Policy paper

Transforming the public health system: reforming the public health system for the challenges of our times

Published 29 March 2021

This was published under the 2019 to 2022 Johnson Conservative government

Applies to England

Foreword

The coronavirus pandemic has shone a light on our public health system. Just as we’ve learnt a lot about the virus, we’ve also learnt a lot about what works and what needs to change in public health. Our experience has shown we need a relentless focus on our health security, while also preventing ill health to improve the general health of the population. To make our public health system fit for the future, we need to be simultaneously effective at both. While the 2 are of course connected, both are so important that we need a dedicated focus to each. These proposals place these two functions – health security and health improvement – into two distinct areas and set out how we can do better at each.

The primary concern of the new UK Health Security Agency [UKHSA] will be protecting against infectious diseases and external health threats – in bad times and in good. It will bring together the UK’s cutting-edge capabilities in analytics and genomic surveillance with our growing test and trace capability. Together, they will form a permanent part of our national defences. It has been conceived amid crisis, but it will help us maintain vigilance in the years to come.

Equally important is health improvement. COVID has revealed many of the vulnerabilities in the health of our population – from obesity to mental ill health. With UKHSA leading on health security, health improvement must also have a dedicated home at national level which can exert influence across the health and care system and beyond. Our new Office for Health Promotion, within the Department of Health and Social Care, will drive our prevention agenda across government. Under the professional leadership of the Chief Medical Officer, the Office will have the clout this agenda so rightly deserves. Not only will it help the Department deliver proactive, predictive and personalised prevention, it will embed promoting good health across the work of the whole government and the NHS.

The final part of our proposals aim to strengthen our local response. This is vital, as so many of the conditions for good health and living well are determined locally. At the heart of our proposals in the forthcoming Health and Care Bill is the concept of population health: using the collective resources and strengths of the local system, the NHS, local authorities, the voluntary sector and others to improve the health of their area. There’s no better example of this than our vaccine rollout, which has shown what we can achieve when we work together. Our proposals for statutory integrated care systems will bring local authorities and the NHS together, so they can take decisions together and strengthen the prevention agenda at a local level.

Our nation’s public health experts have delivered incredible work during this pandemic. We owe it to them – and everyone in the country – to ensure we have a public health system that is fit for the future. I believe these changes will do that, keeping us safe and healthy into better times ahead.

Future of the public health system

In this report, we set out reforms to the public health system in England and invite you to share your insights and experience to help us with the next stages of our work. Your feedback will help to shape the future of the public health system.

This update focuses on structural reforms, which are a vital enabler of delivering better and more equal outcomes on public health, but they are just one aspect of public health reform. Its focus is the public health system for England, but chapter two highlights the interaction with important UK-wide elements of our health protection response.

We will publish a further update later in 2021 with final details on design, structure and implementation, and we will also set out our plans for the policies, delivery and outcomes we want this reformed system to drive and deliver.

Public health fit for the future

Health is an asset to invest in; for individuals, for societies, and for economies. Never has that been more evident than over the past year. Around the world, COVID-19 has highlighted the immense economic, societal and personal costs which ill-health can bring, particularly to the most vulnerable.

We all want longer, healthier, more independent lives for ourselves and our families. Good physical and mental health are central to our happiness and enable us to participate fully in our communities and in society. A healthy nation is vital for a strong economy in boosting livelihoods and productivity. It is estimated that ill-health amongst the working-age population alone cost the economy around £100 billion a year in 2015 to 2016. Better health reduces the pressures on the NHS, social care, and other public services.

We have made great progress in recent decades in enabling people to live longer, healthier lives; we have improved cancer survival rates; reduced stigma around mental health conditions; rolled out new vaccines to prevent infectious diseases; and brought smoking to its lowest levels. But improvements in life expectancy appear to have stalled and on average around 20% of our lives are spent in poor health. Vaccine-preventable diseases are re-emerging worldwide, and the risk from antibiotic-resistant infections continues to grow. The gap in life expectancy between rich and poor areas has widened even further.

