The Covid-19 pandemic has brought to the fore many questions about the organisation of public health services and responsibilities in England. Covid-19 has not affected all communities equally, and inequalities have been a focus of discussions about how to respond to and recover from the pandemic.
Arguably, this is a time when stability of the public health system is most needed, but in August 2020, the government announced the dissolution of Public Health England (PHE) and the creation of a new National Institute for Health Protection (NIHP) - charged with protecting the nation’s health from external threats such as pandemics, infectious diseases and biological threats.
This is a pivotal time for the future of public health in England, and our briefing sets out the key principles which will need to be considered as the new structure evolves.
Strong partnerships between local and national leaders
Successful public health interventions rely on a synergy between national enabling policy direction, local leadership and coordination, and place-based delivery of services and interventions that support the health of diverse communities.
The response to Covid-19 has been centrally coordinated, but interventions to support people with Covid-19, either socially, medically or financially, have been delivered locally. The national social distancing restrictions, coronavirus testing and the vaccination programme have been enabled by local delivery, but there have at times been tensions between the centralised coordinating role, and the desire of local leaders to have enough flexibility to meet the needs of their communities.
For example, the success of the Covid-19 vaccination programme underlines what the health system can achieve with a clear national directive, and local flexibility to deliver. But it also highlights the need for local organisations such as trusts and primary care to be given more flexibility to meet the needs of the communities they serve. But the delivery of the programme, with its nationally coordinated supply chain and delivery schedule, has taken longer to be fully tailored to local communities and their diverse circumstances. More recent modelling shows that the original priority groups did not take account of health inequalities which might lead people under the age of 70 in deprived areas to be faced with the same risk of serious complications of Covid-19 as more affluent 80 year olds – healthy life expectancy in these areas is 19 years lower than in the least deprived parts of the country, meaning people experience the health problems that could make them more vulnerable to the virus younger than elsewhere.
All of these issues raise critical questions for the future of public health, population and prevention functions: whether responsibility for public health functions should sit within the NHS or local government, and subsequently, what the correct balance between centralised control and local agility and autonomy. NIHP will need to work hand in glove with local partners, and maintain strong links to local government public health teams, in order to take advantage of the value these experts bring in engaging with communities, convening wider public services, including housing, justice, parks and leisure, as well as public health services, social care, and education.
While health protection is comprised of a specific set of functions and will benefit from focused leadership to drive the health protection agenda, these must not become divorced from the wider context in which people live their lives, and all the wider factors which influence health, and subsequently vulnerability to the direct and indirect impact of health threats.
Long term investment and sufficient funding
Recent figures from the Local Government Association estimate that councils could face a funding gap of £5.3bn by 2023/24 which could increase to £9.8 billion due to uncertainty around the impact of Covid-19. The public health grant, which is paid to local authorities to deliver public health services, is now 22% lower in real terms compared to 2015/16.
Neither the creation of a national body for health protection, nor a redeployment of other public health functions, can resolve challenges facing the public health system alone. Covid-19 has laid bare the impact of the lack of investment in public health over the years, with well-publicised inequalities in the impact of the virus on marginalised communities. A lack of resource and overly complex funding mechanisms have led to a fragmented and pared back public health infrastructure exposes a need to review the policy trend of deprioritising public health funding across the breadth of its functions. Wherever public health services sit after the creation of NIHP, they need proper funding to enable local services to meet people’s needs effectively.
A sharp focus on tackling health inequalities
The Covid-19 pandemic has highlighted a challenging road ahead for public health; the impact of the virus has been felt unequally across society, and the impact of health inequalities and economic disparity has come to the fore as a key focus for policy makers in the recovery from the pandemic. For example, after accounting for the effect of sex, age, deprivation and region, people of Bangladeshi ethnicity were twice as likely to die from Covid-19 as people of White British ethnicity. People of Chinese, Indian, Pakistani, Other Asian, Black Caribbean and Other Black ethnicity were between 10 and 50% more likely to die from Covid-19 when compared to people of White British ethnicity.
These statistics only serve to emphasise the impact of inequalities that were already deeply engrained in society. The causes behind these patterns for different ethnic communities are complex and interlinked, because inequality snowballs out of structural racism to create inequality in housing, education, employment opportunity and ultimately, health outcomes. Deeply-rooted race discrimination has, over time, created systemic barriers to the conditions needed to live a healthy life, and the pandemic has now shone light on the tragic consequences of these inequalities.
Addressing these inequalities must be a focus for any organisation which takes on responsibility for population health as part of the reforms, whether that is a new national body, an existing national body, or devolved local responsibility at the level of delivery.
There is value in a national role driving a focus on health inequalities and health improvement, particularly at a time when the Covid-19 pandemic has affected communities unequally and shone light on the impact of the pervasive inequalities in society. An ongoing focus on addressing these inequalities is essential, both in the response to the pandemic but also in the wider economic and social recovery from the pandemic.
As the public health system evolves, there is an opportunity to articulate the contribution of the NHS to prevention and public health, through clearer accountabilities and a collaborative approach. Integrated care systems have been defined as the desired mechanism for NHS and other bodies to work together to improve the population’s health, with system partners working together to make shared decisions about how resources are used to improve people’s health.
A window of opportunity
Changes to the organisation of public health at a national level offers a window of opportunity to rethink the way population health, health inequalities and public health services are coordinated and delivered. While we are concerned about the timing of the reforms, and the risks associated with separating health protection and health improvement when the two are so strongly connected, there is a clear opportunity to make positive changes through an increased focus on health inequalities and population health going forward.
However, it is critical to the success of the future public health arrangements that these reforms are not just reactive and expedient, but are founded both on the needs of the population, in response to lessons learned from the pandemic, rather than short term priorities.
The creation of NIHP represents a welcome new focus on preparing better for future disease outbreaks, and managing the impact of Covid-19, but this must not come at the expense of much-needed investment in wider public health functions, and there are currently many unanswered questions about what a restructured public health system means for providers working to support the health of their local communities.