The public health system – redesign during a pandemic

August 20, 2020 in ADPH Updates, Blog, Covid-19, Health Protection by Campbell Findlay

Dr Jeanelle de Gruchy, President, Association of Directors of Public Health

Arguably the time to ensure that we have national organisations able to cope with the surge of an inevitable pandemic is before it arrives. Dismantling a national public health agency in the middle of a pandemic citing this to not be the case is a bold move. Aiming to have set up the replacement within weeks, ready for a potential second wave seems ambitious and presents a significant risk.

As Directors of Public Health (DsPH) we recognise the real sacrifices our communities have already made to tackle COVID-19 and remain focused on managing and preventing outbreaks. The national public health system is critical to our ability to do this effectively. 

Following Sunday’s announcement, there has been both an outpouring of anger at the shocking way it was handled and overwhelming support for Public Health England (PHE) staff. Our Public Health colleagues are amazing, dedicated people – they have gone above and beyond over the last seven months and it was some consolation that this was explicitly recognised by the Secretary of State. Directors of Public Health work hand in hand with PHE colleagues; – locally, they are critical partners in protecting our residents’ health. We could not contain COVID without them.

The public health system is about to undergo significant change. We are keen to ensure the transition does not disrupt our COVID response, or indeed the other health protection and health improvement work PHE provide leadership on. And we will play an active part in ensuring that the new public health system is as effective as it can be to meet current and future public health challenges.

A new National Institute for Health Protection…

Many of us will remember the creation of the Health Protection Agency (HPA), which took local health protection expertise into a national organisation with regional structures. During its 10 years of operation, the HPA combined expertise in infectious disease and environmental hazards with rapid response capabilities and cutting-edge research to underpin its work. The difficulty of balancing the responsiveness of local against the scale and efficiency of national was evident, and has remained a conundrum through the creation of PHE and to today.

Part of the rationale for forming PHE was to bring together the work on infectious diseases and other ‘external threats’ with health improvement work on the wider determinants of health and health inequalities. These ‘upstream’ causes of ill-health are important in tackling ‘downstream’ consequences such as infectious disease. COVID has demonstrated the need to consider the complex interaction between the social, economic, commercial and biological determinants of health alongside emergency response.

The decision has been taken to separate these elements of the public’s health to provide more specific focus. But we must ensure that the new public health system works as one, across organisations, and between national and local, with the ready flow of knowledge, expertise, data and intelligence between them. However, whilst embedding public health across any new system is vital, it requires strong local and national leadership and coordination. Our experience is that in the past this has been difficult. We need to see this culture of collaboration hard-wired into the new system as it is conceived.

The public health leadership and expertise of the Director of Public Health has been rightly recognised. We will work with the new National Institute for Health Protection to really join up the response – both for COVID and future threats to the health of the nation.

What about everything else?

Public health is much more than health protection and these announcements have raised more questions than answers. PHE has a wide range of functions, how will these continue? Functions such as data and intelligence, workforce support, research and policy are all important. How will the current confused responsibilities between and across multiple agencies be clarified? Will the current legislative framework support or obstruct the intentions of new policy? What will be devolved to local? Will the level of resourcing be sufficient for the need?

Before leaping into anything, we need to reflect on the many aspects of the national public health system that have worked well – data, science-led policy, regional teams.

Lessons from other systems, including the German system, tell us that a strong public health system needs strong local leadership and responsibility with commensurate funding to deliver. Local does not mean national telling local what they have to do. ‘Local by default’ with the flexibility of local decision-making is what drives an efficient public health system. Assurance should be based on trust not centralising control. And it does not mean everything is devolved; some things are better done regionally, some done once nationally and shared. It should mean whole system working – a team of teams approach – local government, NHS, other public sector, third sector and business all have a part to play.

We need urgent assurance that the functions of Public Health England will continue through this transition and beyond, alongside increased spending on public health across the system both now and in the long term – if you want ‘local by default’, the majority of the funding should be local, by default .