Our health is shaped by the genes we inherit, the conditions in which we live, the choices we make and the services that we receive. Ill-health is not randomly distributed, nor is it inevitable. Our ability to avoid, manage and survive disease is influenced by the choices we make, the job we do, the air we breathe and the neighbourhood we live in. We can act, as individuals and collectively, in ways that will help us live longer lives in good physical and mental health.

COVID-19 has highlighted the gains which can be realised when we invest smartly in the health of citizens, in preventing disease, protecting people from threats to health, and in supporting individuals and communities to improve their physical and mental health and resilience. The lessons from COVID-19 present government and society with a major opportunity to transform the nation’s health. One vital step in seizing that opportunity is making sure we have the right institutions in place to lead and deliver better, fairer health for the future.

We are continuing to respond to the demands of COVID-19, but as we look ahead to the future we cannot keep doing more of the same and hope to achieve different outcomes. The threats we face in future will be different; from new infectious diseases, new environmental threats or biohazards, to new behavioural challenges. So too will the opportunities to do more about them, through use of new technologies, analytics, cutting edge science and personalised behavioural approaches.

Our experiences of the COVID-19 pandemic show that we need to be vigilant to external threats at all times, with the right skills and capabilities in place. And that we must go further to prevent the underlying health conditions which have a bearing on how vulnerable we are to those threats.

Since 2013, national responsibilities for health security and health improvement have sat together within a single body, Public Health England (PHE).To ensure we have a public health system fit for the future, we are ensuring that going forward both health security and health improvement have their own clear, dedicated focus at national level. By giving each the focus it deserves, and carefully managing the important interdependencies between these elements of our overall public health system, we can do both better.

The health protection capabilities of PHE and NHS Test and Trace will combine into a new UK Health Security Agency. The UKHSA will bring together our national public health science and response capabilities, including cutting edge analytics and genomic surveillance, strengthening our national defences against all health hazards. A primary task of UKHSA will be to ensure the UK is well prepared for pandemics at all times – even long after this one is over. Like financial stability, we must keep the focus even when there is no crisis in sight. And because health threats do not respect borders, it will play a leading role in our global response to these challenges.

The current health improvement, prevention and healthcare public health functions of PHE will transfer to new homes within the health system, aligned to achieve clarity of purpose, accountability and impact. A new Office for Health Promotion will be created in the Department of Health and Social Care, under the professional leadership of the Chief Medical Officer. The Office for Health Promotion will help the whole health family focus on delivering greater action on prevention; and – working with a new cross-government ministerial board on prevention – it will drive and support the whole of government to go further in improving health.

Alongside this, we are strengthening NHS England’s focus on prevention and population health, transferring to it important national capabilities that will help drive and support improved health as a priority for the whole NHS. And important national disease registries functions will move to NHS Digital.

As we implement these changes, PHE will close, and a new public health landscape will take shape during 2021.

But national capability is only part of the story: we also need to strengthen our local response. As we have set out in our White Paper on health and care, we will place population health at the heart of local health and care systems, ensuring the NHS and local authorities work together to improve health in place, and capitalising on the fantastic partnership working at local level that has supported the COVID-19 response.

All these changes are driven by learning from the experiences of COVID-19, and by the need to improve our ability to prepare for, respond to and be resilient in the face of future health threats. We are reforming health protection to ensure that we have an organisation dedicated solely to identifying, preventing and managing threats to health. We are reforming health improvement because we have learned that prevention must be embedded across all those with the levers to help to deliver it and not just given to a single organisation.

Preventing the onset of avoidable physical and mental illness and protecting the nation’s health will always be top priorities for this government. The reforms set out here aim to ensure that the public’s health is given the status it deserves – at the very heart of government’s priorities for action, policy and investment, nationally and locally, across government and across the NHS. Transforming the public’s health, starting with transforming the institutions that lead work to improve and protect it, must be the positive lasting legacy we leave if we are to build back stronger, fairer, healthier and more resilient from the tragedy and disruption of COVID-19.

These reforms complement proposals we have published in our White Paper on health and care reform will put population health and prevention at the heart of the NHS and the whole system, while reducing bureaucracy and promoting integration.

