Options for a future public health system in England

The health of the UK population is deteriorating – life expectancy has plateaued and people are spending more of their lives in poor health, much of which is preventable. At the same time, inequalities are growing, with people in more deprived areas living in poor health for longer and dying earlier than those in less deprived areas. 

The new government’s health mission aims to improve healthy life expectancy for all and halve the gap between different regions of England, with the government looking to shift its focus from treatment of ill health to prevention. Achieving this will require a cross-government strategy to improve health and reduce inequalities, with leadership from the top of government and clear accountability, mechanisms to facilitate cross-government working and a prevention-led approach to policy and spending.

It will also require a public health system that is fit for purpose. In his recent review of the NHS, Lord Darzi highlighted the ‘turmoil’ in the public health system in England, pointing to the decision to reorganise it in the middle of the COVID-19 pandemic as a key contributing factor. 

Here, we summarise where the current national and regional public health system is working well and explore existing structural challenges, including system fragmentation, a perceived absence of system leadership, and a lack of political independence and cross-government coordination. Finally, we present potential solutions for how these challenges could be overcome.

The decision to reorganise public health   

In August 2020, just 5 months after the World Health Organization declared a global pandemic, the UK government announced plans to scrap England’s national public health agency, Public Health England. The announcement provoked criticism at the time because of the inevitable organisational disruption in the midst of responding to the pandemic.

To replace Public Health England, the UK Health Security Agency (UKHSA) was established as an executive agency of the Department of Health and Social Care (DHSC)with responsibility for responding to health threats from infectious diseases and environmental hazards. At the same time, the Office of Health Improvement and Disparities (OHID) was created within DHSC, under the professional leadership of the Deputy Chief Medical Officer for health improvement. OHID took on Public Health England’s responsibilities to improve health, prevent disease and reduce inequalities. Further details on the remit and responsibilities of UKHSA and OHID are presented in Appendix 1. 

The role of the NHS in prevention was impacted less, although some Public Health England functions related to screening and immunisations were transferred to NHS England, including screening quality assurance, screening and immunisation commissioning support, and advice to regional and local NHS teams.

The rationale behind the split in Public Health England’s functions had two main components. First, to create an agency with a sole focus on preparing for and responding to health threats that would integrate the health protection function with separate structures set up during the pandemic to carry out contact-tracing and analytical functions. Second, in relation to health improvement policy, the government hoped that embedding OHID within DHSC would provide greater opportunities to influence cross-departmental policy and allow closer working with the Chief Medical Officer. In reality, this reorganisation has left a more fragmented public health system with less political independence, compounded by a stretched public health workforce. The importance of addressing the structural issues facing the national public health system has been highlighted by findings from the first module of the UK Covid-19 Inquiry. The inquiry identified the complexity and fragmentation of emergency preparedness and resilience systems in the years prior to the pandemic, even when Public Health England was in existence, highlighting the many institutions and structures involved as a key flaw in the UK’s preparedness. This is an issue that the current public health system has exacerbated. The report has recommended a ‘radical simplification’ of these systems, with simpler official structures and leadership. Now is an opportune moment to take stock of the public health system in England and review the opportunities for improvement. 

Our approach

We carried out 16 interviews with national, regional and local public health leaders, with senior officials from government departments within and outside of DHSC, and with external experts on government and public bodies in June and early July 2024 (prior to the new Labour government taking office). We explored their views, not attributable to any individual, on whether the national and regional public health system is fit for purpose, and if not, what should change (Box 1 defines the ‘public health system’). 

The key themes that emerged from the interviews were combined with the evidence and insight compiled as part of our 2020 briefing on recommendations for the public health system (Box 2) to identify what is working well, the structural challenges facing the system, and potential solutions.

What is working well?

Several aspects of the current public health system are working well.

• UKHSA: Health protection has had a relatively high political profile post-pandemic with the establishment of UKHSA. Despite having to manage budget cuts, UKHSA is delivering against its remit and its regional teams – largely staffed by former Public Health England employees – are working effectively with local authorities and with NHS integrated care boards.
• Public health research: Having OHID within DHSC has helped to increase focus on public health research in the department, partly through being closer to the day-to-day running of the National Institute for Health and Care Research (NIHR – part of DHSC). 
• Joint Regional Director of Public Health roles: Under Public Health England, regional directors of public health had responsibility for regional health protection and health improvement functions, with the NHS separately retaining responsibility for health care public health. Since 2021, regional directors of public health have instead been jointly appointed by NHS England and OHID to provide public health leadership and close partnership working across regional teams of both organisations. This has helped to strengthen the role of public health and prevention in the NHS. UKHSA regional teams operate separately under a regional deputy director of health protection.

