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A ‘local first’ public health system

The reform of Public Health England (PHE), the new UK Health Security Agency (UKHSA) and forthcoming legislation on the statutory basis of integrated care systems (ICSs) means we are facing significant organisational change. The long-standing problem of health inequalities and regional inequality has become ever clearer during 2020/21, and the pandemic’s repercussions will exacerbate for some time.

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The reform of Public Health England (PHE), the new UK Health Security Agency (UKHSA) and forthcoming legislation on the statutory basis of integrated care systems (ICSs) means we are facing significant organisational change. The long-standing problem of health inequalities and regional inequality has become ever clearer during 2020/21, and the pandemic’s repercussions will exacerbate for some time.

As the new UKHSA takes over PHE health protection functions, and, as it becomes established, effective collaboration is needed with regions, systems and places. The establishment of UKHSA provides an opportunity for local learning during the pandemic to inform future planning and delivery of health protection and resilience functions at a national, regional, system and local level. A full evaluation of the pandemic response is needed, but early suggestions from local public health is that there should be a shift to more emphasis to the impact on individuals and communities affected.

Local government has many years of experience in operating under a localised approach. When it joined local government, public health, with its skills in data analysis and evaluation, its regional networks, and its basis in evidence-based practice embraced local priority setting. The reform of PHE provides an opportunity for an enhanced ‘local first’ approach in which councils are held locally accountable for improving and protecting citizens’ health, including tackling the social determinants of health and health inequalities are front and centre in protecting the public’s health. We must come together and work at scale wherever this is most effective, but always keep the focus on local places – where people feel a sense of belonging and community, where the direct impact of health improvement and health protection takes place.

Key fault lines

The pandemic has highlighted a number of key fault lines which need to be corrected in any new system:

  • lack of local health protection capacity
  • oversight and accountability across the PH system
  • centralised approach to responding to the pandemic
  • confusion, duplication and delay
  • limited data and intelligence flows
  • poor understanding of roles and responsibilities, levers and powers
  • address inequalities better because the poorest have biggest burden of health protection challenges.

To enable a better system there needs to be enhanced interconnectedness between agencies and between footprints and levels: national; regional; supra-local; and local to give a whole system approach. It will also need sufficient funding at local

and regional level as well as national. Councils have played an innovative role in trialling new national initiatives throughout the pandemic, often building on relationships with existing partners. However, there is also a strong feeling that the skills, expertise and capacity of local public health was undervalued, particularly in the early months of national planning, and that their role had not been better recognised.

For future outbreaks, a national, regional and local partnership of all key sectors, playing to their strengths and operating as a virtual team, is needed. It will be really important that the role and accountability of each is clear and properly resourced.

Reform of the public health system provides a much-needed opportunity to realise real improvements for residents and communities through devolving more leadership, more control, and more resource to local level within an agreed national framework of health improvement, protection, and prevention.

1. Shared governance and accountability

We propose shared leadership and accountability arrangements for UKHSA and wider public health functions. It is crucial that governance and accountability arrangements are set out and understood from day one and that these structures deliver on joint accountability to local government and to Ministers. The governance arrangements must clearly respect accountability to the whole system at a local and at a national level.

There is an opportunity to take an alternative and innovative approach to developing the governance function of UKHSA. The process and format of the UKHSA Board and any regional arrangements should reflect this partnership, including the appointment of the Chair and members of the Board, which should have strong Local Government expertise to ensure the interest and role of Local Government is represented and protected at this level.

The approach to joint accountability for UKHSA presents some practical challenges, it should also be viewed as an opportunity to advance innovative approaches to collaboration. A robust Memorandum of Understanding and Framework Agreement will offer a way to achieve an accountability that doesn’t simply make the UKHSA a function of Ministers.

2. Public Health Improvement and assurance

The statutory assurance role at local level for health protection sits with local government through the Director of Public Health and exercised through the Health Protection Board, reporting to the HWBB. This gives a level of democratic oversight.

We recognise the need for more transparency which both gives government more insight into what is happening and creates incentives for local areas to do well on the issues that national oversight is intended to prioritise. Learning and improvement in public health is a priority for local government, as is ensuring services are effective, continually improving and respond to the needs of local people.

