A new social contract for Public Health

By David Hunter, Newcastle University; Peter Littlejohns, King’s College London; Albert Weale, University College London; Jacqueline Johnson, public health and management consultant; and Toslima Khatun, King’s College London

Air pollution is widely recognised as a serious health hazard while Covid-19 shone a spotlight on the weaknesses of the UK’s public health system

The UK is in the grip of a public health crisis. With depressing regularity, new research shows the growing deterioration of the public’s health. Improvements in life expectancy have stalled, health inequalities have widened, obesity and alcohol misuse are placing an increasing strain on health services, and air pollution is now widely recognised as a serious health hazard. While Covid-19 shone a spotlight on the weaknesses of the UK’s public health system, they had existed for some time. Indeed, as Michael Marmot has argued, most of the deterioration in health stems from 2010 and the Coalition government’s austerity policy. This resulted in cuts to public spending with local government, which is responsible for public health, suffering some of the deepest.

Despite the wealth of evidence testifying to the parlous state of public health and with many studies offering solutions that are both cost-effective and for which there is robust evidence, there remain significant political and organisational barriers to the realisation of an effective public health system. Unless these are confronted, the chances of progress are slim.

A new social contract for public health

We support the case for a new social contract in which health policy is truly public. Public health policies are often criticised by those of a neoliberal persuasion for restricting individual choice and for ‘nanny statism’. We refer to this form of liberalism as ‘vulgar individualism’. Big government and state overreach are viewed as problems which stifle personal freedom and hinder private sector growth on which the economy depends.

In fact, a much bigger problem is state underreach and a failure to take up and apply policies and policy instruments that are known to be effective in order to improve health. But as long as governments continue to subscribe to the view that the health of individuals is a matter of personal responsibility then action of the kind needed will not be forthcoming. Over the past 13 years or so, successive governments have subscribed to this view ignoring all the evidence which demonstrates the flaw at the heart of such thinking, namely, a belief that that government is best which governs least.

In place of such a stunted political ideology we propose a new social contract for public health incorporating the principles of what might be termed ‘social individualism’, that is, a commitment to using the instruments of collective political authority to create the conditions for individual choice and fulfilment.

What are the elements of the new social contract for public health?

First, and importantly, a social contract for public health would focus on prevention, reflecting the significant body of evidence demonstrating how a wide range of public health measures would prevent more serious conditions developing. But while it is easy to state all this, as indeed numerous academics and analysts have done over many years, unless political leadership is in place to confront the challenges the prospect of change happening is slim.

A particular challenge is the tension arising from the urgent driving out the important. With an NHS under extreme pressure in respect of growing waiting lists and staff shortages, for electoral and other reasons, politicians are most likely to prioritise addressing these to the exclusion of longer-term public health measures. Yet, as the Hewitt Review of Integrated Care Systems points out, ‘we have mistaken NHS policy for healthcare policy’.

Second, a new social contract requires a precautionary state, paying attention not only to known hazards but also to remote and uncertain ones. If the pandemic taught us anything, it was the need to be prepared and have sufficient resources in place to enable swift and effective action to be taken. Sadly, for a government emerging from the debacle over Brexit and trapped in a mindset of short-termism with a focus on campaigning rather than governing, adopting a policy of precaution does not come naturally.

Third, social solidarity is required in the face of health inequalities. Social individualism recognises that policies for the most vulnerable are not policies for a particular group in society, but policies for all of us when in need. What is required from public policy is the support to resilience over the life cycle.

Fourth, a new social contract requires a different approach to government and governance. In particular, addressing the short-termism that pervades our politics has to be challenged and replaced by a more sober acknowledgement of how governments need to function. A populist politics that wishes away the need for planning and relies on easy, facile slogans to attain and retain office – ‘the unbearable lightness of politics’ as the historian, Tony Judt, put it – undercuts the seriousness that is needed for effective government.

Above all, a new social contract sees a central role for an active state. To this end, we set out a manifesto to frame the approach to public health that is needed in the hope that it might inform the political debate as preparations get underway for a general election due over the next year.

A manifesto

Much that needs to be done already exists and is supported by a sound evidence base as well as by the main UK public health bodies. The Hewitt Review’s plea for priority to be given to population health matched by new investment is also worth acting on. Some measures could be swiftly adopted by a new government if it so chose. Others will take longer but making a start by implementing what be done quickly would make most sense in tackling the crisis facing public health.

Above all, regardless of the particular topic demanding attention, at the heart of public health policy is the need to work in a cross-organisational and cross-sectoral way. This will not happen without strong political leadership, but to embed a cross-government commitment to public health requires new legislation to place a duty on all government departments to respect in their policies the claims of public health. To monitor how policy is taken forward and implemented, there is a strong case for making the publication of health impact statements obligatory.

If the winds of change blowing through the country offer a turning point in the public’s health, then the incoming government has no time to lose in seizing the opportunity.

For an extended discussion of the issues raised go to our new book: Littlejohns P, Hunter DJ, Weale A, Johnson J and Khatun T (2024) Making Health Public: A Manifesto for a New Social Contract. Bristol: Policy Press

Bristol University Press | Making Health Public - A Manifesto for a New Social Contract, By Peter Littlejohns, David J. Hunter, Albert Weale, Jacqueline Johnson and Toslima Khatun

Authors

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 Sciences, Institute for Psychiatry, Psychology and Neurosciences, King’s College London

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

Jacqueline Johnson, pubic health and management consultant

Toslima Khatun, teaching fellow, King’s College London



References

The answer starts with austerity, The Guardian, 10 August

https://www.theguardian.com/commentisfree/2020/aug/10/england-worst-covid-figures-austerity-inequality

Hewitt P (2023) The Hewitt Review: An independent review of integrated care systems, GOV.UK https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1148568/the-hewitt-review.pdf

Judt T (2010) Ill Fares the Land. Harmondsworth: Penguin Books 

https://www.penguin.co.uk/books/178939/ill-fares-the-land-by-judt-tony/9780718191412 

The views and opinions expressed by the authors are those of the authors and do not necessarily reflect those of Fuse, the Centre for Translational Research in Public Health.

Image:

Image by Jacques GAIMARD from Pixabay.

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.