Public health in local government: Celebrating 10 years of transformation

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This year's tenth Local Government Association (LGA) public health annual report reflects on 10 years of public health in local government and looks forward to the opportunities and challenges of the coming years.

Foreword

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We are delighted to introduce the tenth Local Government Association (LGA) public health annual report, which reflects on ten years of public health in local government and looks forward to the opportunities and challenges of the coming years. 

The public health annual reports trace the progress of public health in local government year-on-year. They provide a valuable legacy that allows us to understand how far we have come and where we need to go. Altogether, 65 public health councils from across England have been featured as case examples.

Based on this information we can say with complete confidence – public health is in the right place! Councils are in the best position to build local partnerships to tackle the wider factors that lead to ill health like substandard housing, unemployment, and lack of physical activity. In this, we work alongside our committed partners in the NHS, the voluntary and community sectors, other public-sector and independent organisations, and, most importantly, citizens, because only through inclusive partnerships and engagement will health and wellbeing become the norm for all.

The years of COVID-19 have been tumultuous and devastating, with public health at the centre of measures to tackle the pandemic nationally and locally. Our admiration for the way public health, wider council colleagues, the NHS and amazing volunteers have worked tirelessly to reduce its impact is unbounded. As it is widely recognised, the pandemic has brought us closer together. We have experienced the value of partnerships where organisational badges no longer matter. We must now make this the basis of our future collaboration across systems, places and neighbourhoods.

Whenever there has been time and space, directors of public health and councils have looked to recovery and renewal – to how the impact of COVID-19 on health and wellbeing can be addressed. There is growing evidence of significant harm to mental and physical health, particularly for those facing inequalities and children and young people whose lives and education have been limited.

Despite this, councils and their directors of public health, as reflected in this report, and its predecessors, remain relentlessly positive about the potential to make a difference. This report demonstrates clearly how work to protect and improve health and wellbeing has greatly expanded since the transfer and how local councils and partners now provide a comprehensive range of measures across all areas of public health.

As we move to a phase of COVID-19 recovery, the task ahead will not ease, but as this annual report shows, we are building on ten successful years of public health in local government and strong collaboration with key partners.

With a growing understanding of the vital importance of the nation’s health and a commitment to improving health and wellbeing for those most at risk, we can be optimistic that public health will continue to grow in confidence and effectiveness in the years to come.

Cllr David Fothergill and Jim McManus portraits

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Introduction

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The LGA’s 2022 public health annual report, jointly published with the Association of Directors of Public Health (ADPH), reflects on and celebrates an important milestone – ten years of public health in local government, including the transitional year of 2012.

Public health was transferred to local government through the Health and Social Care Act 2012, which moved the responsibility and funding for an extensive range of public health services from the NHS to councils in April 2013.

While many of the other reforms in the 2012 Act were controversial and are now being dismantled through the Health and Care Bill, the transfer of public health received cross-party agreement and wide-ranging support from organisations and individuals with an interest in health and wellbeing. The reason, as contributors to this report, points out, is that local government is best placed to embed and extend health and wellbeing with local communities, across all the functions for which they are responsible, and through the extensive range of local and regional partnerships which they lead or support.

The transfer was a major change to public health policy and delivery – “one of the most significant extensions of local government powers and duties in decades” (LGA 2019). Despite the scale of the challenge, relocation was relatively seamless in most areas. A major factor was the year of transition and learning in which directors of public health (DsPH), councils and the NHS shared a determination that this would not be a ‘drag and drop’ exercise, rather an opportunity to build a new locally led twenty-first-century public health service.

The recent report supports the transfer and demonstrate its impact.

Central to this year’s annual report, as in previous years, are case examples from DsPH in eight councils across England covering both rural and urban environments, and with different levels and types of deprivation, affluence, health inequalities and population health needs.

This year we have repeated the approach from the LGA’s popular series of interviews with DsPH on their role in leading the local response to COVID-19 by asking for their personal experiences of public health in transferring to local government, what they have achieved so far and their reflections on the future. We also asked for the views of chief executives and lead councillors on the impact of public health on local government. The interview areas have all appeared in previous annual reports in different years. Some of the directors leading the case examples have been in post since the transfer and were previously DsPH in the NHS. Others were NHS consultants and joined their councils as DsPH more recently. The report also draws on themes identified in the nine previous public health annual reports and information gathered for related LGA public health documents.

