Transforming the public health system: reforming the public health system for the challenges of our times

The response to, and recovery from, an emergency is carried out first and foremost at the local level. Better coordination between the local, regional and national levels of response and greater support for organisations involved in response planning is needed to share and apply learning from exercises and real-life events.


Securing our Health: The UK Health Security Agency

Question 1: What do local public health partners most need from the UKHSA?

The response to, and recovery from, an emergency is carried out first and foremost at the local level. Better coordination between the local, regional and national levels of response and greater support for organisations involved in response planning is needed to share and apply learning from exercises and real-life events.

The UKHSA needs to be able to operate nationally as a global player to major health threats. This needs to be aligned with councils’ ability to react swiftly on the ground, using their local knowledge, expertise, and skills. It is vitally important that we clearly define the role and accountability of each, as well as devolve more leadership, control and resources to councils where needed.

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 already successfully collaborate to deliver on the most appropriate footprint.

Further clarity will be needed around how data, intelligence and the workforce will be connected across the whole system at national, regional, and local levels, including the work of UKHSA and the Office for Health Promotion. A key risk of the reforms overall, remains the fragmentation of the three underpinning domains of public health – health improvement, health protection and healthcare public health.

A fundamental review is needed of the support and resource needs of the local health protection system. A distributed model of support must ensure that capacity is built at the national and regional level with equal consideration made to the resource needs of frontline local public health teams in councils.

Sustainable investment is needed to ensure every Local Authority (LA) has permanent health protection capacity and capability. This may come via UKHSA or through the Public Health Grant.

Councils have seen a £700 million real terms reduction in public health funding between 2014/15 and 2020/21 – a fall of almost a quarter (23.5 per cent) per person. If the Government’s prevention and health protection agenda is to succeed, this must be re-evaluated in future spending rounds.

Question 2: How can the UKHSA support its partners to take the most effective action?

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.

Future relationships will need to be less transactional and more collaborative. It is crucial that governance and accountability arrangements are set out and understood from day one and that these structures reflect 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.

The process and format of the UKHSA Board and any regional arrangements should reflect this partnership, including the appointment 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.

UKHSA need to advance innovative approaches to collaboration. A robust Memorandum of Understanding and Framework Agreement with local government will offer a way to achieve a form of accountability that does not make the UKHSA a function of Ministers.

The relationship between UKHSA and the Office for Health Promotion (OHP) nationally and regionally are crucial in building a robust public health system. There are many shared interdependencies where strong co-ordination is needed. UKHSA needs to have reducing health inequalities built into its delivery requirements. All parts of the system including UKHSA must be held accountable for addressing health inequalities across their activities.

Close collaboration with the public health agencies in the devolved nations will be vital. These connections should be built into UKHSA’s governance arrangements.

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.

At regional level there must be clear working arrangements between regional branches of UKHSA and OHP with Regional Directors of Public Health (RDsPH) playing a key oversight role. The role of RDsPH in relation to UKHSA needs to be strongly and clearly articulated in the detailed plans for implementation of the new system.

Question 3: How do you think the health protection capabilities we need in the future should differ from the ones we have had to date?

The new system needs to learn the lessons of the pandemic rather than simply be reconfigured to address the requirements of the current emergency. A review is needed to fully understand what has worked well, and less well, and to apply the lessons learned to designing a structure which delivers maximum resilience for the future.

While there is no doubt that some elements of the COVID-19 response needed to be done nationally at scale, there should have been greater recognition of the role of local government. A key lesson that must be reflected on, is that locally driven processes and responses are more effective than those prescribed centrally through ‘top-down’ approaches and enable improved coordination and collaboration between agencies.

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 public health reforms present 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 that 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.

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 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.

Going forward, it is vital that LA analytical capacity, including public health analytics is prioritised and resourced. The years of underfunding local public health teams has reduced capacity and capability to manage, analyse and interpret data. Wider cuts to local authorities have also impacted on analytic capacity more generally.

Question 4: How can UKHSA excel at listening to, understanding and influencing citizens?

