The crisis of public health

The UK faces a health crisis. In 2018–20 growth in life expectancy stalled for women and declined for men, taking men back to the level in 2012–14 (ONS, 2021). Although the immediate cause was the outbreak of COVID-19 in 2020, a slowing-down in improvements in life expectancy had been happening for a decade, particularly affecting the most deprived 10 per cent of the population, and falling or stagnating for some groups (Marmot, 2022). In other comparable economies, life expectancy has increased at a faster rate (OECD, 2023), so the latest figures are the culmination of a longer term trend. But COVID-19 also led to a surge in the number of those of the working-age population being unfit for work through extended sickness. Before 2020, less than 5 per cent of the relevant population were unfit for work in this way; by 2022, it was more than 6 per cent (Neville and Borrett, 2023). COVID-19 hit the UK population hard because there had been a failure of public health planning over many years. The result was the growth in a number of health risks that bring illness in their wake and impose severe strains on the National Health Service (NHS). The omens in respect of these health risks look poor.

Consider obesity. As Figure 1.1 shows, obesity rates are high in the UK when set against comparable western European countries. While obesity has increased in all the high-income countries, rates in the UK more than tripled between 1975 and 2016, whereas France and Germany showed much lower rates of growth, as did other European countries like Italy. To be sure, the UK does not equal the US or Australia in its obesity, but it is closer to them than to its European neighbours. Obesity is an important public health measure because being obese leads to a predictor of poor health, causing strain on the skeleton and increasing the risk of fatal heart attacks or stroke. It also leads to an increased risk of type 2 diabetes, a disease that is responsible for some 10 per cent of NHS expenditure.

The background to this book was a research study that took place in 2021 and 2022. It sought to understand the circumstances surrounding the abolition of the main institution responsible for public health in England – Public Health England (PHE) – and its replacement by the UK Health Security Agency and the Office for Health Improvement and Disparities. As well as collecting data from published reports, national and parliamentary committee meetings and interviews, we also collected information on the structure of public health governmental organisations in the UK. The main study findings can be found here: https://arc-sl.nihr.ac.uk/sites/default/files/uploads/files/public-health-report-sept-2022-final.pdf (Littlejohns et al, 2022c).

The relevant issues that emerged as we described how PHE was closed can be found in a paper we published in Health Economics Policy and Law (Weale et al, 2023).

While the reasons were complex, they could be summarised by two competing interpretations: an ‘official’ explanation, which highlights the failure of PHE to scale up its testing capacity in the early weeks of the COVID-19 pandemic as the fundamental reason for closing it down; and a ‘sceptical’ interpretation, which ascribes the decision to blame-avoidance behaviour on the part of leading government figures. We reviewed crucial claims in these two competing explanations, exploring the arguments for and against each proposition. We concluded that neither was adequate and that the inability to address the problem of testing (which triggered the decision to close PHE) lies deeper, in the absence of the norms of responsible government in UK politics and the state. However, our findings did provide some guidance to the two new organisations established to replace PHE to maximise their impact on public health.

We then continued our thinking of what was required and presented a flavour of it in a Lancet Public Health Viewpoint article by Hunter, Littlejohns and Weale on ‘Reforming the public health system in England’ (Hunter et al, 2022).

We came to the conclusion that a completely new way of thinking about public health was required, and that would only be achieved by establishing a new social contract with the British people.

There is now general agreement that the UK is facing a public health crisis. Improvements in life expectancy have stalled, health inequalities are continuing to widen, obesity and alcohol misuse are placing an increasing strain on health services, and urban air pollution is now widely recognised as a serious health hazard. However, consensus on possible solutions is absent. COVID-19 revealed the weaknesses of the UK’s public health system – once thought to be among the best in the world. While we are still waiting for the official Covid-19 Inquiry to report its findings, an increasing number of studies are demonstrating where the problems lie – not only in infectious disease control but more generally in public health. Our own research study took place in 2021 and 2022, and sought to understand the circumstances surrounding the abolition of the main institution responsible for public health in England – Public Health England – and its replacement by the UK Health Security Agency and the Office for Health Improvement and Disparities. The publications that emerged from that original study are detailed in an appendix.

Our findings convinced us that what is urgently needed is much broader than simply targeted interventions. A fundamental public policy debate is necessary to stimulate interest in the vital importance of public health and a new approach initiated. We have come to the conclusion that a completely new way of thinking about public health is required, and that would only be achieved by establishing by a new social contract for the UK population. We are not alone in thinking that fundamental change is required. The Institute for Public Policy Research (IPPR, 2023) recently published its first interim report on health in the UK, advocating a new Health and Prosperity Act supported by a Committee on Health and Prosperity – modelled on the Climate Change Committee and designed to independently advise on the above mission (and hold all governments accountable to it).