How we are working to protect and improve public health

We are continuing to prioritise our response to COVID-19, but it is equally vital that we look ahead to the future, support the country to recover and do more to improve the nation’s physical and mental health. Our aim is to enable everyone to live for longer in good health, and to narrow the gap in health outcomes and experiences between the most and least disadvantaged.

The government has a duty to ensure that the path towards good physical and mental health is well understood by providing high quality evidence and information to show how health can be improved and maintained throughout the life course. The government has a responsibility to help people improve their own health, and in certain circumstances, the government has a responsibility to go further to protect the public’s health:

• to protect children and the most vulnerable in society from harm and physical and mental ill-health
• where the risk of disease is shared across society – such as infectious disease, air and water pollution, or unsafe food – and action cannot be taken at an individual level only;
• where diseases place a disproportionate burden on the NHS, for example the impact and cost of diabetes to the NHS
• where government action is needed to tackle significant inequalities in physical and mental health outcomes
• where individuals are at risk of harm or ill-health as a result of a power imbalance, such as industrial injury and occupational disease, or industries based on addiction like smoking.

We will do this using the range of possible levers at our disposal, working together with citizens, communities, industry and partners across UK public health bodies and society to promote and enable good physical and mental health.

Now is the time to redouble our efforts. Building upon our Prevention Green Paper and the progress made since its publication, and upon the lessons we have learned so far from COVID-19, over the coming months we will set out further detail on our public health strategy which includes 6 key priorities:

Focussing relentlessly on the biggest challenges to better, more equitable health

We are redoubling our efforts to reduce obesity and smoking, drug and alcohol misuse, improve sexual and reproductive health, promote positive mental health, reduce suicides and invest in the foundations of good health for all children. We will empower individuals to take greater control of their physical and mental health, through giving people tailored and targeted information, tools and support to make healthier choices throughout their lives. This includes increasing the reach and impact of screening programmes and NHS health checks, improving mental health literacy and building a more consistent prevention offer to the public. Health is a core element of our commitment to levelling up opportunities and outcomes for people across the country.

Strengthening local and national public health systems

We will support local authorities and their Directors of Public Health (DPH) as leaders of the public health system for England and strengthen the role of Integrated Care Systems (ICS) in driving joined-up local action on population health. We will transform the public health role and capability of the Department of Health and Social Care (DHSC), enabling it to lead national efforts to improve and level up the public’s health, establishing a dedicated Office for Health Promotion as part of the DHSC. We will strengthen the role of the Chief Medical Officer (CMO) as the lead independent public health advisor, providing professional leadership of the new Office for Health Promotion, and other new public health functions of the DHSC, and ensuring the independence of public health advice to government.

Building world-class health protection capability for the future

We will establish the UK Health Security Agency (UKHSA – previously given the working title of the National Institute for Health Protection), investing in the expertise, infrastructure and capabilities we need to be better prepared for a wide range of potential future threats. We are tackling new and evolving threats from infectious diseases through enhancing our infectious disease surveillance capability, optimising the provision of vaccines, and helping to lead the global fight against antimicrobial resistance. We will focus on mitigating the public health impacts of more extreme weather events as the result of climate change and of significant environmental risks such as poor air quality.

Driving action across government on prevention and the wider determinants of health

Many of the factors most critical to good physical and mental health such as work, education and transport, housing and air quality, are the responsibility of partners beyond the health service. This means that transforming public health requires very different ways of working across government, with joined-up action and investment from many departments and partners. Health will no longer only be the business of the DHSC, but a core priority for the whole of government. We will establish a new cross-government ministerial board on prevention, to drive forward and co-ordinate government action on the wider determinants of health. We will enable more joined-up, sustained action by national and local government and our partners, working together in a coordinated way to create a step-change in public health.

Further embedding prevention and health improvement in the NHS

We are focusing the NHS more explicitly on preventing physical and mental ill health, including its work on reducing inequalities, preventing diabetes, supporting smoking cessation, treating alcohol misuse and intervening early to support people with mental health problems. This is supported by our investment guarantee for primary and community services and our commitment to expand and transform mental health services in the NHS long term plan. It is also enabled by the plans set out in our White Paper on the future of health and care, including the development of integrated care systems, a new statutory aim for the NHS of improving health and wellbeing, and a clear imperative for stronger joint working between the NHS and local authorities. These steps will ensure a greater practical focus on prevention and health improvement by the NHS working closely with local government and local partners.