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Summary of key themes

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Becoming public health councils

Local government is absolutely the right location for public health. The NHS has a vital role in health and wellbeing, but councils are public health organisations that can utilise all their functions, community relationships and extensive partnerships to promote health.

Public health and councils influence each other, learn from each other and grow together. Public health councils have health and wellbeing ingrained in their DNA and at the core of their corporate strategy. The direction of councils is being shaped by public health.

Over the years, health has become an important part of council functions, like planning and leisure, and has extended to wider partnerships such as those responsible for work, training, economic development and the environment. Councils and partners are delivering an extensive and comprehensive range of health and wellbeing measures to meet local priorities.

Councils value the evidence-based approach, wide skillset, tools and professionalism of public health. Public health values direct links councils have with communities, the freedom to get on with the job once a direction has been agreed, and access to a wide range of important partnerships.  

Directors of Public Health love their job – “the best job in the world” – despite the toll taken by the pandemic.

Every council is different, and there appears to be no ideal model for how public health should be organised. Over the years, many directors have taken on additional management responsibility for council functions such as community safety and resilience, culture and leisure, and many others. DsPH value direct access to the chief executive and the lead member for health, and membership of the senior management team because of the opportunities to extend and deepen their influence.

Directors came to local government with an ethos of using influence and evidence to encourage all parts of the council to actively promote health and wellbeing – creating a public health council – a council-wide public health team – a public health family. This way of working continues. Effective directors are flexible, pragmatic, opportunity spotters, well-organised and good communicators – all of which has been demonstrated during COVID-19.

Public health councils, working with their partners, have been central to the quick, thorough and joined-up local responses to tackling all stages of the pandemic.

The future

The core of public health work needs to take place locally – in places, neighbourhoods and communities. Only locally based public health can respond to different health needs, disparities, aspirations and priorities in their areas.

Public health generally has the following plans for the coming year:

  • reviewing and strengthening health protection and resilience systems
  • coronavirus recovery – supporting groups whose health and wellbeing has been most affected by the pandemic with a particular emphasis on health inequalities
  • refreshing health and wellbeing boards (HWBs) as integrated care systems (ICS) establish integrated care partnerships and boards to increase joint approaches to prevention and tackle the wider determinants of health and health inequalities
  • caring for staff health and wellbeing following the intense COVID-19 effort
  • returning to local priorities that were interrupted by the pandemic.

Changes to ICS structures (see national developments section below) are seen as a potential opportunity, but more alignment is needed for health and wellbeing initiatives at the levels of place and with communities and neighbourhoods.

A wide view of prevention is needed, one that encompasses health improvement, health protection and tackling the wider determinants. The increased NHS emphasis on prevention is very welcome but there is widespread concern that a medical approach to prevention, focused on short-term gains to reduce immediate pressures on NHS services, must not become the dominant model. National direction is needed so that acute and emergency care priorities do not dominate prevention.

There is great potential for public health to collaborate at system, region and combined authority level on activity best carried out at scale – from collaboration on reducing problems like suicide to employment initiatives and infrastructure projects such as promoting active travel.

There is still much more to be achieved. As public health and councils grow together, policies develop, and opportunities emerge. When partnerships choose a manageable number of priorities and follow through with sustained, consistent action over years, then success follows. Resources are extremely limited, and every action needs to have maximum impact on health and wellbeing.

There are problems recruiting and retaining suitably trained and qualified staff, particularly in rural areas. The pandemic has attracted enthusiastic new staff who need support and training. Public health training and workforce issues need to be addressed on a national basis as well as through local or regional academic partnerships.

Councils and partners learn from sector-led improvement approaches that assess how they can further develop their work in health and wellbeing to address local health needs, benefit local communities, and identify ‘what good looks like’ locally.

Public health has changed and developed significantly during its time in local government and through COVID-19. It is time for a revision of the discipline and the profession.

