Public health: how the cards will fall

A shake-up of public health in England during a pandemic was always going to be disruptive, but it is now essential the opportunity is taken to combat long-term health inequalities and years of under-funding for the specialty. Peter Blackburn reports

Location: England
Published: Friday 14 May 2021
public health

‘I think you have all the right questions – but I am afraid I don’t have the answers.’

Speaking to The Doctor, a senior national public health leader – identity protected to allow freedom to speak – is a little lost for words when it comes to the big questions: what opportunities or concerns might new public health structures bring?

Is a focus on public health and health inequalities owing to the pandemic likely to be supported with proper resources and political will from ministers? What can be done to safeguard an exhausted workforce, tired of reorganisations and likely to lose precious staff through early retirement?

It comes as Public Health England is being disbanded and replaced with two new organisations – the UK Health Security Agency and the Department of Health and Social Care, Office for Health Promotion. 

Each time there is a reorganisation it disrupts the working of the public health system

Dr Jarvis

It has been a controversial process. Public health staff have seen many reorganisations, notably in 2012/13 which resulted in fragmentation of the profession and services, cuts to funding and decreased professional autonomy and freedom to speak up. And the midst of a pandemic seems, to many, like a particularly odd time to be putting new systems and structures in place. 

At the time of writing, most PHE staff have not been made aware what their new roles will be and where these will sit in new structures, what their terms and conditions will be and for most, there has been precious little, if any engagement or consultation.

The Government timeline suggests the ‘future destination of all services and functions’ should be decided during the spring, a ‘formal staff consultation’ and ‘ongoing design work’ for both new organisations will take place during the summer.

It says staff transfers will follow and both new bodies should be fully operational in the autumn of this year.

Serious disruption

Some of the broad concerns are quite clear given the timeline and the context. BMA public health medicine committee co-chair Richard Jarvis says: ‘We are still in a pandemic. We hope it is coming to an end but fear there may be another wave in August and September, just as the new organisations will be trying to set themselves up. There is a danger that we create something that is useful in pandemics just as we are coming out of this one but we fail to create something which is useful in dealing with other aspects of public health.’

richard jarvis JARVIS: ‘It takes around three years for any new organisations to settle down’

The North West consultant in public health adds: ‘In public health we tend to have a reorganisation in England every five to 10 years and this one is pretty much bang on time.

'In some ways that can be good as it presents opportunities to do things better but each time there is a reorganisation it disrupts the working of the public health system as a whole and it takes around three years for any new organisations to settle down, mature and get to work.’

Dr Jarvis’s message is simple: ‘We don’t give reorganisations long enough to settle down, it causes huge disruption and expense each time it happens and we never seem to learn from the perceived failings and strengths of the old system and build those lessons into the new ones.’

It’s really important we seize this moment of opportunity to do something about inequalities

Dr Toff

It may not be totally welcome, but a reorganisation is where we are. So where are things likely to go from here? 

Uncertainty is the overriding feeling for many, but the senior source within PHE made it clear this is not owing to any lack of effort from senior leaders.

‘Everyone is working very hard to design the new arrangements and to capitalise on the current focus on public health, health inequalities and prevention,’ they say.

‘It’s very early days for any new arrangements, most of these have not come into being yet.’

The source outlines one particularly important area of priority: ‘I am especially keen that we think about how to secure the public health workforce we need for the future, as everything else will depend on doing that successfully.

‘Quite a few senior staff are planning to retire this year, or have already done so, which is always a challenge with major organisational transition events like these.’

Learning from past mistakes

The coming days and weeks feel like very significant moments for a profession which has felt systematically overstretched and undervalued for some time. 

The early signs seem quite mixed. On the one hand many doctors have reacted positively to both organisations being given clinical leaders – former deputy chief medical officer Jenny Harries is chief executive of the UKHSA and chief medical officer for England Chris Whitty will lead the Office for Health Promotion. However, concerns have been raised about the terminology used in both organisation titles – and what that terminology might say about future directions of travel.