Investing in critical capabilities and building the workforce to deliver them

We will harness the power of technology and innovation for public health, investing in critical capabilities in data science, digital, behavioural science, and genomics. We will nurture a culture of innovation and collaboration to drive improvements in public health, underpinned by a resilient, multidisciplinary and flexible workforce that will be ready for the public health challenges that lie ahead.

Help us design the future

Our system reforms will aim to transform our national health protection and capabilities, place prevention at the heart of government, and more deeply embed prevention and health improvement expertise, capacity and accountability across local and national government and the NHS.

We will set out more detail on the system reforms and our plans for improving the public’s health later in 2021. Help us to design a system fit for the future by filling out this survey by 26 April 2021.

Securing our health: The UK Health Security Agency

What are we aiming to achieve: health security capability fit for the future

The UK has a global reputation for leadership in health protection science and research and for the quality of our health protection services. Since the outbreak of COVID-19, the country has been facing its greatest health protection challenge for decades. Our response has been built on the world-class public health expertise of PHE. Scientists at PHE were among the first in the world to fully sequence the novel coronavirus viral genome, and we have been able to use our national sequencing capability to detect cases and inform the most appropriate public health action.

This existing expertise combined with the new at-scale operational capacity of NHS Test and Trace and the new analytical capability of the Joint Biosecurity Centre – working with partners in national and local government, the NHS and with citizens – has enabled England alone to carry out over 90 million COVID-19 tests, and contact over 9 million people to notify them to self-isolate.

The experience of COVID-19 has highlighted the agility and impact of our health security and protection system, but it has also shown us that the challenges of protecting and securing our population’s health are changing, as new types of threats emerge. Our health security and protection system must change too, in order to be fully fit for the future. We need much deeper integration between health protection science and at-scale response capabilities, and we need to think radically about the capabilities and capacity we will need as a nation to protect our population from future threats, bringing to bear the best of science, technology and innovation. We need to consider how best to engage with citizens and drive behaviour change in the 21st century.

To lead this mission, we are establishing a new UK Health Security Agency (UKHSA). The UKHSA will focus all its attention, in bad times and good, on health hazards including infectious diseases, and will play a leading role in our global response to external health threats. It will build upon the experiences from the last decade of public health protection, here and around the world, in particular in tackling COVID-19 over the past year.

The UKHSA is being created to ensure that we bring together and enhance the existing expertise and new capabilities we have developed during the pandemic, so that we have an integrated organisation dedicated to protecting the public’s health. It will be a key part of the country’s critical national infrastructure and security infrastructure. It will also represent a core part of UK PLC, driving economic growth and resilience, protecting the country from the societal and economic shocks we have witnessed during the pandemic, and acting as an engine for the UK’s life sciences sector and diagnostics industry.

UKHSA will act as a system leader for health security, providing intellectual, scientific and operational leadership at national and local level, as well as on the global stage. It will be close to policy making and able to exert influence over the system to ensure threats to health security are acted on and brought under control. It will continue and build on successful ongoing cooperation and collaboration with the Devolved Administrations including public health agencies for Scotland, Wales and Northern Ireland.

The change, from our initial working organisational name of the National Institute for Health Protection to the UK Health Security Agency, gives a clearer sense of the critical role this new body will play in safeguarding all our health, and of its role and value for the whole of the UK.

Steps we will take to achieve this

Establishing the UKHSA in April 2021 to strengthen health security across the UK

UKHSA will be formally established in April 2021 and we will transfer staff and systems into the new organisation over the following months. We will manage the transition carefully to ensure no loss of focus or operational risk to our COVID-19 response or any other essential health protection activity.