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Ten years of transformation

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This section looks back at the ten LGA public health annual reports that, together, provide a resource that charts the changing nature of public health in local government. Current DsPH were also asked about their experiences over the last ten years.  From this, three broad phases were identified.

First years – bedding in and reaching out

A key area of interest in the first annual reports was how public health teams were organised within councils. The reports identified a range of different models, from full directorates to small core teams with wider dispersed membership.  A few directors were given additional responsibilities at the point of transfer. These, most frequently, involved emergency and resilience planning, community safety and environmental health and generally applied where directors were already well established in the council through pre-existing joint management arrangements.

DsPH felt strongly that to reflect their senior, cross-council role, they should report directly to the chief executive and the lead member for health and wellbeing and should be part of senior management teams. The case studies showed that councils had developed a range of accountability models.

In the first annual reports, directors described the benefits of the shift to local government, and this was confirmed by the directors interviewed this year. Public health felt closer to local communities and valued the democratic system in which councillors represented citizens’ views. The range of potential partnerships was extensive, and there was a new freedom to take independent action to meet agreed priorities.

Challenges in the transfer included cultural and organisational differences, such as how decisions were made. An initial difficulty experienced by many directors was a lack of understanding across the council of what public health was and what it could do, coupled with high expectations of what it could achieve.

Directors came to local government with an ethos of using influence and evidence to encourage all parts of their council to actively promote health and wellbeing – creating a public health council – a council-wide public health team – a public health family. This ethos continues to be widely embraced today. The same skill set for directors and teams also remains relevant. Effective directors are flexible, pragmatic, practical, opportunity-spotters, horizon-scanners, well-organised and good communicators – all of which has been demonstrated during COVID-19.

One of the issues facing directors was where to start to make the most of the extensive opportunities across councils and partnerships. Typically, they took a pragmatic approach, starting where people were most open to change. This varied from area to area and included planning, licensing, environmental health, sports and leisure, the voluntary and community sector and many others.

Many directors who transferred already had a wish-list of changes that were difficult to achieve in the NHS. Often, this involved using council commissioning skills to re-commission services, such as sexual health, to be more community-based and digitally accessible. Another key aim in many areas was to join-up early years services to create a seamless response across health visitors, education and community services like Sure Start. Some areas focused on preventative support for people receiving adult social care, such as NHS health checks for people with learning disabilities. In county councils, districts came on board to develop health and wellbeing initiatives in their areas.

DsPH often took a lead role in developing HWBs, joint strategic needs assessments and health and wellbeing strategies which led to improvements in data and information analysis, such as establishing observatories. This work underpinned future prioritisation and health and wellbeing strategies.

Midyears – extending influence with limited resources

The midyears of annual reports reflected a surge of energy from local areas as the plans set in place in the first years of transfer came to fruition. Interview questions no longer focused on structures or accountability as it became clear that successful directors found many ways of achieving organisational and political influence. Some directors continued to take on management responsibility for other council functions, seeing this as an opportunity to exert more direct influence over key health-related areas.

In this period, directors were asked to describe the developments in their council, and the case examples became lengthy due to the extensive activity underway or planned. ‘Health in all policies’ and ‘making every contact count’ initiatives were rolled out, usually across the council, also with the voluntary and community sector and in the NHS. Major inroads were being made to improve the social determinants of health, such as restricting alcohol or fast-food licenses in areas where these were over-represented or were causing health problems.

This period saw expansions in asset-based community development in neighbourhoods with significant levels of deprivation, often involving the development of community hubs, anchor organisations and peer support, such as community-led cooking or exercise initiatives. Such developments have proved both effective and popular, but they are often based on short-term funding, and the challenge is to make them sustainable and comprehensive.

Councils were also joining up health improvement services to provide a single point of access with holistic support so that, for example, someone attending smoking cessation support would receive debt advice or healthy eating where needed. Areas were tackling specific health issues that were priorities in their areas, such as male suicide – finding innovative ways of engaging with people like through barbershops, links with sporting venues and men’s sheds.

Regional and subregional collaboration across public health councils continued to develop alongside sector-led improvement activity, including peer reviews. The types of collaborative programmes – on issues ranging from stop smoking, mental health and alcohol harm – provide useful information about what activity can be effective at scale.

