Second joint statement to the Government on public health reorganisation

As organisations committed to improving health and reducing inequalities, we welcome the Government’s commitment to protect the public’s health, improve population health resilience and level up unacceptable variations in health. And the acknowledgement that these commitments must be embedded right across government, the NHS and local government.

This is an ambitious agenda, and it will be challenging to deliver. We have already set out the principles that we believe must underpin the new health improvement system. In our second joint statement we set out the tests that the new system will need to pass if it is to turn good intentions into truly world class outcomes. While our organisations have specific issues which we will address separately, these are the overarching tests that we all believe any proposals should be judged by.

Test 1: Sufficient and secure funding to scale up health improvement interventions.

This cannot be a cost-cutting exercise; more, not less, funding is needed for health improvement as well as for health protection. Any additional spending on health protection must not be at the expense of cuts in funding for health improvement. An analysis by the Health Foundation found that an extra £0.9 billion a year is required to reverse real term per capita cuts since 2015/16 and over £2bn a year extra would be needed to allow additional investment in the most deprived areas where there is greatest need. The Spending Review must put the public health grant on a long-term sustainable footing for the future.

Test 2: Sufficient high-quality public health experts in health protection, health improvement and healthcare public health functions.

The functions currently provided by PHE of evidence-based advice, guidance, and quality assurance to government, both national and local, and to the NHS, require a level of authority and expertise which must be sustained and enhanced, underpinned by full engagement with the training of the public health specialists of the future. There has been significant redeployment to health protection as a result of COVID-19, which has left PHE’s health improvement functions under-resourced. Whatever level of staffing is determined for NIHP from April 2021 onwards, it cannot be at the expense of a reduction in resourcing of the health improvement and wider functions. 

Test 3: The commitment and infrastructure to deliver health improvement at national, regional and local level Britain has an exemplar of successful health improvement which needs to be adopted by the new public health system both for physical and mental health improvement.

We are a world leader in tobacco control, driving down smoking rates by 60% since the start of this century. Success has been driven by a strategy combining population-level interventions delivered at national level such as legislation and well-funded social marketing campaigns, in support of place-based interventions by local authorities which are most effective when supported by regional programmes.

The national function is currently provided by a combination of DHSC and PHE. What is crucial is that it has protected funding and continues to exist, regardless of where it sits. Inequalities in smoking rates remain, but where regional tobacco control programmes have been in place, in accordance with NICE guidance, there have been significantly higher rates of decline, particularly in routine and manual groups. Regional programmes provide an effective and cost-effective bridge between national and local activity, and between local authorities and the NHS.

The new public health system must follow this model at national, regional and local level for all areas of health improvement. This is essential if we are to deliver the Government’s interlocking pledges to ‘level up’ society; significantly increase disability-free life years, while reducing inequalities; to improve mental health; reduce obesity and alcohol harm; and to end  smoking.

Test 4: A stronger health intelligence function which supports both health improvement and health protection and underpins accountability. 

The system must be accountable not just for absolute improvements in health but also reductions in health inequalities on key indicators such as those set out in the Public Health Outcomes Framework. It is vital that national datasets that provide definitive accounts of the health of the nation continue, that access to them is improved and public trust in them maintained. This also requires the current health surveillance, monitoring and analytical functions provided by PHE to be sustained and strengthened.

Test 5: Improved co-ordination between the NHS and local government.

Local authorities must remain the system leaders co-ordinating local public health strategies. However, for the prevention strand of the NHS Long Term Plan to succeed will require joint plans with local government and interoperability of IT systems to ensure speedy and seamless referrals. Integrated Care Systems need to be engaged as part of the move towards greater coordination, but do not have the reach to deliver the regional co-ordination function.

The existing regional structure put in place by PHE has been found to work effectively by local authorities, particularly during the pandemic. The joint Regional Directors of Public Health accountable to the NHS and PHE have a key role to play in both health protection and health improvement. This must be underpinned by a regional public health programme providing support and advice to local authorities as well as to the NHS, in line with the model already developed for tobacco control.

Test 6: Strong relationships across health protection and health improvement across all four nations of the UK.

As the interaction between COVID-19 and inequalities has shown, health protection and health improvement go hand in hand, they are not distinct, separate disciplines. Proposals for the new system must demonstrate that they can deliver effective communication and collaboration across health protection and health improvement; and between our nations. This is essential if we are to deliver better population health and reduce inequalities across the whole of the UK

The text of the first and second joint statements, together with a list of the supporting institutions can be found at https://smokefreeaction.org.uk/phehealthimprov/