We anticipate that the UKHSA will undertake functions in 5 core areas:

• Prevent: anticipating and taking action to mitigate infectious diseases and other hazards to health before they materialise, for example through vaccination and influencing behaviour
• Detect: detecting and monitoring infectious diseases and other hazards to health, including novel diseases, new environmental hazards, and other threats though world class health surveillance, joined-up data, horizon scanning and early warning systems
• Analyse: analysing infectious disease and other hazards to health to determine how best to control and respond to them, through coordinated and intelligent data analysis, modelling, and evaluation of interventions based on robust evidence and developing the knowledge base
• Respond: taking action to mitigate and resolve infectious diseases and hazards to health when they occur, through direct delivery, supporting health protection system partners with tools and advice, engaging with citizens, and flexibly deploying resources, including scaling operations at pace
• Lead: providing health protection system leadership, working in partnership with wider central government, the devolved administrations and public health agencies for Scotland, Wales and Northern Ireland, local authorities, the NHS, academia and industry to provide effective preparation and response to the full range of threats to health and strengthening the health protection system and workforce

The UKHSA will co-ordinate across the UK, building strong collaborations with public health agencies for Scotland, Wales and Northern Ireland, and will operate internationally for the UK to help understand, prevent and respond to global threats to health.

The UKHSA will encompass existing UK-wide activities, including operational agreements supporting pandemic management, the whole-UK role of the new Joint Biosecurity Centre as a shared intelligence resource, and a wide range of domestic collaborative activity to pool expertise and co-ordinate responses.

Investing in building priority capabilities

It is clear that the UKHSA will need world class data and analytic capability, and the agility, partnerships and systems to scale up at speed. It will need to connect and integrate local delivery work, regional coordination and national strategy and policy. It will need to demonstrate flexibility, being able to scale down as well as up, in a way that best retains knowledge and maximises assets built for emergency response.

The UKHSA will prioritise building critical health protection capabilities, including data science and analytics, genomics and diagnostics innovation, and behavioural science. It will facilitate effective decision-making across the health protection system with better use of analytics enabled by the right technology and data infrastructure. It will ensure an ever ready and scalable emergency response capability, assuring readiness across the wider system for all hazards. It will work with academics and private organisations to ensure the latest behavioural science insights guide its work with citizens. And it will be rooted in the highest quality science, research and data, working to exploit the potential of new techniques and technologies and to drive innovation in the science and practice of health protection. Above all, the UKHSA must be an organisation which can continue to learn and evolve, adapting fast to keep pace with changes in the threats we face and the world around us.

Building a system

The UKHSA will lead a collaborative, partnership-driven health protection system, with the needs of local communities at its core. It will act to strengthen health protection capability from top to bottom, ensuring clear roles, relationships and accountabilities to enable a ‘whole system response’ to health threats, with robust arrangements for emergencies. It will lead and co-ordinate action with national government, local health systems, academia, industry and citizens to tackle all health protection issues, working in partnership as a ‘team of teams’. Over the coming months, we will build on current partnership working arrangements with local leaders by designing a strong sub-national operational structure for the UKHSA that will work closely with Directors of Public Health to deliver health protection that is responsive to the needs of local communities.

Ensuring a strong focus on the needs of all citizens

The UKHSA will place a strong focus on reducing inequalities in the way different communities experience and are impacted by infectious disease, environmental hazards, and other external threats, targeting action towards disproportionately affected groups. It will work to understand ever better the needs of citizens, and to build that understanding into the design and continuous improvement of services. This will require strong partnership working with local communities to ensure that UKHSA’s services and communications are well-tailored to a community’s diverse and specific needs.

Ensuring an effective model for vaccines, immunisations and screening

The UKHSA will be our national hub for expertise and evidence on vaccine-preventable diseases. Its role will include providing independent expert advice on vaccines and immunisations, including support for the independent Joint Committee on Vaccines and Immunisations, (a role currently provided by PHE).

We are considering the options for the placement of expert advice on screening, which supports the UK National Screening Committee; and the national screening programme quality assurance functions (currently provided by PHE), to ensure that scientific independence and safe, high quality delivery of screening services is maintained. The NHS will continue to deliver the screening and immunisation programmes.

How you can help us

Our work over the coming months will focus on how to translate these core functions and principles into the design and operating model of the new organisation. We want to ensure that the design and culture of the UKHSA retains the best of PHE and NHS Test and Trace, builds upon learning from COVID-19, and forges and organisation which is agile and adaptive, continuing to learn and strengthen over time.