Improving access, updating communication methods and use of technology were priorities for public health. More services provided online access, particularly helpful for people living in large rural councils and working-age adults, while initiatives for children and young people, such as preventative mental health or bullying, used engagement methods designed by young people themselves.

A challenge during this period were the national cuts to the public health grant, which limited existing activity and curtailed new initiatives, such as pump-priming pilot studies or partnership initiatives. These stringent cuts, against the background of wider local government budget constraints, have had a significant impact on what public health can achieve. However, people who were directors in both NHS and local government point out that the NHS public health budget was the first to be “raided” by local health leaders to meet funding deficits in acute services. While budgets were even tighter in local government, at least there was more opportunity to discuss how resources could be allocated, and savings made, on a cross-council basis.

Recent years – public health councils, comprehensive public health measures and COVID-19

In recent years, local authorities have become public health councils. Public health is an automatic part of their work, “part of their DNA”, “like the bins”.  Health and wellbeing are at the core of corporate strategies, and sometimes the corporate strategy and health and wellbeing strategy are combined. This can be an important shift in emphasis – moving from a series of interlinked strategies for which different councillors and directors are responsible, to shared objectives to which everyone contributes. Health and wellbeing are at the heart of this approach and central to the work of councils.

Another approach in some councils, particularly those with areas of high deprivation, is to develop neighbourhood working in which services operate in and with local communities, aiming to provide joined-up, holistic support. Integrated neighbourhood working across councils, NHS and other public sector functions, working closely with the voluntary and community sector and actively promoting asset-based community development and health improvement can be seen as a gold standard for improving health and wellbeing.

As in previous years, the way public health is organised in councils varies greatly, as does the size. Some are teams, and some are extensive departments. Line management by the chief executive, membership of the senior management team and working as a portfolio holder remain important to DsPH. Some say they would not accept a job that did not provide this level of seniority.

During this period, the range and extent of public health activity, both direct and through influencing partners, became so large that it was not possible to produce annual report case studies covering all activity, so these shifted to specific examples of good practice or innovation. Public health made inroads into most council functions that influence the social determinants of health. A theme in recent years has been greater public health involvement in training, employment and poverty, involving partnerships with local business and training sectors and wider collaboration in combined authorities, regions and sub-regions. Similarly, public health teams work closely with environmental and climate change agendas and have ongoing involvement in the health aspects of large infrastructure projects such as eco-housing and active transport.

A theme in recent years has been a small but noticeable shift away from commissioning public health services to returning these in-house. Direct management is seen by some as facilitating more effective integration of public health services and wider health, care and community services.

Throughout its time in local government, public health has developed inventive solutions and new models of service delivery. It has also been involved in partnerships with academic institutions, carrying out research with practical benefits in a wide range of areas such as community development, the impact of pollution on health and healthy employment.

Directors are clear that there is still much more that can be done to develop health and wellbeing. Councils and public health grow together. Priorities change, and opportunities can emerge at any time. For example, a council may shift its operating model to focus on community development or to place health at the centre of sports and culture.

The DPH interviews show that where an issue is a shared local priority and is the focus of clear, ongoing partnership commitment over several years, successful outcomes follow. But resources do not allow this level of attention to every health need, so prioritisation, strategic agreement and long-term planning are crucial to tackling the issues that really matter in an area.

The directors all felt that their councils were proactive public health environments but were aware of some colleagues working in other areas where things seemed to happen more slowly. All councils and partners will benefit from the sector-led improvement approach to assess where they can best further develop their work in health and wellbeing to address local health needs, benefit local communities and identify ‘what good looks like’ locally.

Years of public health working across councils, with the NHS and local communities were fundamental to the superb local responses to COVID-19 described in last year’s annual report 'Public health at the heart of policy: meeting the challenges of COVID-19’. Since then, partners have continued their efforts to tackle the pandemic by the tremendous vaccination effort, clear communication, contact tracing and testing, advising on safe environments, improving data, and maintaining services as much as possible.