Our book does not try to revisit all the theories and initiatives to improve public health but explores some of the fundamental barriers and why interventions (even those based on good evidence) are not adequately implemented. We address several key political and governance issues around the social contract idea. We build on the thinking outlined in the history of public health by David Hunter et al, The Public Health System in England (Policy Press, 2010).

Introduction

As we saw in the previous two chapters, the UK now has a new public health settlement. As far as England is concerned, in place of Public Health England (PHE), there are now two bodies, the UK Health Security Agency (UKHSA), with primary responsibility for health protection, and the Office for Health Improvement and Disparities (OHID), with primary responsibility for health promotion. (UKHSA also has responsibility for non-devolved health matters for the whole of the UK.) In addition, the administrative structure of the NHS has been altered with the establishment of integrated care systems (ICSs) intended to bring together local authorities, the NHS and other agencies with the intention of taking a population-based perspective. The one part of the original 2013 Lansley reforms that survived these changes concerns the public health responsibilities of local authorities.

The English reforms have been high-profile changes. Developments in Scotland, Wales and Northern Ireland, while significant, have largely involved a concentration of public health responsibilities over time as part of planned changes to administrative arrangements. In each case, however, the direction of change is the opposite of what has occurred in England. Instead of a separation of health protection and health promotion, the devolved governments have created integrated bodies. These bodies still have to liaise with local government, but they do so from a position in which public health can be seen as a set of overall responsibilities.

This chapter focuses on the policy and process issues to which these new structures give rise. The Hancock reforms, like many machinery of government changes, underline the point that, in some circumstances, organisational arrangements become the prime object of policy. Reorganisation provides a way of deflecting blame and also a way of seeming to make a new start quickly and visibly. Moreover, machinery of government changes are attractive to high-level political representatives, since they signal interest in an area of policy without the need to go into detail about any one aspect of policy. Thus, the political attraction of reorganisation is that it makes the politician play the role of God in eighteenth-century Christian theology, whose responsibility was to create the system that would then look after itself, according to its own laws. However, successful policy must go beyond the establishment of new organisations.

Introduction

In the previous chapter we saw how Public Health England (PHE) was the product of the Lansley broader reforms of the NHS, reforms that also included the return of public health functions to local government. A notable feature of the transformation of the UK since 1998 has been the extension and devolution of powers from Westminster and Whitehall to Scotland, Wales and Northern Ireland. Devolution means that in areas of policy that are not reserved to the UK government, which in health policy are very few, the governments of the home nations have the freedom to determine their own policies, priorities and structures. This has been notably true in the provision of health care services, where the Welsh, Scottish and Northern Ireland governments have opted for greater stability in place of successive structural reforms, and have not made competition and performance management a central guiding principle as the UK government has done to an increasing degree since the Thatcher reforms. However, the distinctiveness has also shown up in public health policies and structures.

Looking at public health in the devolved governments is important for a number of reasons, quite apart from the simple need to avoid Anglo-centrism. In the first place, the organisation of public health in the devolved governments provides interesting points of similarity and difference to those in England. If the replacement of PHE took place without any forethought, the same is not true in the other home nations where, in keeping with health care services, there has been great stability of organisation, alongside policy developments. So patterns of structural organisation provide interesting evidence of the various ways in which public health functions can be organised. As we shall see in this chapter, there is no one uniform set of functions that are the responsibility of the public health bodies. Functions that are the responsibility of a public health agency in one of the home nations may be the responsibility of, say, the environment agency of another home nation.

Variation in the home nations in the organisation of public health also potentially poses another challenge to effective public health. If public health requires intersectoral collaboration across government, the conduct of policy in the UK requires collaboration across the governments of the home nations.

Chapter 1 laid out the challenges of public health together with the intrinsic dilemmas and conflicts involved in making health truly public. The source of those dilemmas is to be found in the fact that public health identifies many sources of ill health in the determinants that are formed in complex social and economic systems. Ill health is the effect of multiple causes. In terms of governmental organisation, this means that a public health body must interact with a wide range of agencies and sectors across government. However, it also means that any such interaction needs to be based on a strong and well-resourced core of public health bodies, at different levels of government, which can identify health problems and formulate effective policies, even when those policies need the cooperation of other departments of state.

