Public Health at a crossroads again: meeting the challenge of a reformed system in England

Posted by David Hunter, Newcastle University, Peter Littlejohns, King’s College London, and Albert Weale, University College London



With health policy understandably preoccupied with the pressures on, and changes occurring in, the NHS arising from the impact of COVID-19, implementation of the Health and Care Act 2022, and various strikes among the workforce, it is imperative not to overlook the public health system reforms in England.

Public Health England’s (PHE) sudden demise in August 2020 followed mounting criticisms of its performance during the early stages of the pandemic and general unpreparedness.1 Rather than consider how PHE might be reformed, the government rushed to replace it with two new bodies: UK Health Security Agency (UKHSA), and Office for Health Improvement and Disparities (OHID). Like PHE, the UKHSA is an executive agency with close ministerial oversight while still permitting ‘independence in the delivery of policy advice’. It will act as a ‘system leader’ for health security with responsibility for pandemic preparedness and external threats across the UK while bearing in mind that health is a devolved responsibility.

PHE’s remaining functions in respect of the wider public health, including health improvement and population health, lie with OHID. Located within the Department of Health and Social Care (DHSC) and jointly accountable to the Secretary of State for Health and Social Care and the Chief Medical Officer for England, it enjoys even less independence than the UKHSA. Building on the work of PHE, OHID’s priorities include tackling obesity, improving mental health, promoting physical activity and other population health issues, notably inequalities.

There is merit in taking stock to identify any lessons which might be gleaned from the mixed life of PHE and whether the new bodies offer hope to do things better.2

Learning the lessons

The findings from a research project to explore the circumstances surrounding the rise and fall of PHE may assist with the learning process.3 Five broad underlying issues were identified in the research which contributed to PHE’s demise.

• 

  PHE did not possess the capacity to undertake a testing regime
   of the size and complexity required by the pandemic

  Severe funding cuts in public health spending, nationally and locally, since 2010 meant that PHE functioned with reduced capacity when the pandemic struck
• PHE did not possess the capacity to undertake a testing regime of the size and complexity required by the pandemic, the absence of which was the basis of the case against the organisation
• The governance of PHE as an executive agency meant it lacked independence
• While decisions made by PHE at the start of the pandemic were later considered mistakes (and judged outside the law by a judicial review) at the time there was little information about the nature and possible effects of the virus and limited capacity in the health system which required tough prioritisation decision to be made
• The sudden closure of PHE without any consultation was widely reported to be due to blame-avoidance behaviour on the part of key actors, principally Dominic Cummins (as former Chief Advisor to the Prime Minister, Boris Johnson) and Matt Hancock (as former Secretary of State for Health and Social Care). There was also a view that the decision was based on policy favouring use of the private sector and contracting out functions like test and trace.

Key lessons from these findings centre on two major areas of concern: the respective remits of the new bodies, and their governance.

Remits

The respective remits of UKHSA and OHID need to be clearer and more transparent if the risk of fragmentation is to be avoided. A welcome feature of PHE was its attempt to bring together the key public health functions that had previously operated in separate silos. As things now stand, separating communicable diseases (CDs) from non-communicable diseases (NCDs) is a retrograde move since, as the pandemic highlighted in stark terms, close links exist between them when it comes to those groups and communities which suffered most in terms of illness and death. A syndemic understanding of diseases and their underlying social factors is pivotal in preventing disease in the future and avoiding fragmentation.4

Governance

Governance of the new public health bodies requires careful attention. As an executive agency, PHE was criticised for its lack of independence from government which restricted its ability to ‘speak truth to power’. Given UKHSA enjoys the same status, it remains unclear how it intends to avoid a similar fate. The problem is a deep-seated and pervasive one within government. The idea that OHID being housed in the DHSC will allow it to exercise greater influence and have a closer collaboration with ministers could be a good move, or, more likely if history is any guide, it may be overly optimistic. There is a risk that OHID may disappear into Whitehall and become invisible, lacking even the limited degree of independence PHE had. To succeed, OHID has to be visible and have allies inside government.

