By Anna Coleman and Stephen Peckham
Since April 2013, we have been investigating the changing public health system in England. These changes came about as a result of the Health and Social Care Act (2012) and have had profound implications for the organisation and delivery of public health. Prior to the reforms, the public health system was criticised as lacking synergy and suffering from inefficiencies due to overlapping responsibilities. Hence a key objective of government policy was to address the perceived fragmentation through a number of changes made to the structures and organisation of public health functions, chiefly by moving public health into Local Authorities (LAs) in order to:
- increase the emphasis on public health and disease prevention;
- create a more joined-up system with clearer leadership;
- have a greater impact on the wider determinants of health at local level.
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.
Transferring public health activities into local government sought to build on the developing role of Local Authorities (LAs) in shaping local places to create healthier environments through spatial planning and local initiatives to improve health and wellbeing. At the same time a new body, Public Health England (PHE), was created to bring national health service leadership and commissioning and further changes were implemented with the creation of NHS England (NHSE) – at ‘arm’s length’ from Government – and Clinical Commissioning Groups (CCGs) which commission healthcare services at a local level . These structural changes have had wide ranging implications for the way in which the public health function is approached, organised and delivered. Since 2013 the key responsibility for improving the health of local populations, including reducing health inequalities, rests with democratically accountable upper tier and unitary LAs – although the NHS retains some responsibilities for protecting and improving the population’s health and reducing health inequalities through all its clinical activity.
Throughout our research we utilised ‘systems thinking’ to help us to focus on inter-relationships and emphasise holistic thinking gathered from multiple perspectives. This enabled us to describe what we found to be “a chaotic, sprawling, dynamic set of practices which were often intensely political, and a set of activities that might more closely resemble a non-system”, which was still developing as our research was conducted.
Our most recent report, is based on the findings from the last 3 years and included an initial scoping review; a review of the Communities and local Government Select Committee investigation (2013) into the proposed changes; interviews with national stakeholders; case studies in 5 LA areas (including interviews, observations, collection of documentation) and two rounds of web-based surveys (of Directors of public health and elected councillors with roles in public health) in 2014 and 2015.
Our research showed that initially LA public health teams concentrated on developing the structures and processes required for effective operation (Gadsby et al 2014). We demonstrate that this concern with structures and organisation has continued (Peckham et al 2016). Financial insecurity created additional problems with LAs sometimes unsure of the details of their financial settlement from government until many contracts had been negotiated. Budget cuts across other departments within LAs also brought pressures to public health teams, as costs were transferred and shared across departments. Similarly contracts have received new scrutiny, and both existing and new contracts have had to be (re)negotiated within a new provider landscape.
The organisational position of the public health team and the director of public health were also found to be important in terms of ability to influence strategic decision-making and work with other departments. System co-ordination remained an area where roles and responsibilities of various actors were not always clear. In addition, actors within the system had to negotiate ways of working with others, in a situation where much was new and still changing. This was further complicated in two–tier council areas where responsibilities are spread between organisations creating additional complexities of inter-organisational working. However, our surveys (Jenkins et al 2015, Jenkins et al 2016) showed public health teams in two-tier authorities appeared to have fewer capacity issues in terms of supporting the information needs of CCGs.
Our research provides an early overview of the development of the public health system in England (2013-15) and highlights some important issues that have both policy and practice implications including:
- support for a stronger LA role in public health;
- a system still in flux and some continuing confusion about organisational responsibilities in terms of commissioning;
- financial constraint impacting on capacity of public health teams alongside broader financial constraint in local government;
- competing policy objectives; an ongoing struggle between local agendas (e.g. tackling inequalities) and a central government push (e.g. towards integration);
- some innovation and creativity in using public health resources, but also some concern expressed about inappropriate use of public health funding;
- the development of collaborative work between some LA departments, but some poor linkages with CCGs;
- distinct differences in development across our sites.
Overall, our findings suggest that the development of the new public health system in England is still in progress with both the internal organisation of public health in LAs, the NHS and PHE in a continuing state of flux. Despite much activity around the re-organisation of systems, structures and processes, which have had important consequences for roles, relationships and functions, we haven’t seen a corresponding shift in priorities and strategies. We identified a mismatch between the rhetoric at policy level, emphasising the importance of prevention and the reality, which has seen cuts in public health funding. We found that the Health and Social Care Act (2012) and associated policies paid insufficient attention to the nature and quality of relationships across the various organisations and individuals that constitute the new public health system. As a result, some of the challenges identified during the passage of the Health and Social Care Bill have been averted, although many remain. Some of the opportunities identified have been realised, but many are highly dependent on a range of locally contextual factors.
Our findings also mirror those set out in another recent blog, where Brackley argues that more work is needed to recognise the value of public health professionals within local authorities, the long term benefits of the prevention agenda and that “interventions that cannot easily be measured – at least in the short-term – in pounds and pence” are important.
For more details and a wider discussion of our data and finding refer to our final report which has just been published.
James Brackley (2016) ‘Everything is public health’: opportunity or threat for local public health professionals? 24/5/16
Erica Gadsby, Stephen Peckham, Anna Coleman, Julia Segar, Neil Perkins, Linda Jenkins, and Donna Bramwell. (2014) PHOENIX: Public Health and Obesity in England – the New Infrastructure eXamined: First interim report: the scoping review. University of Kent, PRUComm.
L.M. Jenkins, D. Bramwell, A. Coleman, E.W. Gadsby, S. Peckham, N. Perkins, J. Segar (2015). Integration, influence and change in public health: findings from a survey of Directors of Public Health in England. Journal of Public Health Advance Access published October 20, 2015.
Stephen Peckham, Erica Gadsby, Anna Coleman, Linda Jenkins, Neil Perkins, Donna Bramwell, Jayne Ogilvie, Harry Rutter and Julia Segar (2016). PHOENIX: Public Health and Obesity in England – the New Infrastructure Examined: final Report. University of Kent, PRUComm.
Nick Riches, Anna Coleman, Erica Gadsby and Stephen Peckham (2014) The role of local authorities in health issues: a policy document analysis. Kent University, PRUComm.