UKHSA should support strong collaborative leadership. System-working to improve population health requires a collaborative culture in which leaders across health and local government have an individual and collective responsibility to look beyond their organisational boundaries to achieve the best outcomes for their community.  This requires time to develop trust, confidence and a shared understanding between leaders across places and systems, and a strong leadership development offer based on a peer-led approach.

Bringing people with lived experience and local government expertise from a wide range of disciplines to advise on developments and give feedback from the ground, would make sure the UKHSA works for those it is intended to help.

UKHSA should undertake an annual audit on how they involve people with lived experience in the development of their work. These audits and any accompanying action plans are to then be added to their respective Partnership Board agendas and reported on regularly to ensure that the voices of those we are looking to protect are central to the way UKHSA operates and develops.

Good communication about UKHSA’s function and powers will be crucial in developing the public’s trust and ensuring meaningful engagement with local communities.

UKHSA should also strengthen their links with voluntary and community sector organisations, recognising them as a vital part of the public health system. They play two core roles: service provision (commissioned/grant-funded) and advocacy and articulation of local needs and assets. Greater engagement and better communication between public health leaders and the third sector is needed to give communities more ownership of health protection through asset-based approaches and co-production.

Improving our Health

Question 1: Within the structure outlined, how can we best safeguard the independence of scientific advice to Government?

The “strengthened role” for the CMO is essential to safeguard the independence of scientific advice to government and to ensuring the effectiveness of the public health system across government and at national, regional and local level. The policy paper envisages a direct oversight role for the CMO which we strongly support.

There should be a clear understanding between scientists, advisers and policy makers on what advice is being sought, by whom and for what purpose.

When asking experts to identify or comment on policy options prepared by others, those involved should respect the line between the responsibility of experts to provide advice, and the responsibility of departments for any subsequent policy decisions based on that advice. ‘The Principles of Scientific Advice to Government’ are a useful tool for ensuring the respective roles are clear.

Gathering evidence from a range of experts (particularly those with frontline local government public health expertise) or from an expert committee ensures a more independent cross-sectional view.

We agree with the principle, stated in the Principles of Scientific Advice, that ministers should explain publicly their reasons for policy decisions, particularly when a decision is not consistent with scientific advice and, in doing so, should accurately represent the evidence.

Like the Chief Medical Officer, at a local level, Directors of Public Health will be an independent advocate for the health of the population and provide leadership for its improvement and protection.

The Director of Public Health will be the person who elected members and senior officers look to for expertise and advice on a range of public health issues, from outbreaks of disease and emergency preparedness through to improving local people’s health and access to health services. The principles of scientific advice will be just as relevant at a local level as they are at the national.

Expert independent standing committees (eg the National Screening Committee and Joint Committee on Vaccination and Immunisation) are crucial to ensuring the independence of expert advice. Opportunities to set up new scientific advisory groups should also be explored (ie on health inequalities, non-communicable disease prevention).

Question 2: Where and how do you think system-wide workforce development can be best delivered?

Public health services require all those involved in the transformational aspects (planning and design within a complex system), as well as commissioning and delivery, to be well informed, use the evidence base and be fit to practice. It is delivered through a series of interlocking functions requiring a multi-agency approach led by groups of professionals with complementary skills.

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 Public Health Consultant numbers and a recognition that Directors of Public Health (DPH), as local leaders for public health, need to have strong links with public health colleagues 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 – both 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.

There is an urgent need to develop a viable national dataset on the public health workforce to enable proper workforce planning; DHSC should work with partner organisations on this. Without the ability to do decent workforce planning, stability of the public health workforce in the post-covid environment cannot be guaranteed.

A single organisation needs to have a coordinating role because there is a such a diverse and growing group of employers with a need to ensure a pipeline of specialists in the future and encourage shared career development opportunities and portfolio careers. There is also a suggestion that the standing group should form the basis of an advisory group to help ensure employer, professional and other interests are central to workforce development.