‘Health promotion’ is a term which has not been used widely for some time in public health and there is a feeling it ignores the reality that many of the most significant drivers of people’s health outcomes are not their own life choices but owing to the circumstances in which they live. 

For BMA public health medicine committee co-chairs Dr Jarvis and Penelope Toff there are a range of priorities if mistakes from previous reorganisations and the lessons of the pandemic are to be learned, including ensuring there is no further fragmentation of services, that there is vertical and horizontal integration between public health functions, as well as with the NHS and other agencies and that staff can operate across the public health system.

This is a crucial opportunity to build and properly resource a new public health system

Association of Directors of Public Health

Chief among the concerns will be that the focus and spotlight on public health and inequalities, as a result of the pandemic and the disproportionate effect on people from more deprived geographical areas and socio-economic circumstances and from some ethnic minority backgrounds, is followed up by genuine political will for levelling up to be more than just a slogan – and for that commitment to be followed by proper resources and priority.

Dr Toff says: ‘It’s really important we seize this moment of opportunity to do something about inequalities. The establishment of a cross-government committee to address these issues is very welcome. You need to impact the wider determinants of health – putting health in all policies – and properly resource local public health and local government to do this effectively.

‘These are problems which already existed and have been highlighted during the last year – most starkly through worse illness and more deaths from COVID but crucially from people’s different ability to self-isolate and in disproportionate loss of income and homes.’

She adds: ‘On the workforce side, the pandemic has demonstrated the importance of maintaining and properly funding full capacity of public health services across all areas.

‘It’s also shown us at every level how important it is to address those health inequalities – it has shown us how much people have suffered because of the disparities with which we went into the pandemic and how those have worsened since.’

A national necessity

It is an important moment of opportunity that organisations and experts across the system can see.

A statement from the Association of Directors of Public Health said: ‘This is a crucial opportunity to build and properly resource a new public health system which is able to drive forward the lessons from COVID-19, by tackling health inequalities.’

And Jo Bibby, director of health at the Health Foundation, adds: ‘A strong public health system isn’t a luxury – beyond the obvious benefit to the individual, good health brings with it huge economic and social benefits that are vital to the country’s prosperity.

‘The Government has pledged to increase healthy life expectancy and narrow the gap between the richest and poorest, but it has a mountain to climb to reverse the current trends.’

The potential for further fragmentation of services will also be a concern. Public health system reforms and budget cuts had already left many staff in public health feeling isolated – and during the pandemic, these problems were crystallised, as local directors of public health spent months denied full access to test and trace data about their own populations, which was key to responding effectively to the pandemic.

Dr Toff says: ‘After the last reorganisation we ended up with fragmentation of the public health system between those working in different functions of the specialty and also in terms of its connections to the NHS and other agencies.

‘That was reflected in inconsistencies in workforce terms of employment and resulting siloing of expertise, in barriers to essential data-sharing and people’s ability to collaborate for the benefit of the population.’

Engagement fears

It is concerning those close to the corridors of power, too. The source within PHE says: ‘We have to avoid fragmentation of the public health workforce if at all possible because public health remains by its nature a cross cutting function, whatever the role of individual bodies and organisations.’

Staff consultation and engagement on the shape and direction of the plans has been minimal thus far. A genuine period of engagement and consultation is not only the right and proper process to follow but also a requirement for the new organisations to be designed in such a way that they can make best use of existing expertise and have a positive effect on the population’s health.

On top of that, proper conversations around establishing standard NHS-equivalent contracts for staff, regardless of employer, are required, as well as other measures to ensure their ability to move around the system and the UK.

It is also vital that health improvement and healthcare public health functions, as well as health protection, are given appropriate care and thought during this process. Resources will be important.

Prior to the pandemic, the budget for public health services sat at around £400m and in 2020/21, the public health grant to local authorities has been cut by 24 per cent relative to 2015/16.

The COVID-19 crisis has shown the folly of cuts to public health budgets and the damage of repeated reorganisations. As Dr Jarvis says, this time round the lessons of the past must be learned.