level. The same permissiveness is also visible in terms of the roles and functions of the seven NHS England and NHS Improvement regional offices.
It is also the case that ICSs will continue to vary greatly in their size and are also likely to vary in their internal organisation with respect to both place and provider collaboratives (agreements between two or more hospital trusts to work together, often including other partners) all acute and mental health trusts are expected to be part of a collaborative by April 2022). This in turn is likely to have consequences for how and when ICSs need to work together, eg, on specialised services or workforce and other functions, some of which could be taken up by NHS England and NHS Improvement regional offices.
This means there may not be a single model for an NHS regional office going forward and equally, no single model for how public health functions integrate with NHS structures at the regional level. However, integration is important. Without it there is the risk that the rather neat match between the NHS, local government and public health that exists at place and at ICS level disappears at regional (and national) level with a single ‘NHS’ hierarchy going up through the regional teams to national level. Instead of this separation, the NHS and public health bodies (the Office for Health Improvement and Disparities and the UK Health Security Agency at regional level) need to work towards a ‘team-of-teams’ approach that ensures there is a single, coherent narrative, approach and strategy for ICSs and place that connects health care and public health. This could be achieved in several ways including through creating joint teams or appointments as appropriate, but requires clarity and aligned communications and messaging.
The government has now set out how Public Health England’s specific functions and responsibilities are split between the three national bodies as set out above; and each will have a regional presence to discharge those functions. However, there are three additional roles that need to be more clearly held at regional level that need designing and cohering across public health and the NHS: data and surveillance, accountability and support for improvement.
First, data and surveillance. As the Office for Statistics Regulation has said, the pandemic and the effort involved in developing, sharing and using statistics for surveillance has been remarkable. However, there have also been problems with sharing data and intelligence. The reformed system needs to ensure that these are resolved, and that data and intelligence flows well between the more complex landscapes at local and regional level, as well as up and down between the local, regional and national levels. The regional level should be at the nexus of these flows and the data-sharing, linking, infrastructure and analytical resource that goes with it.
Second, this data and surveillance system at regional level underpins the knowledge required to properly, and fairly, hold to account for population health actions and outcomes across the system. How this works needs a lot of thought for two reasons: first, there are new ICS structures at sub-regional level to be held to account in some way by the region, and second, these new structures are made up of two core partners – the NHS and local government – who have historically different ways of holding to account and being held to account, and these need to better align. On the NHS side the challenge from the past is to make this function less top–down and less one-size-fits-all so that ICSs and their constituent places retain ownership and control and any intervention is light touch. For public health, sitting mainly in local government, the opposite is the case: there is no top–down or regional structure to hold to account for public health outcomes1 since the implementation of the reforms in 2013, since accountability is local through the ballot box.
Between these two alternatives there needs to be a middle way. There will inevitably be a set of outcomes ICSs are expected to deliver (or expected to improve). These must not be solely NHS outcomes, as this risks focusing the energies of ICBs and the NHS on these to the exclusion of wider population health outcomes. Wider outcomes are bound to require input from public health and local government and rightly so if systems are genuinely expected to work together on improvement. The conversation between regions and ICSs should encompass both traditional NHS priorities (such as waiting times) alongside wider health outcomes. This will mean public health teams recognising a tighter degree of oversight than has been the case for years. But this may also help make the case for investment in public health at national level, as it may help create a clearer link between additional spending and improved outcomes at local level.
Finally, the regional level is the best level to develop support for system improvement. Accountability without the means to improve is merely penalty and leads to fear and resentment. So, an accountability role at regional level needs to be twinned with a stronger system support role providing tools, approaches and on-the-ground support where needed, and co-ordination of efforts. There are many models for how that can be done and there are elements already in place, for example, the sector-led improvement methodology common in local government, learning from the national support teams model, and supported communities of practice. The key is that support is available at scale and offered flexibly, and the regional level provides economies of scale of expertise and support, which is less available at sub-regional level. The more centralised NHS has kept some of these support functions at national level. Even if these remain there, there should be a streamlined offer to ICBs and to their constituent parts.