For any proposal in this area to work effectively, government would need to work with all partners to construct a shared framework on ‘what good looks like’, the Quality Framework in Public Health produced in 2019 with key partners provides a basis for further development. There is a wide variety of possibilities for how assurance could be approached as well as its scope and focus. Whatever is developed must be done in partnership with local government and we would favour a review-driven approach looking at whole systems/place with an emphasis on outcomes, rather than an inspection-driven approach focussed on things that can be measured.

Any developments around assurance would need to be accompanied by a New Burdens assessment to fairly capture the capacity and resource implications for councils of supporting any changes to the regulatory approach.

To ensure clear accountability and strong assurance to the government we propose a significantly stepped up sector led improvement programme providing both challenge and support with a strengthened approach to managing the risk of under-performance. Local government developed support such as Sector led Improvement provides collective responsibility and represents significant value for money – operating at a fraction of the cost of alternatives such as national inspection regimes – resources which would be better invested in directly improving health. The enhanced element of public health SLI would increase the emphasis on robust challenge and accountability, and on shared learning, both locally and nationally.

3. Subsidiarity

The LGA will continue to advocate for greater subsidiarity: what can be done locally should be done locally, what must be done nationally should be done nationally. This means a locally led public health system where place is central to decision making as well as delivery; where elected members, officers and Directors of Public Health can use their system leadership role to bring partnerships together to improve and protect health using research, evidence, intelligence and a close knowledge of their populations Directors of Public Health and LAs already successfully collaborate to deliver on the most appropriate footprint.

4. Collaborative commissioning

There are plenty of excellent examples from around the country of councils collaborating, both among themselves and with CCGs and NHS England, to commission integrated services. Councils are also working closely with NHS commissioners to plug potential gaps in service provision and use resources more cost-effectively.

There is a need to address the unacceptable variation in joint collaborative working across commissioning. Simply putting more public health functions into NHS England will not resolve this issue and risks creating an NHS orientated model for public health which focuses on specific health services rather than the whole health of communities. We support improving collaborative commissioning and the reasons for the unacceptable variations need to be addressed, including by making sure all areas are supported and encouraged to follow the best practice.

5. Integration

We support a joined-up approach to improving population health. Many Integrated Care Systems (ICS) Leaders strongly underline our message that local government leaders need to be at the heart of ICS leadership, in order to achieve their objectives of improving health and addressing inequalities. Some ICS leaders also fully support our message that most action and planning needs to be taken by place and led by Health and Wellbeing Boards (HWBs) – as the place-based forum where political, clinical and community leaders come together to drive local priorities for health improvement and addressing health inequalities.

But there is a risk that national priorities of NHSE – getting on track with elective care, bringing health institutions to financial balance etc – will dominate the resources and focus of ICSs. Also, some ICSs are still strongly focused on the NHS, rather than the wider health and wellbeing of their populations. They will struggle to make an impact on population health improvement and addressing health inequalities unless they have a wider and inclusive approach.

We propose we build on and strengthen the role of Health and Wellbeing Boards (HWBs) by introducing a new reciprocal “duty of collaboration to improve population health and address health inequalities” on all NHS organisations and local authorities. Require ICS to ensure meaningful involvement and an equal partnership with local government, with a ‘place by default’ approach. ICSs required to involve local government and HWBs in the development of plans. This goes further than signing off final plans and involves early and ongoing engagement in the development of plans. Furthermore, ICS plans to devolve the development of place or locality plans to HWBs, based on JSNAs and joint health and wellbeing strategies.

ICSs need to be accountable and inclusive of local place-based leaders – whether or not they are put on a statutory footing. Also, having a solitary local authority representative on an ICS board is not sufficient to ensure full local authority involvement, especially in areas where the ICS footprints spans several LAs.

We propose a ‘place by default approach’ with strong local government inclusions where systems are only responsible for what cannot be planned or delivered at place level.

6. Build on the good work

Bringing public health back into local government in 2013 was never a ‘drag and drop’ exercise. It was, and continues to be, about improving health for all citizens by building a new and enhanced locally-led 21st century public health system, where innovation is fostered and promoted, supported by the expertise of professionals and key partners

Local authorities have a statutory duty to improve the health of their populations. Councils are best placed to embed the health and wellbeing agenda within their local communities across all the policies for which they are responsible. To further enable local government to meet their duty a full review of public health law including ongoing powers for DsPH is needed to ensure councils have the right powers to exercise. We know that there is still work to be done on getting the public health system to work consistently and in particular how it can work together better in two tier areas.