Four structural challenges in the current system

1. System fragmentation

The current public health system has become more fragmented, with three separate bodies leading on different domains of public health practice at a national level – UKHSA on health protection, OHID on health improvement and NHS England on health care public health – with limited structural or formal coordination between them. This fragmentation is mirrored at regional level, with each organisation having its own regional structures, replacing the previous Public Health England regional teams that used to cover health improvement and health protection. 

As a result, collaboration at national level largely relies on personal relationships and individual efforts. While also fragmented at regional level, there is better coordination between health improvement and health care public health functions led by regional directors of public health.

This fragmentation is a particular problem for the many public health priorities that cut across domains such as sexual health or tackling health inequalities, and for underpinning system functions such as workforce development, data and surveillance. Further, it causes problems for support functions like specialist public health communications and IT that have been split between organisations as part of the reorganisation. 

2. A perceived absence of public health system leadership

With a fragmented public system across different parts of DHSC and its arm’s-length bodies (NHS England and UKHSA), and thus no single chief executive or director general responsible for all parts, there is a perceived absence of national public health system leadership. This includes a lack of ownership by any single organisation on cross-cutting functions like workforce development. 

This limits the ability of the broader public health system to provide a unified voice to politicians and the public. While the Chief Medical Officer provides independent health advice to ministers in DHSC and across government, as well as professional leadership for local government Directors of Public Health and the medical profession, the Chief Medical Officer does not provide overall leadership or control over the various parts of the national and regional public health system, unlike the role of the previous chief executive of Public Health England.

3. A lack of political independence

As a result of being embedded within DHSC, OHID lacks independence from ministers. This has reduced the ability for public health professionals and civil servants in OHID to advocate for public health priorities that do not align with political priorities. 

Under the previous government, OHID’s resources were progressively deployed to match ministerial priorities rather than necessarily aligning with broader public health needs, compounded by cuts to staff and budgets. Further, OHID’s lack of political independence reduces its autonomy over its recruitment, work programme and highlighting gaps in public health policy.

4. A lack of cross-government coordination 

Finally, OHID has limited independent influence across other government departments and with ministers. This is despite the original intentions of the previous government for OHID to lead work across government to improve health and tackle inequalities, including the creation of a new cross-departmental ministerial board on prevention to lead and coordinate action across government. This board did not come into existence and the subsequent promised cross-government white paper on health disparities also failed to make it to publication – both falling victim to public health and inequalities being politically deprioritised. 

While OHID’s limited cross-departmental influence is mainly linked to a lack of policy focus on public health under the previous government, there was also no formal coordination to facilitate cross-government working. The new health mission board may now provide such a mechanism, designed to facilitate collaboration across departments, and ensure a focus on delivery.

Drawing together the findings from our interviews and the evidence we compiled as part of our 2020 briefing (see Box 2), we present potential solutions to the structural challenges identified.  

Some solutions – particularly around whether or not to move OHID into an arm’s-length body – provoked a wide range of views among interviewees. Some strongly felt that a new public health executive agency like Public Health England was needed, with a dual mission for health improvement and health protection. Others felt that any public health benefits of a new organisation would be limited and outweighed by the disruption and costs such reform would entail. 

Some interviewees felt that a key advantage of the current model is that it affords OHID proximity to political decision making that was not available to Public Health England, while recognising that its capacity to influence will depend on political priorities and its resources. Others thought that the consequences of its lack of political independence were too important for OHID to remain as a department within DHSC. 

These differences in views are expanded on below, in relation to the pros and cons of the solutions presented. Analysing the economic costs to government of different solutions was out of scope.

Reduce system fragmentation

Create a new public health agency

One way to address system fragmentation would be to recreate a public health executive agency with a dual mission of health improvement and health protection at national and regional levels. This would take learning from what did and did not work at Public Health England, as well as from OHID and UKHSA, to integrate health improvement and health protection functions into a single organisation. The health care public health function would continue to sit separately within the NHS. 

Collaboration with the NHS on cross-cutting public health priorities could be facilitated through joint public health leadership positions at national and regional director level with NHS England, mirroring existing regional director of public health roles. In addition, support functions and cross cutting priorities, such as communications, public health intelligence, and workforce planning would be brought back within the remit of one organisation. A small team could be retained within DHSC to provide specialist public health policy advice and facilitate close working with ministers and the office of the Chief Medical Officer.

The main disadvantage of creating a new public health agency would be the disruptive and likely costly reorganisation this would entail in the short term. Given the recent reorganisation of Public Health England, there is limited appetite among public health professionals for yet further major structural reform, with the inevitable negative consequences for productivity and employee morale. 

This disruption could be mitigated by merging OHID into UKHSA, both at senior leadership and operational levels. However, there would be a risk that the existing culture and identity of UKHSA, which is focused on health protection, would dilute that of OHID and limit its influence within the organisation. Full integration of health protection and health improvement roles would require UKHSA having an updated remit and new internal governance and management structures that could end up being not dissimilar to creating a de facto new organisation altogether. 