The precise configuration of the regional role, and how this is distributed between the NHS, the UK Health Security Agency, the Office for Health Improvement and Disparities and others needs to be settled and in practical detail will vary in different parts of the country. But at the end of that process there needs to be a common, or at the very least strongly coherent, approach to the three inter-related and mutually supporting functions of data and surveillance, accountability and system support..
Public Health England’s role was not to hold to account, but to provide support to the local system. There was, in extremis, accountability for poor financial management and misuse of the public health grant, for example, by Northamptonshire council, but no equivalent to the NHS’s performance and accountability system.
Clarity and new complexity at local level
In comparison to the regional level, at local level there is a clear and relatively straightforward mesh between the reformed ICS structure and public health structures, at least in principle.
This is true because place-based partnerships are generally based on a local government footprint. This meshes well with both the location of DsPH and of health and wellbeing boards. Under the Health and Social Care Act 2012, health and wellbeing boards were introduced for each local authority and tasked with undertaking a joint strategic needs assessment of their local areas and creating a health strategy to meet the needs of the local population in response to it. While it is true that the influence and operations of these boards varies across England, they should play a greater role in the reformed system.
This is partly because they are on the same or aligned footprint and because they often have overlapping membership with place-based partnerships. It is also because the new ICS legislation passing through parliament ensures that the ICS has to give due regard to this health and wellbeing strategy in setting the overall ICS strategy. In particular the ICB must ‘set out any steps that the integrated care board proposes to take to implement any joint local health and wellbeing strategy to which it is required to have regard under section 116B(1) of the Local Government and Public Involvement in Health Act 2007’.
The proposed legislation emphasises that ICBs and ICPs should build up from place, with a clear expectation that they call on public health expertise and advice: ‘Each integrated care board must obtain advice appropriate for enabling it effectively to discharge its functions from persons who (taken together) have a broad range of professional expertise in – (a) the prevention, diagnosis or treatment of illness, and (b) the protection or improvement of public health.’ In addition, NHS England and each ICS must make available services or facilities, where reasonable and practical, that ‘enable local authorities to discharge their functions relating to social services, education and public health’. To achieve this, they will need to work closely with local government public health teams and with the strategic support and advice of DsPH.
The ICB is also required to have local authority representation and all constituent local authorities are required to be in the ICP. While the creation of this more complex ICB and ICP approach cannot guarantee closer system working by itself, it does provide a flexible framework to bring together the wider health and care system within which closer working can occur, and a clear route for the influence of public health insight and influence. In many geographies there will be a simple correspondence between place-based partnerships and public health structures.
As previously mentioned, for some, one of the implications of the separation of the NHS and public health after 2012 was the perception that prevention was not the core business of the NHS. One other change being introduced through the new legislation is clarity that the NHS needs to pursue the ‘triple aim’. This applies to all NHS bodies – whether commissioners or providers. They must consider the effects of their decisions on:
- the health and wellbeing of the people of England
- the quality of services
- the sustainable and efficient use of resources.
The purpose of this triple aim is to explicitly ‘encourage these bodies to not only continue a culture of working in the best interest of their immediate service users and organisations, but also on public health and prevention for the wider population, and will include working together strategically with other relevant bodies and the public’. The King’s Fund has argued that the reduction of health inequalities should be explicitly added to the triple aim.
With the NHS triple aim making it clear that improving population health (ie, the health and wellbeing of the people of England) is core business for the NHS, there should also be greater alignment among NHS bodies and their partners. While the challenges of developing the trusted relationships that system working (at ICS or place) and of understanding – and then meeting – local need cannot be underestimated, there is at least clarity that the health of the population and the role of public health and prevention within that, not just the quality of services provided to patients, is core business for the NHS.
System reforms always come with risks, not least in the churn of leaders that so often occurs during transition. However, unlike in 2012, these reforms are, at least on the NHS side, evolutionary and largely what the NHS's leaders have asked for and wish to see, seeking to enable NHS England's vision for integration. The reforms are about facilitating and speeding up change that has been gathering momentum ever since the last set of health reforms. But reforms for the NHS come at the same time as public health reforms. For public health it is true that the latest changes leave the fundamentals of 2012 in place, leaving much responsibility with local government. However, abolishing Public Health England and sending its components in three directions has added complexity. This makes the regional role at the intersection between systems and between national and local even more significant than it has been in the past.
