The new public health landscape throws up more questions than answers

Last August the health and social care secretary Matt Hancock announced that Public Health England (PHE) would be replaced with the National Institute for Health Protection. COVID-19 has taught us that further strengthening public health is a good move, so the news was met with some uneasiness across the NHS Confederation.

Structural reform of this scale, and mid-pandemic, is a risky move, we said at the time. We also voiced concerns that the reorganisation would lead to more problems in the national test and trace system and questioned where PHE’s health prevention and health improvement functions would sit.

One becomes two

Seeking to address the concerns expressed by our members and the health policy community, the Department of Health and Social Care (DHSC) released Transforming the Public Health System, which outlines its vision for public health. It confirmed that PHE would be spilt into two agencies: the United Kingdom Health Security Agency (UKHSA) and the Office of Health Promotion (OHP).

On the surface, UKHSA seems to be well thought out and may be an important addition to our biosecurity and national defenses as new communicable diseases evolve. Moreover, if the test and trace system learns from former mistakes and becomes an ‘agile and adaptive’ organisation working closely with local systems, we may ultimately have the ‘world-class’ test and trace system that the government keeps promising. This would be welcome considering the 2020/21 test and trace budget stands at £22 billion. But only time will tell.

The Office of Health Promotion, on the other hand, presents many questions and has me wondering what this ‘new’ public health landscape will look like. Its initial remit seems narrow: ‘tackling obesity, improving mental health and promoting physical activity’. This is confusing as the pandemic has shown that a national strategy on health inequalities should be front and centre.

A large part of PHE’s role was to improve health disparities and health and wellbeing, by addressing the social determinants of health, such as housing, employment and early interventions for children. A component of PHE’s work focused on improving health and outcomes for mothers and infants, children, teens and young adults; helping those at risk from health inequalities to live long and healthy lives; and ensuring where people lived, their health and wellbeing was promoted, especially those in vulnerable communities suffering from health inequalities.

But with PHE now dismantled, which body will drive this agenda? And where will PHE’s extensive library of resources for NHS organisations and local authorities on reducing health inequalities now go?

Health in all policies?

I am pleased that DHSC has finally realised the importance of leading work across government. Its plan to set up a “new cross-government ministerial board on prevention” sound good to me.

But I’m left with yet more questions. Will we see health in all policies, as Marmot suggests? Will the board have the power to actually drive change across government, putting public health at the heart of all government decisions? Or is it merely an advisory board with no clout?

Putting money where your mouth is

My number one question is whether the government will put its money where its mouth is and prove its commitment to public health. This year’s budget once again decreased public health grant allocations to local authorities. How can integrated care systems and partners in local authorities address the enormity of health inequalities without a long-term commitment to public health funding? How is it that NHS Test and Trace, beset with problems from the start, gets £22 billion and yet the public health grant receives £3.324 billion?

Ready and willing

As the Department of Health and Social Care enters the next phase of public health system reform, and starts to develop the architecture of UKHSA and OHP, we hope our members will have the opportunity to shape the new public health system.

Our members are ready and willing to help DHSC rise to the challenge of addressing the critical issue of health inequalities. I hope the government is ready to accept this assistance.

Nasima Hossain is a senior policy adviser at the NHS Confederation. Follow us on Twitter @NHSConfed