ViewpointPublic health in England: an option for the way forward?
Introduction
It was clear as soon as it was announced that UK Health Secretary Andrew Lansley's unexpected decision to subject the National Health Service (NHS) in England to revolutionary change1 would have profound consequences for public health.2 The White Paper, Healthy lives, healthy people,3 proposes that the public health function currently based in Primary Care Trusts be fragmented (figure). Some elements will move to the Department of Health, to a division called Public Health England, while others will move into local government. Health-care planning elements might move to proposed Commissioning Consortia and the NHS Commissioning Board, although this is not explicit.4
Section snippets
The problems with the current proposals
First, placing Public Health England within the Department of Health sits uneasily with the claim to be “liberating the NHS…from political control”,2 and will strip those transferred of their independent voice as advocates for the health of the population. Independent public health advice is crucial to build public trust. It has taken many years for public health professionals to regain that trust after the bovine spongiform encephalopathy affair,5 and as illustrated by the government's
Building on achievement
It is essential not to lose sight of the enormous achievements of public health in England in the past decade. The government justifies its reforms by citing what it sees as past failures. Its criticisms levelled at the NHS have been discredited,11 while those of public health for failing to narrow health inequalities are better laid at the door of the Treasury and the Department of Health, as noted by the Public Accounts Committee.12 Coalition ministers have said less about: the implementation
Principles for moving forward
We suggest an alternative that addresses many of the problems with the current proposals. First, however, we enunciate the principles that any solution should include (panel), drawing on lessons from the system in place in the UK before 1974—when public health doctors were based in local government—and the experience of other countries.
Practical proposals
We propose a model that would minimise the extent of disruption to the public health function and would result in much less fragmentation and professional isolation of the workforce. In this proposal, the existing NHS-based public health workforce would be identified and transferred to a new body, which could still be called Public Health England. This body would ideally be within the NHS (as a special health authority) or else be an arm's-length body sponsored by—but not part of—the Department
Conclusion
The unexpected decision to propose a complete reorganisation of the NHS has already led to disruption to the function of public health in some places, such as in NHS North West London.21 The current proposals will create further disruption that, we believe, can be mitigated—and thus avoid destabilisation at a time of historic change within the NHS.
The government calls for a public health system that can deliver world-class outcomes. We believe our model is more likely to achieve this goal than
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Cited by (22)
LSE–Lancet Commission on the future of the NHS: re-laying the foundations for an equitable and efficient health and care service after COVID-19
2021, The LancetCitation Excerpt :Where necessary, we recommend enactment of legislation to mandate such changes. The profession of public health has long had a core task of being the population's health advocate, but this central leadership role has been successively undermined by changes in health services over the past 3 decades.470,471 The role requires re-examination to establish what leadership models should look like in the future.
The english national chlamydia screening programme: Where next?
2013, Public Health'Decipio': Examining Virchow in the context of modern 'democracy'
2012, Public HealthCitation Excerpt :At the same time, it sets out a vision to improve public health by moving responsibility to local government, promising to ring-fence the budget. Yet, this is happening at a time when local councils are facing budget cuts of up to 25%, existing criteria for appointing directors of public health are being discarded, councils are receiving no new powers to act on the determinants of health, and organizations providing services to people in the community are seeing their budgets slashed.25,26 Taken with cuts in other areas, the Government is taking the opportunity to reduce the size of the state drastically.
Public health: Profession, health system, government control
2011, The LancetPolicy success and public health: The case of public health in England
2012, Journal of Social PolicyPolitical views of doctors in the UK: A cross-sectional study
2018, Journal of Epidemiology and Community Health