DHSC should take this coordinating role as many of the existing functions are being absorbed into the department. It is likely that Health Education England (HEE) will need a role on coordinating training courses and placements etc. but it must have a better remit to look at current workforce development needs if it is to be involved as opposed to focusing largely on future pipeline of specialists. The Faculty of Public Health will need to take account of the changing system and public health needs post-covid in curriculum development and work closely with the accountable organisation and there are some opportunities for development specialist registration further through UKPHR.

The LGA, ADPH, FPH and PHE produced The Standards for employers of public health teams in England. These Standards help ensure that the workforce is fit to practice and are relevant to employers and workers with a role in the commissioning or delivery of public health functions.

Question 3: How can we best strengthen joined-up working across government on the wider determinants of health?

Local government’s public health sector is a pragmatic one which has a long history of working effectively with national government and other national partners to improve services for the people we all serve. In this way, councils carry out their functions within numerous national parameters. The best of these are genuinely coproduced with councils as an equal partner, not an afterthought in an engagement process. It is essential that Government approaches the new Public Health reforms in line with this tradition, acknowledging – and making ample space for – the unique contribution that only local councils can make across the wider determinants of health.

We strongly welcome the commitment to joined-up working across government in the policy paper, and the acknowledgement that health is driven by wider determinants, which are within the remit of other departments.

Processes need to be put in place to ensure that the new ministerial board on prevention is able “to drive and co-ordinate cross-government action on prevention and improve accountability on the wider determinants of health.” The lessons of the past are that deliverables based on outcomes are essential to drive true accountability.

The Prime Minister should chair the new ministerial Board to ensure authority to act.

The Board working through the Number 10 Delivery Unit, should ensure that Government departments are held accountable for progress in their respective areas of responsibility and that they engage effectively with key stakeholders such as DsPH to ensure their roles and expertise are valued and resourced.

To further enable local government to meet their public health duty a full review of public health law including ongoing powers for DsPH is needed to ensure councils have the right powers to exercise.

In Wales, the importance of improving social determinants in order to ensure future wellbeing has been recognised nationally through the Well-being of Future Generations (Wales) Act 2015. The Act requires public bodies in Wales to think about the long-term impact of their decisions, to work better with people, communities and each other, and to prevent persistent problems such as poverty, health inequalities and climate change.

The forthcoming National Health Index developed by ONS to sit alongside GDP as a measure of national success is a welcome step forward. The function could provide regular reports on trends in healthy life expectancy and health inequalities and could be further developed to assess options for action to improve health in view of these long-term trends. It is crucial that expert health economic advice to Government is independent and made widely available.

Tackling the social determinants of health is closely bound up with reducing health inequalities, since the factors that influence overall health are the same as those that result in differences, inequalities and inequity in health. Also, more equitable communities tend to be more healthy communities.

Many councils have adopted a Health in All Policies approach. Health in All Policies (HiAP) is a method that systematically and explicitly considers the health implications of the decisions we make. It targets the key social determinants of health, looks for synergies between health and other core objectives and the work we do with partners. There is a lot that national government can learn from HiAP approaches in local government and around the world.

A stakeholder advisory group should be established, bringing together key stakeholders including public health bodies and charities to advise on policy and implementation.

There should be greater flexibility and mobility of public health expertise across Government (ie through secondments and fellowship schemes).  A Health Inequalities Strategy should be developed with shared accountabilities across Government departments. This should build on the Prevention Green Paper and include binding national targets to reduce child poverty.

Question 4: How can we design or implement these reforms in a way that best ensures prevention continues to be prioritised over time?

Insufficient public health funding remains a key challenge. The Singapore Health Promotion Board has been cited by Government as an example of success for the OHP to model itself on, but the per head investment is more than double that currently in place in England.

In addition to increased investment in public health, there also needs to be better alignment of the existing money within the system. The Secretary of State must deliver on his commitment to “put the power of the NHS budget behind the prevention agenda”, by empowering the ICS locally to support the integration of NHS and LA responsibilities to promote good health and give them the powers to work together as equal partners to deliver on that promise.

Local authorities must be an equal partner in all ICSs and the DPH role in ICSs must be influential across whole agenda and not side-lined to one work stream. Similarly, ICSs should be actively engaged in Health and Wellbeing Boards.