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Future priorities

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There are significant similarities in the future priorities and challenges identified by this year’s example areas, shaped by the pandemic experience. While COVID-19 and its legacy are a terrible experience for individuals, staff and communities, there have been positive impacts on organisations and partnerships, which are at the heart of future priorities.

COVID-19 legacy

The increased profile of public health during the pandemic provides a window of opportunity to promote work on health and wellbeing across multiple partnerships including:

  • increased public understanding of the importance of health and, potentially, a commitment by individuals to living more healthily
  • increased awareness of the importance of health in staff groups – could lead to extending health and wellbeing workplace opportunities
  • deeper engagement with local communities
  • improved collection and use of data
  • an appreciation of how single-minded focus on shard goals across organisational boundaries can result in great achievements
  • DPH networks, such as sector-led improvement groups used for joint work on the pandemic, as well as peer support, have been greatly strengthened.

Challenges include:

  • the impact on people’s health, and catching up on an activity that had to be paused
  • the exacerbation of health inequalities
  • an exhausted workforce.

Strengthening whole-system health protection and resilience

Areas intend to review their health protection, resilience and emergency response systems to make sure they apply to learn from the pandemic and are effectively organised and resourced for future threats. The focus is not just on future outbreaks, but all health protection measures, from antimicrobial resistance to weather events and climate emergencies. Areas also intend to focus more on impacts on communities and individuals and strengthen public engagement.

COVID-19 recovery                                                                          

Areas are taking a range of measures in their corporate COVID-19 recovery plans. This may involve reviewing and augmenting existing services that have been scaled back due to staff redeployment or shortages. Investment is also being made in groups that have been particularly affected by the pandemic. Dependent on local priorities, these include mental health – both adults and children/young people; children, young people and families; drug and alcohol harm; homelessness; and domestic violence.

COVID-19 recovery and health inequalities

A key priority is to deliver an inclusive recovery for groups experiencing worsening health inequalities. Understanding of health inequalities has increased across all organisations during the pandemic, which provides a good opportunity for partnership work. Measures include health improvement interventions targeted at particular groups and communities; asset-based community development or neighbourhood working; and levelling up interventions around developing skills and promoting employment.

NHS partnerships

Most areas are looking to refresh their HWBs and health and wellbeing strategies, in light of COVID-19 impact and changes through the Health and Care Bill (summarised in ‘national developments’ below), particularly the creation of integrated care partnerships, the development of place-based arrangements and primary care networks (PCNs).

Directors are supporting the development of integrated care partnerships and their relationship with their health and wellbeing board. They are seeking to further embed health and wellbeing in places, PCN partnerships and provider collaboratives, such as an integrated approach to social prescribing across councils, communities and PCNs, or health improvement projects linked to secondary or primary care services. Most areas are looking to build on the improved data infrastructure, collection and analysis developed during the pandemic. All are hoping to revitalise or establish a comprehensive and resourced approach to prevention through integrated care partnerships and boards.

Caring for staff

Directors are aware of the impact of the pandemic on public health staff who has been on the frontline and working at an unsustainable pace for two years and believe it is essential to support their health and wellbeing. They report that, although tired, staff are now enthusiastic to move beyond the pandemic and focus on recovery plans.

Collaboration at scale

Public health collaboration and peer support across councils was extremely helpful in tackling the pandemic and has led to a renewed interest in further developing partnerships across health systems, regions/sub-regions and combined authorities.

Revisioning local government public health

Public health brought a rich collection of methodology, research, evidence, and models to local government. These include data analysis, health impact assessments and health equity audits. It has greatly extended its reach into many new areas, like community development and promoting employment, which were only lightly touched on in the NHS. Public health models continue to develop learning from operational experience, local studies and academic research.

Arguably, the ethos of public health is changing through its work in councils, with greater emphasis on fairness, equality and learning from individuals and communities. As a profession, some DsPH and members of their teams now have both management responsibilities, as well as their advisory and expert roles. How these two roles best work together needs to be considered.

An environment that requires strict prioritisation of resources leads to questions like What works best? How do we know? How can we measure effectiveness?  Ten years of case examples demonstrate a high degree of synergy between the approaches public health has taken in different areas. However, a small but significant minority have questioned whether some approaches are sufficiently effective in terms of value for money and health impact – most notably NHS Health Check, population health analysis, making every contact count type-initiatives, and behaviour change campaigns.

