The public health function in England post 2013 – shaken AND stirred?
The major health and social care reforms encompassed within the Health and Social Care Act (2012) profoundly changed the way the public health function is organised and delivered in England. Our research project – PHOENIX – examined those changes over a three-year period, using national surveys, key informant interviews and in-depth case study work. The research was carried out by a team within the Policy Research Unit on Commissioning and the Healthcare System (PRUComm).
Before the reforms, the Government were clear that improvement was needed: some outcomes, particularly for ‘avoidable’ deaths, compared unfavourably to other high-income countries; the structure and organisation of the public health function was felt to be fragmented and inefficient[i]; and it was felt that not enough focus was given to disease prevention, particularly through impacting on wider determinants of health at local level.
So, during the reforms, the public health structures and organisations were well and truly shaken, and the emotions of the public health workforce were effectively stirred:
- A new, national service – Public Health England (PHE) – was created by bringing together over 70 former public health organisations. Many (around 5000) scientists, researchers and public health professionals went to join central, regional or local PHE hubs.
- Key public health duties, staff and funds were transferred from local NHS organisations (Primary Care Trusts, abolished in 2013) to local government – specifically to 152 upper tier and unitary councils.
- A Health and Wellbeing Board (HWB) was created in each of these councils to bring together the key NHS, public health and social care leaders in each local area to work in partnership and to co-ordinate commissioning of their services.
- A public health grant was created to fund public health services, separate from the budget managed through NHS England for healthcare, to ensure that investment in public health was ring-fenced (although it was still subject to the running-cost reductions and efficiency gains that have been demanded across the system).
The health and social care reform process was not easy – many organisations and professional groups loudly voiced their opposition, and there was a pause in the legislative process to allow for a ‘listening exercise’, but the key Bill was eventually passed and received Royal Assent on 27th March 2012. The changes enabled by the Act, however, followed very quickly. With much of the nation’s focus being on the changes happening to healthcare commissioning, there was relatively little attention paid to the public health system. Some public health teams (made up of consultants, specialists and health improvement practitioners) transitioned into local councils as early as April 2012, with little clarity around roles, responsibilities, budgets, security of staffing, terms and conditions, and so on. We found from our research that many public health professionals had had to muddle through the transition process, with little guidance from Government. Consequently, the transition process was prolonged, stressful, and created bad-feeling in some quarters. The ease with which a public health team moved into its new local government home was in part determined by previous working relationships and the complexity (or not) of the local health and care system, but also the receptiveness of the council and the willingness of the public health professionals to adapt to new organisational cultures and ways of working.
Examining the impact of such changes has been challenging, especially in the context of the broader changes to the health and social care system, to other government policies in areas such as education and welfare, and the wider austerity environment. Our final report draws on the wealth of data we collected over the period from May 2013 to October 2015, and reflects on the key changes that have occurred.
Overall, our findings highlight that the public health system in England is still far from settled, with the internal organisation of public health in local councils, the NHS and PHE in a continuing state of flux. Some important concerns – many of which were identified during the passage of the health and social care bill – remain. Several of these have been discussed in the ongoing Health Select Committee Inquiry into Public Health post-2013. In particular, the increasing lack of independence of the public health profession, and the inability of public health consultants to speak out without fear of prejudice or other repercussions, featured as a concern both in our research and in the Committee inquiry. At local level, we found that public health directors were not always in the strongest position, organisationally, to influence strategic decision-making and work with other departments. Other important concerns that our research highlighted included: the risk of increased fragmentation across the system, with continuing confusion about organisational responsibilities in terms of commissioning; the demoralisation and fragmentation of the public health workforce; the impact of intense financial constraint in local government on capacity of public health teams; the distance created between public health and health services commissioners and providers, making them increasingly remote to the local public health systems; and distinct differences in development and approaches to the public health function across the country.
Whilst some anticipated opportunities have been realised – particularly with regards to public health specialists working across local councils – many are highly dependent on a range of local contextual factors. There has been widespread support for a stronger role for local councils in public health, but there is considerable variation in how the public health function and responsibilities are being developed. As Brackley argues in his recent blog, more work is needed to recognise the value of public health professionals within local authorities.
A period of great change in public health activities and services has begun, as council decision-makers work out how their public health grant (and staff) can best serve their communities. Contracts for public health services have received new scrutiny, and most councils have embarked on decommissioning and/or renegotiating health improvement services. We have been witness to much change in the public health function over the past three years, and we predict there will be more to come, as the ramifications of the reforms (and the budget cuts) continue to filter down to the level of activities, services and outcomes for population health.
Erica Gadsby worked on the PHOENIX project as part of a team of academics from the University of Kent, University of Manchester and the London School of Hygiene and Tropical Medicine. Other members of that team were:
CHSS: Stephen Peckham, Linda Jenkins, Jayne Ogilvie,
University of Manchester: Anna Coleman, Donna Bramwell, Neil Perkins, Julia Segar,
LSHTM: Harry Rutter.
For more details and a wider discussion of our research data and findings, refer to our final report, now freely available on the PRUComm website.
The research was funded by the Department of Health. The views expressed are those of the researchers and not necessarily those of the Department of Health.
[i] Hunter D, Marks L, Smith KE (2010) The public health system in England. The Policy Press. Bristol
Photo: World Obesity Federation © World Obesity
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