To support our work on this, we are inviting feedback on the questions below. Please fill out this survey by 26 April 2021.

• Question 1: What do local public health partners most need from the UKHSA?

• Question 2: How can the UKHSA support its partners to take the most effective action?

• Question 3: How do you think the health protection capabilities we need in the future should differ from the ones we have had to date?

• Question 4: How can UKHSA excel at listening to, understanding and influencing citizens?

Improving our Health

What we are aiming to achieve: giving responsibility for health improvement to all those who can make a difference

The factors which cause or prevent poor physical and mental health are shaped by different parts of our lives, and many different parts of government, public services and the health system. We are living longer, but spending a fifth of our lives in poor health. As a nation and a society, we must do better, investing in everyone’s health. Driving change in the prevention of disease, improving our health and reducing health inequalities will require a range of organisations and actors, at all levels, to take responsibility for this change. No single organisation can transform the public’s health – but working together, many can contribute to it.

As we design the future of the functions that support health improvement and healthcare public health, currently delivered by PHE, our aim is to deliver lasting transformation in health outcomes, by ensuring that the public’s health is given the priority it deserves. To do that we will locate functions where they can have the greatest impact in driving change, ensure that roles and accountabilities are clear and aligned with delivery capability, and focus on building critical capabilities that are vital for the future. For many of these functions, the place where they will have greatest impact is in DHSC where we will create a new Office for Health Promotion: under the professional leadership of the Chief Medical Officer, helping the whole Department focus on delivering proactive, predictive and personalised prevention, and supporting a drive for the whole of Government to go further in promoting good health.

Alongside this, we are reinforcing the national focus and capability of NHS England on supporting better health, as part of a drive to put better population health front and centre for the whole health and care system. And the important work of operating national disease registries will be best placed with NHS Digital.

Steps we will take to achieve this

Transforming the public health role and capabilities of DHSC – a new Office for Health Promotion

Driving change on prevention depends above all on strong and ambitious policymaking across government, underpinned by the best evidence and expertise, and translated into effective delivery through a wide range of partners and channels. Given the cross-cutting nature of public health and prevention, it is vital that DHSC strengthens its public health role and its public health analysis, policy-making and implementation capability. We will ensure that core public health responsibilities and capabilities are placed at the heart of government, with a new Office for Health Promotion in DHSC reporting into the CMO and the Secretary of State for Health and Social Care, supporting them to execute their roles in improving the public’s health and narrowing health inequalities.

The Office for Health Promotion will be a dynamic, multi-disciplinary unit that will oversee policy development, expert advice and implementation on prevention of ill-health. It will house a range of skillsets and expertise, spanning functions such as policy making and delivery, data and actuarial science. This office will lead a new age of health promotion. It will set direction on prevention and will work to support and drive prevention across national government, local government, the NHS and the wider health system. It will also house prevention delivery projects. It will operate as an integral part of DHSC, supporting the whole DHSC to go further in promoting good health. And it will develop evidence and policy advice on the links between prevention policies and long-term health expenditure on preventable conditions

PHE currently plays a vital role in supporting national policy development on health improvement by providing expert advice, analysis and evidence. It also plays an important role in national policy delivery. We are proposing to move most of the functions that directly support development and delivery of national health improvement policy from PHE into the Office for Health Promotion, alongside existing DHSC capability on prevention and health improvement, as they are integral to policy development and delivery, and directly support national decision-making. This will include subject-matter expertise on a range of important public health issues, including but not limited to obesity and nutrition, physical activity, alcohol, tobacco, drugs, sexual health, public mental health, children and young people’s public health.

These changes will put public health at the heart of DHSC, shifting the DHSC’s centre of gravity and ensuring prevention is prioritised. Bringing expert advice, analysis and evidence together with policy development and implementation will ensure that decision-making and delivery are better informed, more effective and joined-up.