Notably, we would not recommend integrating health improvement and/or health protection functions within the NHS, given the significant risk of these functions being deprioritised at the expense of tackling short-term clinical pressures. 

Create a new coordination mechanism within existing structures

To avoid a costly and disruptive reorganisation, a different option is to maintain existing structures but with stronger mechanisms for coordination across OHID, UKHSA and NHS England at national and regional levels. One approach would be through an oversight committee with representation from senior public health leaders from the three organisations and with responsibility for identifying shared priorities and coordinating policy approaches. Maintaining the OHID model in its present form would allow for the retention of public health professional expertise close to political decision making. But some system fragmentation would remain, with three separate organisations leading on each of the three key domains of public health practice. 

Bolster public health system leadership

The leader of a new public health executive agency (whether an entirely new agency or one based on a merger with UKHSA), with a dual mission of health improvement and health protection, would hold a mandate for providing national public health system leadership. By contrast, the creation of a coordinating committee working across domains at national and regional levels would be less likely to solve this challenge, unless the committee chair had significant delegated responsibilities for public health prioritisation.

An alternative approach would be to expand the remit of the deputy or chief medical officer role to become ‘Chief Public Health Officer’ and provide a system leadership function across UKHSA, OHID and public health functions within NHS England. Such a role exists in the Canadian system (instead of a Chief Medical Officer), and its remit includes advising the Minister for Health, providing joint leadership of the national public health agency together with its president, and working in collaboration with other government departments as well as other organisations and countries on public health matters.

However, this would mark a significant shift in the role of the Chief Medical Officer’s office from a principal focus on providing medical leadership and advice to government alongside professional leadership, to having considerable managerial responsibilities. It would require a significant increase in resourcing for the Chief Medical Officer’s office and major changes to the governance structures of UKHSA, OHID and NHS England. As such, this option is likely to be difficult to implement in practice.

Political independence

As compared with the current OHID model, integrating the national and regional health improvement function into a new public health executive agency would permit greater independence from politicians. The organisation would also have greater autonomy over its recruitment and work programme.

If maintaining the existing OHID model, measures could be taken to increase its de facto independence, such as establishing an independent advisory body, staffed by external experts, to provide oversight and champion OHID’s public health priorities at a senior level with civil servants and ministers. 

Indeed, in our recent briefing on improving health through mission-driven government, we identify the need for independent advice and accountability as a key condition for securing long-term action across government on health improvement and inequalities, and argue for the establishment of an independent Advisory Committee on Improving Health. This Committee should be a non-departmental public body, chaired by a senior expert, and staffed by civil servants, with responsibility for providing impartial advice to government, monitoring its progress in improving health and reducing inequalities, and conducting independent analysis to inform policymaking. Further, the committee should be put on a statutory footing to mitigate the risk of the power of such an advisory committee being eroded by government over time. This committee could set the direction for OHID’s priorities and work programme, and galvanise other departments to work towards these priorities in collaboration with OHID. 

Improve cross-government coordination

As highlighted above, the new government’s health mission board, in addition to the creation of an independent Advisory Committee on Improving Health, may provide the structures needed to better facilitate cross-government working on public health priorities.

Alongside such coordination mechanisms, ensuring a policy focus and shared goal of better health across the boards for the other four government missions (economic growth, clean energy, safer streets, and breaking down barriers to opportunity), is crucial to achieving an effective cross-government approach. In our briefing on improving health through mission-driven government, we argue that this would be further strengthened by ringfenced prevention spending across all government departments, and long-term and interim targets to improve health and reduce inequalities.

The new government has placed public health and prevention as core to its health mission, but the current public health system in England is not best placed to support this. The system faces four key structural challenges: fragmentation; lack of clear system leadership; lack of political independence, and limited cross-government coordination. 

To solve these problems, the principal question for government is whether to establish a new public health executive agency, with a dual mission of health improvement and health protection at national and regional levels – or whether the challenges can be adequately solved in a less costly and disruptive way. 

Prioritising health and prevention is a political choice. It is possible that existing public health structures would be more effective if they were simply more adequately resourced by the new government, alongside the new health mission board facilitating more effective cross-government working. However, without additional structural changes, national and regional public health systems and programmes in England would remain vulnerable to being deprioritised and rendered less effective in the future. Instead, the government has a chance now to establish public health structures that have the levers, stability and resilience required to meet the nation’s longer term challenges.

Finally, key to any national prevention agenda is an adequately resourced public health workforce. There is a crucial need for a national public health workforce plan, complementing the refresh of the NHS Long Term Workforce Plan. 

Although the focus for current health and care reforms is on the NHS, it is clear that government should also act to address some of the ‘turmoil’ in the public health system. We have set out how this could be done, what is at stake and some of the decisions that need to be made.