After the pandemic: is the new public health system in England fit for purpose?

The CHPI has been commissioned by the Joseph Rowntree Charitable Trust to conduct research on the new public health structures which have been put in place in England since it was announced Public Health England was to be abolished in 2020.
As the current pandemic has shown an effective, well organised accountable public health system is not only key to controlling the spread of a disease – permitting the wider economy and public services to function – but is also vital in addressing growing health inequalities.

To be effective a public health system must have the trust of the public and those who work within in it and there must be a clear of understanding of roles and responsibilities. To achieve its goals, it must also be joined up effectively with the NHS, social care and other parts of central and local government.

Background to the creation of the new public health system

The recent creation of the UK Health Security Agency (UKHSA) and the Office of Health Improvement and Disparities (OHID) to replace Public Health England has led to significant disruption to the public health system, with thousands of staff transferring to new organisations in the middle of the pandemic. These changes happened with no formal consultation and little Parliamentary scrutiny.

The UKHSA – which took on responsibility for the mainly outsourced “Test and Trace” function created during the pandemic – has seen its initial budget reduced by £12 billion which was 85% of its original budget – as the government wound down its response to COVID 19. This is estimated to be the largest reduction in the budget of a public authority over the course of one year. In addition, the structure of the NHS at local level has been radically re- structured with the creation of Integrated Care Systems under the Health and Care Act 2022. These new bodies are required to work closely with local authorities on issues relating to public health and health inequalities.

Research findings

We carried out a survey of all local Directors of Public Health (DPHs) in England between November 2022 and January 2023. We received 57 responses, which is around half of those Directors currently in post. We also undertook in depth interviews with 11 DPHs in December 2022 and January 2023 and held a seminar in March with DPHs and other public health academics.

As Directors of Public Health have responsibility for public health within local authorities we wanted to understand their perspective on the following issues:

• Are the objectives of the new system clear to those working in public health?

• Is it clear to those working in the system who has responsibility for protecting the public’s health at both a local and national level?

• Can public health specialists working in the new organisations give advice and undertake their roles without undue political interference?

• Is the new system more or less joined up than the one it replaced?

• Does the new system make the UK better prepared to respond to a pandemic?

Our survey results and interviews led to the following results and recommendations:

DPHs are much clearer about the aims and objectives of the UKHSA compared to OHID.
In relation to OHID 42% of DPHs were either quite unclear or very unclear about its goals and objectives, however in relation to UKHSA 66% of DPHs were either very clear or quite clear about its goals and objectives.

There is a lack of clarity amongst DPHs about who takes decisions at national level.
Prior to the abolition of PHE over 85% of DPHS were either very clear or quite clear about who took decisions at national level, however, since the creation of UKHSA and OHID now almost 50% of all DPHs were either not very clear or not at all clear about this issue.

A significant number of DPHs are not clear about the legal powers available to them to protect their local populations.
Nearly half of DPHs stated that they were not very clear or not at all clear about the legal powers available to them to protect their populations during a public health emergency.

The recent changes to the public health system, including the creation of Integrated Care Systems has made the system less joined up at local level.

Before the abolition of PHE and the introduction of Integrated Care Systems – 85% of the Directors who responded to the survey found that the system was either quite joined up or very joined up in their local area. After the recent reforms were introduced, 53% stated that the system was now not very joined
up or very disjointed.

There was significant concern amongst DPHs about political interference in the work of the new bodies, particularly in OHID.

Half of Directors of Public Health said they considered that those working for the UK Health Security Agency had limited freedom to provide advice and data without political interference; with 14% saying that they had no freedom and 25% saying that they had some freedom.

Almost half of DPHs said that they thought the recent changes would make the UK worse prepared for a pandemic than under the previous system.

Half of those surveyed said that the recent changes would make the UK either much worse prepared or slightly worse prepared to respond to a future public health emergency or the ongoing pandemic.

Our recommendations

Given the significant disruption caused to the system as result of this large scale transformation we do not recommend further major changes. However, we consider that there are 5 measures which can be taken by government to improve both the accountability and the functioning of the current system. We therefore recommend that the Department of Health and Social Care should:

• Set out the aims and objectives of the public health system and who is responsible for what.

• Clarify the role of public health within Integrated Care Systems.

• Enhance the independence and transparency of OHID.

• Ask the Law Commission to review the UK’s Public Health Law.

• Clarify the overall budget for England’s public health function for the next 3 years.

Project Advisory Board

Advising the project are Professor David Hunter (University of Newcastle), Professor Peter Littlejohns (Kings College London) Professor David McCoy (United Nations University) Professor Albert Weale (UCL) and Professor Martin McKee (LSHTM).

You may be interested to read the outcome of the recent research by Peter Littlejohns, David Hunter and Albert Weale into the abolition of Public Health England here which we have used to inform our current research project which you can find here.

If you have any further questions about the research or would like to be kept informed about the outcomes, please do get in touch here: [email protected]