As the architect of the public health reforms, Andrew Lansley is both proud of what has been achieved, but frustrated by some of the missed opportunities.
“I think it is pretty clear it has been beneficial,” he says, pointing out this view has been independently corroborated by the King’s Fund which published a review of reforms in 2020 that concluded the move to local government was the “right one” and had prompted significant innovation and influence on policy.
“Having public health in organisations that have a significant impact on the wider determinants of health is important and I am pleased to see councils have seen it as an opportunity. On the whole, they have done their best to grasp it.”
But Lord Lansley accepts cuts to the public health budget have held council back too. “There has been significant under-funding. My expectation at the time was that the public health budget would rise at least in line with the NHS. The fact it didn’t is a major reason why the benefits were not as great I had hoped.
“And austerity lasted longer than expected. If you had said in 2012 it would be in latter end of second parliament that we would get back to traditional funding levels we would not have believed you. It was only ever meant to be for one parliament.”
Why fragmentation criticism is wrong
Lord Lansley also said there were some reasons specific to individual areas of local government that also explain some of the missed opportunities.
“In planning we have not seen the benefits realised as much as we have in other areas. It is a result of responsibility in two-tier areas not sitting in same council as public health and I think it has also proved quite difficult for planners to take into account the wider public health agenda when they assess the merits of individual applications even though we know the importance of green spaces and neighbourhoods that encourage activity.
“The role of local authorities in education has also changed much when you compare what was happening pre 2010 to what happened afterwards. It has meant the ability of directors of public health to influence those crucial stages all the way up to 16 to 18 has been more limited than we would have expected.”
Lord Lansley also defends the reforms against one of the most common criticisms levelled at them – that they led to increased fragmentation. One example often cited is sexual health where both local government and the NHS have roles in commissioning.
He said there was a clear logic to how the system was organised – and the reasoning behind it still holds true today. “The reforms were designed so that population health was within local government and individual health the NHS. If you look at who has responsibility runs through it all.
“So it was only right that with the rollout of PrEP the NHS lost its challenge. It should sit in local government and I think we are seeing the benefit of that in what is happening with PrEP.”
PHE dismantling ‘absurd’
Lord Lansley is also disappointed with some of the policy decisions taken once he left the role of health secretary in 2012. “In wake of 2013, the government did not do what I had set out. The commissioning board became NHS England. Now, some people will say that is just a name, but it is more than that. They have become involved down to a local level, one top-down approach has replaced another.
“Looking back I can see we tried to do things too quickly. But I’m certainly not alone in politics wishing things had happened different and feeling there is unfinished work.”
Lord Lansley is critical of the dismantling of Public Health England too and the creation of two new bodies – the UK Health Security Agency to focus on health protection and the Office for Health Improvement and Disparities to look after health protection.
“It was absurd to do it in the middle of the pandemic. It seemed to me that PHE were doing what they were told. They did not have a large testing infrastructure and then they found the finger of blame pointed at them.
“Now directors of public health have two organisations they need to liaise with. That relationship between local public health and central public health is crucial and it has been made more complicated.”
What I would tell future health secretaries
Looking to the future, partnership work is going to be crucial, Lord Lansley said, as public health and the NHS face up to the challenges of the next decade. “We have a serious problem with poor health – and I think that cost us in the pandemic. We have seen life expectancy rises stall and there is a particular problem with healthy life expectancy.
“We’ve made progress with smoking, but poor diet is a major problem – and I say poor diet rather than obesity because you do not have to be obese for poor diet to have an impact on your health.
“This going to be a major challenge in the coming years. My concern is that the focus is still not right in the NHS. It is still too focussed on targets rather than outcomes. What matters is not how long you wait in A&E, but that when you are seen you get the right treatment that means when you leave you can be assured of your health.
“Integrated care boards may help us get there, but the problem is it is so hard to move the system away from targets to outcomes. Health and wellbeing boards were meant to be the forum to bring local government and the NHS together and help make that shift, but they have not been properly implemented.”
So what advice would he give to secretary of state’s in the coming years? “There are three things,” he said. “Firstly, work towards achieving a cross-party, bi-partisan approach. Secondly, greater devolution. Greater Manchester has shown the benefits of this in terms of public health and moving towards pooled budgets. It allows a greater focus on outcomes.
“And, thirdly, remember politicians are not going to know more than the clinicians and other experts working in the field. Get them more involved in decision-making. That too will help you move towards a more outcomes-focussed way of working.”