The transfer back in 2013 generated many innovations in both commissioning and delivery: a clearer focus on prevention in tobacco control, not just treatment; reshaping the health visiting and school nursing strategies to respond better to local needs; and remodelling sexual health provision to improve access and focus on prevention.

The transfer remains one of the most significant extensions of local government powers and duties in decades. It has created huge opportunities for local authorities, with their partners, to make a stronger impact on improving the health of local communities and helped to rightly re-frame public health to a social, rather than medical model of health and wellbeing. Improved outcomes for citizens must continue to be the focus for any future plans for public health reform and we must ensure we build on the strong foundations we have.

7. Workforce strategy

We are calling for the proposed new public Health workforce strategy building on Fit for the Future to embrace the concept of public health careers that involve experience throughout the new system. Health protection capacity at local level has increased over the pandemic and must be sustainable. Proper integrated workforce planning requires improved data on the public health workforce. We support plans to see a significant increase in PH Consultant numbers and a recognition that Directors of Public Health (DsPH) as local leaders for public health need to have strong links with public health people employed locally and regionally by the NHS and as part of the DPH team. Some development and training opportunities for specialists require national coordination and investment but this must be done with local employers.

Mobility around the system is crucial – across and up/down and this requires a solution to the long-standing problems about portability of terms and conditions We see there is great potential for secondments from local into national to provide expertise and develop understanding.

8. Whole-system health protection

a new model for health protection – one which does not just tackle outbreaks or incidents, but responds to the impact on individuals, and harnesses the power of communities. It is imperative that any model for health protection includes links with health improvement to reduce inequalities because, as evidenced from Covid-19 those with existing inequalities have biggest burden of health protection challenges.

To ensure we can respond to current and future pandemics a full preparedness and surveillance system both nationally and internationally is required to ensure preparation for more emerging and novel infections and antibiotic resistance. For future outbreaks, a national, regional and local partnership of all key sectors, playing to their strengths and operating as a virtual team of teams, is needed.

The UKHSA needs to be able to think, mobilise and act nationally (labs, research, highly technical skills, systems capability) to respond as a global player to major threats to health. This needs to be aligned to ‘boots on the ground delivery’ so when there is a major health protection threat it is able to tap into the local delivery capability in councils (public health, environmental health, emergency planning, communications and engagement, contact centres etc).

9. Data and intelligence

We propose a unified data sharing process for all national public health agencies and other data generating institutions through improved capacity-building and systems development.

Decision making in public health, from routine responses to acute public health threats and long-term planning of interventions to improve the public’s health, is increasingly reliant on the efficient use of data. Reluctance or delay in data sharing to share can hinder or slow down the response. During the early phases of the pandemic it became apparent that delayed sharing of information about the situation hindered the local response. We are calling for increased data harmonisation, timely access across organisations, a code of conduct for data producers and data users and an acceptance that LAs are safe havens for personally identifiable data.

10. Hardwire existing structures into the UKHSA

Local/regional work to plan for emergencies is coordinated via Local Resilience Forums (LRFs) in England. These serve as multi-agency partnerships with representatives from a range of local public services, including the emergency services, local authorities, the NHS and Environment Agency local teams. In the new health protection system, the links between Local Resilience Forums and resilience responses need to be much clearer and aligned where possible. We propose direct representation on LRFs from UKHSA.

The 2015 Strategic Defence and Security Review gave particular prominence to the role of LRFs, highlighting that the response to, and recovery from, an emergency is carried out “first and foremost at the local level”. It committed to better coordination between the local and national levels of response and greater support for organisations involved in response planning “to share and apply learning from exercises and real-life events”.

The report on Exercise Cygnus in 2016 found uneven levels of resilience and limited capacity in some areas to surge resources into excess death management, and health and social care. The report called for more national-level operational guidance to ‘scale up’ the local response.


Paul Ogden, Senior Adviser

Phone: 020 7664 3277

Email: [email protected]