A further issue concerning the governance and working style of both agencies, especially OHID, centres on their ability to operate effectively across government. Public health comprises numerous ‘wicked issues’, that is, multi-faceted problems that are complex and for which there are no simple or single solutions. Confronting them will be especially challenging for a government which, for all its rhetoric about ‘levelling up‘, remains topic- and department-focused, operating in silos rather than concerned with cross-government issues.5

OHID has a steep hill to climb if it wants to lead a transformational agenda across the wider determinants of health which demands a whole-of-government approach. The hill just got steeper following government delays in tackling child obesity and its failure to implement a national food strategy. In keeping with the prevailing political ethos, there is a renewed focus on individual behaviour change and lifestyle choices rather than tackling the influence on health of commercial interests via taxation and regulation.6,7 If significant inroads into the population health agenda are to be made, then confronting powerful vested interests in, and lobbying from, the food and drinks industry and their ’friends’ in government engaged in what has been termed ’institutional corruption’ cannot be avoided.8 Whether OHID has either the backing from government or competences for such a struggle remains doubtful in the extreme.

Conclusion

Public health once again finds itself at a crossroads. It can either continue to ‘muddle through’ with a broken political and public policy system that is not fit for purpose.9 Or there is an opportunity to construct a strong and confident public health system that is well-placed to confront the challenges facing it. The aftermath of COVID-19 should make the choice of options self-evident. However, as things stand, it is unlikely that the UK’s broken political system with its focus on short-term fixes is up to the challenge. Without major systemic change aimed at overhauling the UK’s political system, a risk of further deterioration in the state of the public’s health may be unavoidable.

References:

1. Calvert J, Arbuthnott G. Failures of state: the inside story of Britain’s battle with coronavirus. London: Mudlark, 2021. https://harpercollins.co.uk/products/failures-of-state-the-inside-story-of-britains-battle-with-coronavirus-jonathan-calvertgeorge-arbuthnott?variant=39528280391758
2. Vize R. Controversial from creation to disbanding, via e-cigarettes and alcohol: an obituary of Public Health England. British Medical Journal 2020; 371:m4476 http://dx.doi.org/10.1136/bmj.m4476
3. Littlejohns P, Khatun T, Knight A, Hunter DJ, Markham S, Coultas C, Kelly MP, Ahuja S. (2022) Lessons from the demise of Public Health England: where next for UK public health? London: NIHR ARC South London. https://arc-sl.nihr.ac.uk/sites/default/files/uploads/files/public-health-report-sept-2022-final.pdf
4. Horton R. Offline: COVID-19 is not a pandemic. The Lancet 2020; 396: 874. https://doi.org/10.1016/S0140-6736(20)32000-6
5. Pope T, Shearer E, Hourston P. What levelling up policies will drive economic change? The need for a long-term focus on skills and cities. London: Institute for Government, 2022. https://www.instituteforgovernment.org.uk/publications/levelling-up-policies?
6. British Broadcasting Corporation (BBC). Junk food: obesity strategy falling apart, Jamie Oliver says. 15 May 2022 https://www.bbc.co.uk/news/uk-61449921
7. Ralston R, Smith K, O’Connor CH, Brown A. Levelling up the UK: is the government serious about reducing regional inequalities in health? British Medical Journal 2022; 377:e070589 https://doi.org/10.1136/bmj-2022-070589
8. Draca M. Institutional corruption? The revolving door in American and British politics. SMF-CAGE global perspectives series: 1. 2014. http://www.smf.co.uk/wp-content/uploads/2014/10/Social-Market-FoundationInstitutional-Corruption-the-revolving-door-in-American-and-British-politics.pdf
9. Ricketts P. Hard choices: the making and unmaking of global Britain. London: Atlantic Books, 2022. https://atlantic-books.co.uk/book/hard-choices

David J Hunter, Emeritus Professor of Health Policy and Management, Population Health Sciences Institute, Newcastle University

Peter Littlejohns, Emeritus Professor of Public Health, Centre for Implementation Science, Institute for Psychiatry, Psychology and Neurosciences, King’s College London

Albert Weale, Emeritus Professor of Political Theory and Pubic Policy, University College London

The views and opinions expressed by the authors are those of the authors and do not necessarily reflect those of Newcastle University, King’s College London, University College London, or Fuse, the Centre for Translational Research in Public Health.