Directors in the interviews felt that the years of working in local government and responding to COVD-19 have brought about significant changes in public health and that the time is right to explore and evaluate how it operates in the new world and to develop a new vision for the profession and the discipline.

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Challenges

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NHS restructuring and prevention

While NHS partnerships were seen as offering significant opportunities for extending prevention and tackling the wider determinants of health, there were major concerns that opportunities may not be realised.

Relationships with the NHS varied in case study areas; all were described as good, very good or excellent, but in some areas, they were seen as less close than in previous years. Often this was attributed to the development of ICSs, with power shifting from place to provider collaboratives and systems, and with insufficient alignment between PCNs, council services and neighbourhoods.

Although the use of data across councils and the NHS had improved during the pandemic, there were different views about the direction of population health management in systems, places and PCNs. Directors support a broad approach that combines aggregated health data with qualitative information from communities to produce a full picture of health needs and priorities, which takes account of social and economic factors.

Directors welcomed the increased NHS emphasis on prevention but were concerned that this could be narrowly applied to interventions aimed at relieving immediate pressures on NHS services. While there are many examples of NHS services taking a wider view of preventative health, such as GP practices organising walking groups, these often happen because of individuals’ interests rather than aligning social prescribing with community and health improvement services. Local NHS organisations are often keen to do more but must focus on national priorities. A national shift is needed to ensure that health systems are encouraged to take a longer-term view of prevention, including the wider determinants of health, health inequalities and levelling-up, and to have the freedom to invest in the wide range of preventative activity.

Skilled workforce

Securing a trained and highly skilled public health workforce was identified as a significant challenge, particularly in rural areas. Work to tackle the pandemic has introduced new workers into public health and many are keen to stay and take on new skills. Local action is being taken to attract, train and support the workforce, but training is seen as a national issue with the new investment needed.

Funding concerns

Analysis shows that the public health grant, which provides dedicated funding for all council public health functions, has been cut by 24 per cent in real terms per capita since 2015 to 2016, equivalent to a total reduction of £1 billion. The greatest cuts have been in deprived areas with the highest levels of health inequalities. The public health settlement for 2022/23 provides some stability to plan vital services, but no real-terms increase in public health funding, yet again, inevitably sets limitations on what can be achieved.  The LGA and partners including the Association of Directors of Public Health (ADPH) are clear that public health needs long term funding, matching the growth in NHS funding, to allow councils to provide current services, to expand to meet growing health needs and health inequalities, and to properly contribute to the levelling up agenda.

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Overview of national developments in 2021/22

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New national structure for public health oversight

How public health is structured nationally changed during the COVID-19 pandemic, with the disbanding of Public Health England (PHE) and the creation of a dual structure:

  • The Office for Health Improvement and Disparities (OHID) sits in the Department for Health and Social Care (DHSC). It is jointly led by the Deputy Chief Medical Officer for England and the Director General for Public Health who report to the Health and Care Secretary and the Chief Medical Officer. Its remit includes tackling the top preventable risk factors for death and ill health including obesity, addiction and inclusion, mental health, and physical activity. OHID will assist ministers to work across the government to improve the nation’s health and to level up disparities in health using the latest data and digital tools.
  • The UK Health Security Agency (UKHSA) is an executive agency of the DHSC with the roles of health protection, planning the response to external health threats such as pandemics, and overseeing the Joint Biosecurity Centre and NHS Test and Trace. It is seen as a global organisation, contributing to world health security, and building on lessons from the COVID-19 pandemic. The DHSC gives the UKHSA targets and priorities for its work plan and investments.

Prevention, health inequalities and levelling up

In ‘Building back better: our plan for health and social care, prevention is described as a ‘central principle’ for reducing pressure on the NHS and levelling up. The Government intends to put a new requirement on NHS England to report on prevention expenditure and outcomes, including a ten-year projection relating to major preventable diseases such as diabetes.

In the White Paper ‘Levelling up the United Kingdom’, published in February 2022, ‘health’ and ‘wellbeing’ are both levelling up ‘missions’.