Both sets of reforms also come in the context of the Covid-19 pandemic and its immediate effects on health and the health and care system, and the consequences for the determinants of the population’s health beyond the short term. The impact of the pandemic will be felt for the long term and the new system will need to be able to adapt and plan for that. So while there is now the opportunity and need to ‘get this right’, there are also key risks that need to be avoided in the remaining design work and in implementation. There are five key risks to manage.
The first and most pressing is that the elective backlog and pressures on primary care, may dominate both policy and practice. While these are critical issues the system lose momentum on the changes that are needed in integration and the opportunities to bring together more coherently public health and wider health and care system.
The second and third risks are corollaries of this. Second, ICSs – and ICBs in particular – could focus only on the NHS’s internal treatment and service priorities and not do justice to the wider principles of partnership and contribution to the other drivers of population health in place. Integration must not be allowed to wither to become about NHS integration alone. And third that the ‘due regard’ clauses in the legislation around the influence of local health and wellbeing strategies may not implemented meaningfully. Without a clear link between the priorities at place and at ICS level there is a risk that the strongest connection between NHS services and public health – at place – is weakened through the imposition of other priorities by the ICB.
Fourth is that integration of, and within, public health is not hard-wired. For example, there remain risks that, despite the signals in the legislation, public health’s voice will not be loud enough around the ICS table, and that health protection increasingly becomes a function of the UK Health Service Agency alone over time, and local DsPH are peripheral and without appropriate funding for health protection. In short, that lessons learnt from Covid-19 are short lived.
Fifth, and underpinning everything, is the workforce. The shortages faced by the NHS and social care are well known and the ongoing failure to confront them will leave both services in crisis whatever structural reform is undertaken. But there are similar pressures on the public health workforce. In particular, DsPHs and their teams have been at the heart of the Covid-19 response in local areas and have the skills and relationships to be at the heart of the reformed system, but they need the resources, support and permission to do so. While structural change may provide the permission and encouragement required, if there simply aren’t enough people to do the job, all the reform in the world cannot overcome this core deficit.
There are two inter-related sets of reforms ongoing in England: to integrated care, with key enabling legislation on its way through parliament, and to public health, with the demise of Public Health England and creation of new bodies to replace it. Both, if successful and used well, provide an opportunity to focus on improving population health and reducing health inequalities. How this could work is clearest at local level and at the level of the ICS. The changes to legislation, consistent footprints and the experience of Covid-19 has brought a new recognition and ability to collaborate between the NHS and public health systems, through ICSs and beyond.
It is currently much less clear how this will work at the regional level, and what the role of the region will be; this needs to be addressed. While the details will, and should be, different in the different parts of England, the regional role will be more important than ever as it is at the nexus of a more complex system taking shape above and below it. It needs to have a key place in developing and communicating the data and intelligence to help the new system function, and to help those flows to travel up and down the hierarchy – something that Covid-19 has shown needs to improve. This data and intelligence in turn need to support a clear accountability function for population health outcomes at regional level, married to a strong system support offer to ICSs and the rest of the system.
At national level, government needs to be much more joined up on population health. It is incumbent on the Department of Health and Social Care and the new triumvirate of NHS England, the UK Health Security Agency and the Office for Health Improvement and Disparities to present a united, coherent face to the health and care system and its partners and to model the integrated approach that the rest of the system is expected to pursue. The establishment of the Office for Health Improvement and Disparities in particular also brings with it the promise of better co-ordination across government policy for health in Whitehall and in turn, through Whitehall department’s delivery chains to support more coherence across the pillars of population health in local systems.
None of these things will happen overnight, and none of them is a given. Success will depend on leaders wanting to do this work, being in a position to do it, and having the support and funding to do so. However, the legislative reforms, if – and it is an if – interpreted in the right spirit will give them a better chance to do so.