In this chapter we look at the history of those core organisations in England between 2013 when Public Health England (PHE) was established by the 2012 Health and Social Care Act, and 2020 when the announcement was made that it was to be abolished. Our aim is to show how the dilemmas and challenges identified in the previous chapter played out during this period. Figure 2.1 summarises the key points in the timeline.

Public Health England

As part of the Lansley reforms affecting the whole health system and not only the NHS, public health was reformed both nationally and locally as set out in a White Paper, ‘Healthy Lives, Healthy People’ (Department of Health, 2010), and subsequently in the Health and Social Care Act 2012. PHE was established as an executive agency to provide national leadership for public health, while locally the lead responsibility for public health returned to local government, where it had been located prior to the 1974 NHS reorganisation. Although separate from the Department of Health (now the Department of Health and Social Care, DHSC) and organised into regional outposts, from the outset PHE lacked the independence accorded to some other national bodies, notably the National Institute for Health and Care Excellence (NICE). As a civil service agency rather than an arm’s-length body, it remained part of the central DHSC.

We have argued that there is a fundamental puzzle at the heart of the public health crisis that now faces the UK. Although the problems are large, there are many policy measures capable of addressing them that are highly cost-effective and for which there is robust evidence. The importance of these measures has been recognised for decades by informed commentators on health services, the latest example of which has been the creation of integrated care systems (ICSs) and the proposals from the Hewitt Review for government to give a lead in prioritising preventive measures. Unless government implements these measures, the burdens on the NHS will increase, forcing an increasing rationing of medical care among the sick. To be sure, the administrative and governance barriers to action can be formidable. The measures require interorganisational collaboration, never easy for any organisation let alone governments, and an ability at the heart of government to think long-term. The measures also require being explicit about the trade-offs, including the trade-off between more private consumer spending and greater public health protection, that are involved in making health truly public. They require addressing the commercial determinants of health, strengthening and supporting those commercial activities that promote health and regulating and disincentivising those commercial activities that harm health. In short, the challenges of public health require a relentless focus on implementation and policy learning, with firm political leadership to ensure that measures are put into practice and the organisational barriers to public policy coordination overcome.

In this context, the focus on finding one right organisational structure displayed in the abolition of Public Health England (PHE) is inadequate. The view, expressed by Matt Hancock as Secretary of State, that the creation of the UK Health Security Agency (UKHSA) in place of PHE would be sufficient to avoid a repeat of the failures to upscale testing and tracing on the part of PHE was an example of naive ‘if only’ thinking, resting on the assumption that if only PHE had been like the Robert Koch Institute all would be well. Yet distinguished witnesses to the Covid-19 Inquiry, like Sir Chris Whitty and Sir Patrick Vallance, suggested the failures of PHE were the results of successive public underfunding, such that the UK was left without adequate stocks of personal protective equipment or the facilities to manufacture vaccines.

Introduction

The COVID-19 pandemic, it has been claimed, poses the gravest threat to the health and livelihoods of the British people since 1945 (Crewe, 2020). It is impossible to understand the devastating impact of the virus across the UK involving significant loss of life, and the government’s much criticised response to it, without applying the lens of a sociopolitical perspective. The virus has cruelly exposed deep-seated and long-standing societal inequalities and deficiencies in the infrastructure of public services.

Following the successful vaccine rollout in the UK and growing confidence that a return to some form of normality is in sight, it is easy to overlook the incompetence of the government throughout most of 2020 and early 2021 (Calvert and Arbuthnott, 2021).

A substantial body of evidence exists to show that the virus has had a disproportionate impact on poor communities, and on care homes, reflecting widening health inequalities and the effects of deep public spending cuts since 2010 (Marmot, 2020a, 2020b; Marmot et al, 2020a). With over 200,000 deaths recorded as of 9 September 2022, the UK has suffered the highest number from the virus in Europe apart from Russia. It therefore comes as little surprise to conclude that the government’s response to the virus from the outset has been found wanting and overly reliant on a public sector infrastructure that has been significantly hollowed out following a decade of austerity as part of a deliberate policy to roll back the state and reduce the size of government. This in turn has reinforced problems already evident in regard to the persistence of a dysfunctional health and social care divide, an overcentralised system of governance, a preference for uncritical outsourcing to the private sector, and a tendency to regard the National Health Service (NHS) as a special case – an institution meriting protection – while ignoring the significant public health challenges facing local government that has borne the brunt of spending cuts. Indeed, as Aileen Murphie states (Chapter 9, this volume), ‘spending pressures have fallen most heavily on local authorities’ adult social care, housing and public health services’.