In ‘health’, the focus is on tackling “stark disparities” in health outcomes, with the mission that by 2030 the gap in healthy life expectancy (HLE) between local areas where it is highest and lowest will have narrowed, and by 2035 HLE will rise by five years. The policy programme will focus on:

  • improving public health
  • supporting people to change their food and diet
  • tackling diagnostic backlogs.

As well as continuing with ongoing priorities, such as the obesity strategy, several national policy documents supporting this agenda are expected in 2022. A White Paper on Health Disparities will set out the Government’s ambition to reduce the gap in health outcomes, with a focus on prevention, the wider determinants of health and disparities relating to ethnicity, socioeconomic background and geography. It will also reflect the positive partnerships and shared commitments to common goals shown during the pandemic. A new Tobacco Control Plan for England will set out plans to reduce smoking rates, with a focus on the most disadvantaged areas.

‘Wellbeing’ is an overarching levelling up mission that spans the three ‘Spread opportunities and improves public services’ missions of health, skills and education. The aim is that by 2030, wellbeing will have improved in every area of the UK, with the gap between top-performing and other areas closing. Wellbeing is described as the extent to which people “lead happy and fulfilling lives” and as being affected by a range of different factors such as health, jobs, community relationships and the environment.

While work needs to be done to effectively define and measure wellbeing, establishing this as an overarching mission shows the interconnectedness of social and economic factors on people’s lives and effectively reflects the role of public health councils in tackling the wider determinants of health. The expertise and input of public health will be vital for many of the levelling up missions within the White Paper – not least, communities, culture, sport and housing.

The creation of OHID is identified by Government as one important way of promoting cross-government action on health. OHID has reported on the review to the NHS Health Check programme which proposes a shift to an “intelligent” programme focused on individual behaviour and personal wellbeing. Local authorities will be asked to amend contracts to put more emphasis on long-term behaviour change. ICSs and health partnerships will be asked to ensure integration, with preventative interventions like smoking cessation and social prescribing. The programme will be available to younger people between 30 and 39 and there is an expectation of improved access for people who are most likely to benefit, such as people from deprived areas.

The Institute of Health Equity produced a report on the work of Greater Manchester (GM) Health and Social Care Partnership and the GM Combined Authority which are working together as a Marmot City Region. Build back fairer in Greater Manchester: Health equity and dignified lives sets out a health equity framework with recommendations for how the city region can build on its work to reduce inequalities. It concludes that a devolved city region is well placed to lead health equity through leadership capacity, partnerships and strong identity.

The new statutory planning and delivery landscape

The Health and Care Bill, passing through Parliament at the time of writing in January 2022, will establish ICSs to oversee the planning and delivery of joined-up health and care services in their system. Their four overarching aims are:

  • improve outcomes in population health and healthcare
  • tackle inequalities in outcomes, experience and access
  • enhance productivity and value for money
  • help the NHS support broader social and economic development.

Subject to the passage of the Bill, ICSs will have two statutory components: integrated care boards (ICBs) and integrated care partnerships (ICPs).

ICBs will be statutory bodies that bring NHS organisations and “partner members” together to improve population health and care. Clinical commissioning groups (CCGs) will be disbanded and ICBs will be taking over responsibility for their services. ICBs will be able to delegate functions and budgets to place-based partnerships and to provider collaboratives while maintaining overall accountability for NHS resources.

ICPs are statutory joint committees to be established by the ICB and local authorities in the system as equal partners. ICPs bring together, as a minimum, partners from health, social care, public health, the voluntary and community sectors, and the views of people who use health and care services and communities. Each ICP will develop an integrated care strategy to address the health, social care and wellbeing needs of the local population.

The planning landscape of system, place and communities, and neighbourhoods provides opportunities for public health to influence the development of prevention that shifts resources from acute health care and to deliver interventions that are more effective when delivered at scale using combined resources. ICPs will be able to build on existing ICS population health streams and on the work of HWBs, which will continue to have a key role at the place level. Most HWBs have already shifted, or are shifting, to put increasing focus on the social determinants of health. Greater collaboration may also bring opportunities to work with a wide range of partners and with devolved arrangements such as combined authorities to address difficult issues that cross organisational boundaries.

