Lindsey Davies, President, UK Faculty of Public Health
Alongside its reforms of the NHS, the government plans to put in place what are arguably the most far-reaching changes to the English public health system since the first medical officers of health were appointed in the middle of the 19th century. County, unitary, and London Borough local authorities (LAs) will be given new responsibilities for protecting and improving the population's health. To help them discharge these, they will be required to appoint directors of public health (DPH; currently employed by primary care trusts [PCTs]), manage ring-fenced public health budgets and establish multiagency Health and Wellbeing Boards to provide strategic leadership and coordination. The DPH will be the LA's principle advisor on health. They will report annually on the health of the population and will work with colleagues from all sectors, including clinical commissioning groups, GPs, and NHS providers, to identify and address health needs
A new organisation, Public Health England, is being set up as an executive agency of the Department of Health to support national and local government; and there will be a new emphasis on outcomes, encapsulated in a public health outcomes framework.
Health needs and expectations are increasing. Epidemics and disasters do happen. The economy shows no sign of imminent recovery and health inequalities are likely to be exacerbated by the increasing disparity in income between the very rich and the poor. Now, perhaps more than ever, we need a robust public health system that protects people from harm, encourages healthy lifestyles, and ensures that effective and appropriate treatment and care can be accessed easily when needed. The UK is already recognised as a worldleader in public health. Will the benefits of this major reorganisation outweigh the risks?
At its heart, public health is about the organised efforts of society: coordinated activity across whole populations to makea significant and sustained impact on health. It depends fundamentally on reliable evidence, clarity of purpose, constructive relationships, and active participation. The new system could enhance each of these, but this will require changes to the planned legislation, adequate resources, and inspired implementation. At worst, existing relationships will be fractured, expert resources lost, and no one will know who is in charge when disasters strike.
If, for example, the DPH is part of the LA's most senior executive group, and is supported by a well-resourced expert team, they will be in a strong position to increase the health impact of every LA activity. A DPH in a less senior position, or with insufficient staff, will struggle to make their voice heard. Similarly, Health and Wellbeing Boards populated by senior local leaders who take this responsibility seriously could be a tremendous force for good health, bringing challenge and coherence to an increasingly fragmented NHS. Without that level of engagement, Boards may deliver little more than hot air.
Nationally, if Public Health England is, as proposed, part of the civil service it could be seen as an arm of the state rather than a trusted source of expert advice. Transparency in its working arrangements and independence for its professional staff and scientific committees will be essential if it is to inspire confidence. This should not be impossible, but would be a new and challenging way of working for any government agency.
There are further challenges in that the future employment arrangements for public health consultants and trainees are unclear, the continuing uncertainty is becoming dispiriting, and reductions in PCT budgets are now having a real impact on public health staff numbers. Public health observatories are a case in point: their analyses support public health activity across the UK and worldwide, but their funding has been cut and their future remains opaque.
National negotiations continue. The Bill is not yet law and it will be at least 2 years before any new system is in place. Meanwhile, the public's health demands action and we must all do what we can to ensure that the many excellent initiatives already in place are not lost in the turmoil of transition.