Public Health England is now closed, more than a year since staff learned of its closure via a press leak on a weekend night. It is now the home of its functions and team, which are housed at the UK Health Security Agency (UKHSA), NHS England, NHS Digital, and the Office for Health Improvement and Disparities in the Department for Health and Social Care. The new OHID faces a daunting task, given the widening of health inequalities before the COVID-19 pandemic and the unintended consequences of the pandemic. What are the chances of its success?
The new OHID cannot succeed on its own. The wider determinants that affect health must be addressed, which requires Whitehall and beyond to take action. As Jill Rutter, long-time Whitehall expert and commentator, has said, the ‘track record suggests that in the not-exactly-collegiate environment of Westminster, it is very hard to drive a cross- cutting agenda from a Department’. The OHID has a mountain to climb if it wants to be a leader in a truly transformational agenda that takes into account the greater determinants of health, including education, housing, and work.
Compare briefly how the government approaches health inequalities and its approach to leveling up. Instead of relying on Whitehall’s usual machinery, the leveling-up initiative has a new (albeit temporary) Permanent Secretary who reports to Michael Gove, the Secretary of State for Levelling Up, Housing and Communities, and the Prime Minister, as well as a task force, instead the usual Cabinet Committee. Health Improvement and Inequalities is placed under the Department of Health and Social Care with a Ministerial Board.
How can the new OHID improve its chances of winning if all the odds are against them?
Cross-government working
OHID must have a clearly defined Whitehall engagement strategy in order to assist other Departments in seeing the benefits of the health improvement agenda. Recent examples show that aligning the health agenda with another Department’s priority can unlock radical thinking and policy. This is evident in the joint efforts between the Department for Environment, Farming and Rural Affairs, Public Health England, and the Department of Health and Social Care to improve air quality. Another example would be the Department for Transport’s work on active travel. This doesn’t just happen. It takes effort to establish the relationships and to help other Departments understand the link between their policies and health. (There aren’t many health economists outside of the Department of Health and Social Care.) Let me add a note of optimism. The new Secretary of state is an experienced Whitehall operator who has run five departments. He is aware of the limitations that a single Department has, and he looks across Whitehall. This could be the key to setting up the strategy that OHID requires. Linking health improvement and inequalities to the wider ambitions of leveling up offers another opportunity to combine agendas for impact.
Transparency, voice, and voice
Public Health England was both a part of Whitehall and yet not a part of Whitehall. It could provide independence, transparency, and clarity of the evidence and the actions needed. It was not easy to juggle the two roles of being a part of the system and being seen as an independent voice of public health. OHID does not pretend to be separated. It is important to ask how OHID can ensure transparency and a powerful voice even when its views are not always welcomed. This is important for national decisions, but it’s also crucial for local ones. It is a good idea to continue using the term ”inequalities rather than the more comforting language of disparities, whatever the organizational title.
Public health: a shared vision
The OHID team must learn to both look up and out simultaneously – influencing Whitehall but also looking at regions and localities as leaders in the many determinants of healthcare. OHID made a good first step with the appointment of Jeanelle de Gruchy as the Deputy chief medical officer co-leading the Office. This is an important step to ensure that local governments feel part of this agenda. It is also critical because the role of directors in public health is so central to the local community. DsPH should and can play a more prominent role in health and care following COVID-19. This is based on the experience of the last 18 months. The OHID team must also work closely with the UK Health Security Agency (UKHSA), NHS England, and NHS Digital in order to achieve coherence, alignment, and consistency across the various public health functions that have been thrown into four corners of the healthcare system. Fragmented efforts will only make an already difficult task even more difficult.
Growing the workforce
The workforce is another area that needs to be addressed. The pool of public health consultants and directors is limited, so it is important to establish a workforce model. How can OHID, the public health system, and other stakeholders make the most of the expertise that is available today and expand it over time? There is a larger workforce than just the public health professionals that can help support local change, as their roles have a greater impact on health. The King’s Fund leading for population health course is a way to reach out to a large pool of people who do not have ‘public health’ in their title but are passionate about population health and can make a difference locally. To be successful, OHID needs to grow the public health workforce as well as support the transfer of skills and contributions of a much wider workforce in order to improve population health.
The new OHID faces a daunting task. The new OHID faces a daunting task.