Impact of the pandemic on health and wellbeing

A growing body of evidence from many sources points to worsening population health needs and increasing health inequalities stemming from the pandemic. PHE’s 2021 Health Profile for England provides a summary. Key findings include:

Between March 2020 and July 2021, deaths were 1.14 times higher than expected across England based on data for the previous five years. They were particularly high in deprived areas – 1.17 times higher, and in Black and Asian populations – 1.5 times higher, reflecting the disproportionate impact of the pandemic on certain groups. Increased mortality has impacted life expectancy, with a fall of 1.3 years for males to 78.8 years, and 0.9 years, to 82.7 years, for females.

Fewer people with worsening health conditions accessed healthcare. For example, there were ten thousand fewer GP referrals to memory assessment services up to March 2021, and 16 per cent fewer cancer diagnoses between April and December 2020 compared with the previous year.

There are wide and growing inequalities across all indicators of child health between the least and most deprived areas – low birthweight, the prevalence of obesity, infant deaths and dental decay. In 2020, one in six children aged between five and 16 were identified as having a probable mental disorder, up from one in nine in 2017.

Data from the National Child Measurement Programme for 2020/21 shows large increases in childhood obesity from 2019 to 2020. In Reception, it was up from 9.9 per cent to 14.4 per cent and in Year six up from 21.0 per cent to 25.5 per cent. Children in the most deprived areas are more than twice as likely to be obese compared with those in the least deprived – 20.3 per cent to 7.8 per cent in Reception; 33.8 per cent compared to 14.3 per cent in Year six.

There was an “unprecedented” increase in deaths from alcohol, rising by 20 per cent in 2020 on the previous year, most likely due to increased consumption by an already at-risk group of heavy drinkers. The prevalence of ‘increasing or higher risk’ drinking remained above pre-pandemic levels until June 2021. It was greatest in the highest household-income group.

One positive note is that smoking prevalence dropped by a quarter to 15 per cent over the last seven years (PHE 2018), and in the pandemic there has been an increase in the number of people trying to quit, with a third more smokers trying to quit in the months up to June 2021. However, smoking prevalence remained much higher for some groups: people in manual occupations, with a long-term health condition, in deprived areas, and mixed ethnic groups.

There were wide inequalities in the proportion of adults meeting recommended level of physical activity and fruit and vegetable consumption. There was a reduction in physical activity levels, particularly among Black and Asian people and lower socioeconomic groups.

Long-term exposure to air pollution in the UK results annually in around 28,000 to 36,000 deaths, with the highest exposures in deprived urban environments. Up to July 2021, less road traffic led to improvements in air pollution levels.

References

Association of Directors of Public Health (2021) ‘Local leaders call for long term funding certainty for councils in Spending Review'

Buck, David (2020) ‘The English local government public health reforms’, King's Fund

DHSC (2021) ‘Build Back Better: our plan for health and social care’.

Department for Levelling Up, Housing and Communities (2022) ‘Levelling Up the United Kingdom’.

Health Foundation (2021) ‘Cuts to public health run counter to levelling up’.

Institute of Health Equity (2021) ‘Build Back Fairer: the Covid-19 Marmot Review’

Institute of Health Equity (2021) ‘Build Back fairer in Greater Manchester: Health Equity and Dignified Lives’

LGA (2019) ‘Improving the public’s health: local government delivers’.

LGA (2021) ‘Public health grants to local authorities 2021/22’

LGA (2021) ‘Public health annual report 2021: rising to the challenges of COVID-19’.

LGA (2022) ‘Levelling Up White Paper: LGA briefing'

NHS Digital (2021) ‘National Child Measurement Programme, England 2020/21 School Year’

OHID (2021) ‘Preventing illness and improving health for all: a review of the NHS Health Check programme and recommendations'.

PHE (2021) ‘Health Profile for England: 2021’

 

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Interviews with directors of public health

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In a series of interviews, councils and their directors of public health were asked for their personal experiences of public health in transferring to local government, what they have achieved so far and their reflections on the future. We also asked for the views of chief executives and lead councillors on the impact of public health on local government.