Strengthening the role of the Chief Medical Officer as the source of independent expert public health advice

The public health system and government needs a trusted source of independent scientific advice on health improvement, to ensure evidence-led national decision-making and a focus on health inequalities. The Chief Medical Officer (CMO) is an independent position: the UK Government’s most senior medical adviser and the head of the public health profession. Teams, within the Office for Health Promotion, providing expert public health or medical advice, evidence and analysis will be professionally accountable to the CMO. Ministers will remain in charge of and responsible for policy decisions and direction.

Driving action across government on prevention and the wider determinants of health

Strengthening DHSC’s role and capabilities in this way will enable it to promote, inform and support a stronger shared focus on physical and mental health right across national government, influencing the wider policies most critical to population health, as we can see in current joint action on drugs, such as Dame Carol Black’s Independent Review of Drugs.

We will drive joined-up cross-government action on the wider determinants which shape our health, and foster innovation and collaboration in policy making and delivery. We want to ensure that health is a shared outcome prioritised across government, not just within DHSC. We will therefore establish a new ministerial board on prevention to drive and co-ordinate cross-government action on prevention and improve accountability on the wider determinants of health. Our aim is to ensure that we realise the huge potential of government departments working together to improve and level up the population’s health.

Further embedding prevention and health improvement in the NHS

The NHS has a hugely important role to play in preventing ill-health, working alongside local and national government and other partners. We are focusing the NHS more explicitly on preventing ill health, and supporting stronger collaborative working between the NHS and local partners to tackle population health challenges. The NHS long-term plan commits to action in England on prevention and health inequalities, including specific action on smoking, obesity and alcohol misuse, as well as an investment guarantee for the primary and community services which are at the forefront of NHS efforts to support better population health.

Our White Paper on the future of health and care, published on 11 February, sets out the legislative proposals which will support the NHS to deliver in a way that is more integrated, less bureaucratic, and more accountable. NHS England, Integrated Care System NHS bodies and NHS providers of care will have a statutory aim of better health and wellbeing for everyone, recognising the vital part the NHS must play with partners in securing better health for the whole population. We will work with NHS England to ensure that implementation and accountability arrangements follow through to deliver a sharpened NHS focus on population health in practice.

To ensure clear accountability for commissioning and delivery of national immunisation and screening services and other NHS national public health programmes, we also propose that those PHE staff who are currently embedded in NHSE&I supporting commissioning of NHS services should transfer substantively to NHSE&I employment, while continuing to work collaboratively as part of the wider regional and local public health system.

Ensuring a strong data and analytics capability across the system

To help ensure that data and intelligence are at the heart of our public health approach and support progress on reducing physical and mental health inequalities, we are proposing to transfer PHE’s cross-cutting national knowledge and intelligence capabilities into DHSC, with PHE’s health protection analytic functions moving into the UKHSA. Data and analytical functions for public health will be overseen by the CMO and DHSC’s Chief Scientific Advisor, and we will put in place appropriate governance structures to ensure the independence and transparency of scientific evidence and analysis is preserved.

This change will give ministers and policy teams ready access to a wealth of data, enable a better understanding of variation across the country and between different groups, and so help to make policy more responsive, agile and targeted. Our commitment to a system-wide approach to data and analysis aligns with the overall ambitions for better use of data in the UK as set out in the national data strategy and the forthcoming NHSX health and social care data strategy. Strengthening our analytics capability will help to build the evidence base for where preventative activity adds most value and will support identification and sharing of best practice. We will enhance our ability to draw on and link data across the system to maximise analytical insight where it is needed at the national, regional, and local levels, including for the NHS and local government. This capability will be pivotal in our efforts to take a place-based approach to health across the system – providing the data to allow us to identify challenges and evaluate interventions to have most impact.

Strengthening the design and delivery of behaviour change interventions and programmes

Alongside changes to policy and service delivery, we must do more to support and enable people to adopt healthy behaviours. Innovative, evidence-based behaviour change and public engagement activity is needed across public health – from important population-level messaging to targeted and personalised interventions that support individuals to understand and manage their own risks. As an example, we are using this approach to develop a new way of supporting people to make healthier food choices and engage in more exercise by testing the role incentives and rewards can play in encouraging these behaviours. We will be seeking to work in partnership with a range of public and private providers to develop and test cutting-edge incentivisation programmes that will help to support people in being healthy and active over the coming years.

