From the first weeks of the new UK government, it is clear that improving health and reforming social care are priorities for Andy Burnham.
Given some evidence of population health benefit associated with devolution in Greater Manchester (1,2) and the sizeable contribution made to health outcomes by social and economic determinants, the question being asked is whether further devolution of power can support delivery of the Government’s health ambitions (3,4,5).
However, many public health specialists in England are quietly wondering how this ambition can be achieved given the failings of the system they work in. Despite political will, evidence from the experiences of health devolution in Greater Manchester revealed a continued narrow focus on treatment-orientated approaches, with public health and prevention marginalised (6) – fixing this is crucial if devolution is to be a success for health.
Action to improve the population’s health couldn’t be more urgent – today England faces profound public health challenges. Improvements to healthy life expectancy have stalled and gone into reverse (7). Across the country, rates of obesity, (8) long-term illness, (9) and poor mental health are rising (10).
Uptake of childhood vaccinations has fallen, and in many communities, rates are perilously low (11) – in 2026, England lost measles-free status with frequent outbreaks becoming the new norm (12). The NHS faces recurring challenges around care quality and patient safety, particularly in services for the most vulnerable populations (13). Injustices and inequities pervade these challenges with the poorest in society living shorter, sicker lives, and with health inequalities widening (14).
While individuals, families, and the NHS bear the most visible impact of this burden, the costs to the nation extend well beyond the health system. Poor health is now one of the major barriers to participation in the labour market, stifling productivity and economic growth (15). For young people, ill-health is now a defining marker of who becomes, and stays, economically inactive (16). Alongside the economic cost, our worsening health leaves us with a society less resilient and more vulnerable to the threats posed by climate change, future pandemics, and geopolitical uncertainty (17).
To resolve this crisis, the new government’s political economy must place health creation at the heart of decision making nationally, regionally and locally. Devolution of power in and of itself, is not a guarantee of improved health outcomes. Without strong, professionally trained and registered public health leaders, there is little assurance that local decision-makers will opt for the choices that create and promote good health. A rising tide of online misinformation and populism risks short-sighted decisions that harm communities (18).
And even with the best of intentions, poorly designed initiatives can widen health inequalities (19). Visible and independent public health leadership is a vital safeguard – essential for both effective decision-making, and public scrutiny of those decisions. Equally important is integrated delivery, across organisational boundaries, of the three domains of public health: health improvement, health protection and healthcare public health (20).
Unfortunately, the current public health system in England does not meet these requirements. Since 2013 it has become progressively more complex and difficult to navigate (21) with its outcomes diluted. Successive reorganisations have left functions fragmented, (22) siloed and scattered across local government, NHS bodies, UKHSA, OHID and DHSC.
Organisational barriers inhibit collaborative, flexible, and agile working across the three domains (22,23). Resourcing is insufficient to meet the demands placed upon it with local government public health funding 15% lower in real terms than a decade ago – over the same period, NHS spending has risen 20% (23,24).
Proposed structures under devolution and the 10-year health plan could compound this already complicated state of affairs. New mayoral strategic authorities – the administrative bodies central to the government’s devolution agenda – and new NHS integrated health organisations will both have duties to improve population health but are being established without clear links into existing public health structures (21,25).
It is unclear how they will obtain independent public health leadership and guidance and the government risks repeating the mistake it made with integrated care bodies, which also lack sufficient public health input (26). Inconsistent geographical boundaries between local and strategic authorities and the NHS further complicates matters (4).
The result? A system in England in which everyone is responsible for public health, but no one is in charge. The risks from this disconnect between devolved power and public health expertise are clear: confusion, duplication and waste, and a failure to deliver on improving health outcomes (4,21).
The system needs fixing. Few in public health desire a repeat of the painful reorganisations that have come before. However, there are principles that we suggest are fundamental to an effective public health system, from which the Government can develop solutions that improve existing structures: prevention must be given equal priority to treatment; public health advice must be provided by trained and registered professionals; public health leadership must be independent of political leadership and visible to the public at the national and local level; and the public health workforce must be supported to operate as an agile, integrated system.
The merger of NHS England and the Department of Health and Social Care and associated health bill have been missed opportunities to fix public health (26). Prime minister Burnham can correct course but his government must avoid the pitfall of rhetoric without resourcing. If the nation invests in public health and prevention, it will be a sound investment – the evidence shows that public health interventions are highly cost-effective generating on average £14 of benefit for every £1 spent (27).
But to reap this reward, and make devolution a success, the Government must create a professionally led, integrated public health system that is sufficiently resourced to improve health, reduce inequalities, and support delivery of much needed growth and prosperity for the public.
Chad Byworth is chair of the BMA public health medicine registrars subcommittee and deputy chair (workforce and regulation) of the BMA public health medicine committee. Heather Grimbaldeston is chair of the BMA public health medicine committee
Footnotes
Provenance and peer review: not commissioned; not peer reviewed. The authors would like to thank David Cloke for feedback on a draft of this article.
References
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