Strengthening our local response

Question 1: How can we strengthen the local authority and Director of Public Health role in addressing the full range of issues that affect the health of local populations?

Local government has a political and representative responsibility, with a mandate deriving from the same source as central government. Local government must be seen as more than a set of institutional arrangements for delivering, or overseeing, public health services.

Inappropriate national priorities that do not allow local public health teams the flexibility to address their own priorities will create unhelpful barriers.

Local Authorities are an important point of continuity between the old arrangements and the new. DsPH need a meaningful role in both ICS and Health and Care Partnerships to ensure that they can play their essential prevention role across the system. Health and Wellbeing Boards are already in place as a statutory function and have the potential to deliver the partnership working that is needed between local authorities and the NHS and the local and regional system.

Local authorities need stable funding arrangements that allow them to undertake the long-term planning and investment needed to secure improvements in public health.

Public health grant allocations have fallen in real terms from £4.2 billion in 2015–16 to £3.3 billion in 2021–22. On a per head basis that equates to a 24 per cent cut since initial allocations were made in 2015–16. LAs need stable and sufficient funding arrangements that allow them to strengthen their workforce, and undertake the long-term planning and investment needed to secure improvements in public health.

Government should consult on what additional powers and responsibilities could accelerate local public health action on the wider determinants of health. Planning, transport, licensing and other areas offer potential for more action in support of public health. The consultation should include consideration of the inclusion of public health as a licensing objective for local authorities.

Question 2: How do we ensure that future arrangements encourage effective collaboration between national, regional and local actors across the system?

The public expect their levels of government to be working together, and to see evidence of that.  Including local government representatives in ministerial discussions would demonstrate a strong unity of purpose and a combined commitment to promote and implement health improvement.

Better coordination between the local, regional and national levels of response and greater support for organisations involved in response planning is needed to share and apply learning from exercises and real-life events.

There needs to be a clear policy of subsidiarity (ie the appropriate footprint for action with authority to deliver for maximum effectiveness and efficiency) to enable and prioritise local decision-making.

Council areas are unique with no two the same, even at a regional or sub-regional level.  Some big cities may have high levels of deprivation and a high number of residents with chronic long-term conditions, whilst other more rural areas may be relatively prosperous but have a high number of retired people. Freedom and discretion to make local decisions on public health is therefore crucial.

A strong set of national objectives and supportive metrics which provide the accountability framework for the whole system is essential. However, local and regional flexibility is also needed to ensure that approaches are responsive to the needs of local communities.

Question 3: What additional arrangements might be needed to ensure that regionally focussed public health teams best meet the needs of local government and local NHS partners?

Regional teams need to be adequately staffed to be able to effectively support RDsPH in their convenor role. They need to be able to work across UKHSA, NHS and local government across the region to provide the glue that links the system together.

Regional arrangements must be co-designed with local partners. Flexibility should be built into the system to allow for differences across the regions and to ensure cohesion with local systems. A one size fits all approach must be avoided.

Regions need to have the scope and independence to develop regional approaches built on local insights while also being accountable to the national vision. A clear role needs to be articulated for the RDsPH so they are able to deliver a locally responsive but nationally accountable strategy for the region.

Key to the successful functioning of regional activity is adequate Knowledge and Information teams. The way in which these will operate needs to be clearly set out showing how they will support the functions of the RDsPH and provide the insights and data needed locally and nationally as well as regionally. 

Secondments (ie national and regional to local; local to national and regional) should also be used to mobilise expertise across the system and should be part of workforce development.

The system must allow for robust and complete data and intelligence flows across organisational boundaries with the geographical granularity and timeliness to support action at regional and local levels. This should include wider demographic and health data to allow for action on inequalities and wider determinants.

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.

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 focused on things that can be measured.

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 sector led improvement would increase the emphasis on robust challenge and accountability, and on shared learning, both locally and nationally.

Contact

Paul Ogden
Senior Adviser
Phone: 02076643277
Email: paul.ogden@local.gov.uk