To strengthen behaviour change activity across public health, we are developing options for a new ‘incubator’ function to support action on prevention in priority areas (such as obesity and smoking) in the public health system. The incubator would draw together behavioural science, digital and design expertise, and work to support policy teams in designing and delivering behaviour change interventions. It would give us better capability to translate science and evidence on behaviour change into action at scale, growing our knowledge of what works while also testing and building our ability to translate this knowledge into high-quality delivery through the different delivery routes at our disposal.

Delivering strategic workforce functions

We are working with stakeholders to ensure that the leadership of the public health workforce is effectively delivered in the future system, including key workforce functions such as workforce intelligence, training, development and career pathways that strengthen both core public health capabilities and support the wider health and care workforce. In line with the expanded role of the CMO as the professional leader of the public health workforce, we expect to conclude that DHSC will play a stronger role in workforce strategy development and oversight. This will help to ensure there is sufficient public health professional capacity to meet the needs of the whole system. We will ensure that professional revalidation systems remain robust and we are reviewing whether delivery of other key workforce functions may best sit with other partners at national or subnational level.

Ensuring effective delivery of national disease registration functions

National Disease Registry functions, currently delivered by PHE, are critically important for our understanding of cancer and other diseases, for improving treatment outcomes, and for tracking the overall performance of the health system. An independent review by Professor David Forman has concluded that these national disease registration functions, including the national cancer registry, should become part of NHS Digital as the national information and technology partner to the health and social care system. We agree in principle and are working through the detail of this recommendation prior to a final decision being implemented.

How you can help us

There are some questions below where we would particularly welcome further evidence and views at this time. Please fill out this survey by 26 April 2021.

• Question 1: Within the structure outlined, how can we best safeguard the independence of scientific advice to Government?

• Question 2: Where and how do you think system-wide workforce development can be best delivered?

• Question 3: How can we best strengthen joined-up working across government on the wider determinants of health?

• Question 4: How can we design or implement these reforms in a way that best ensures prevention continues to be prioritised over time?

Strengthening our local response

What are we aiming to achieve: stronger local systems

The places where we live have a fundamental impact on our physical and mental health – from the homes that we live in, to the air that we breathe and the local services that we receive. Before the COVID-19 pandemic, health outcomes varied significantly across different parts of the country, with more deprived communities suffering a greater burden of ill-health than less deprived communities. COVID-19 has exacerbated this trend and it is therefore more important than ever that we take steps to level up health across the country. At the same time, the COVID-19 vaccination programme is a shining example of what we can achieve when the whole system pulls together.

Local authorities play a central role in providing local leadership for health improvement, commissioning public health services locally, and influencing local action to address the wider determinants of health and health inequalities for both physical and mental health. They have been on the front line of our response to COVID-19, leading the local public health response. Alongside them, the NHS plays a major role in improving the health of local communities, through the range of services it provides to prevent and treat ill health and through the opportunities presented by many millions of individual contacts. We want to preserve and build upon these strong foundations and further support and strengthen local public health systems and their leaders. We are not proposing to make any changes to the scope of local authority public health commissioning responsibilities.

Steps we will take to achieve this

Building integrated care systems (ICS) with population health at their heart

Our White Paper on health and care, and the legislative plans it sets out, has at its heart the concept of population health – using the collective resources of the whole local system, including the NHS, local government and third sector partners, to improve the health of people in their area. ICSs, in partnership with local government, will be responsible for the health and social care needs of the population within their defined geography, and securing the provision of health services to meet the needs of the system population. To be effective, ICSs must be a genuine ‘partnership of equals’ between NHS and non-NHS bodies in order to improve population health – with local authorities and the NHS taking decisions together, and adopting a broad-based approach which includes ‘upstream’ action on the wider determinants of health. Given the critical importance of partnership working at place level, ICSs will build on existing effective partnerships, notably Health and Wellbeing Boards and the expertise of local Directors of Public Health and have regard to its constituent local Joint Strategic Needs Assessments. In addition, we expect local Directors of Public Health to have an official role in both the Health and Care Partnership and the ICS NHS Body. We will leave the precise arrangements for local determination, but this is a clear expectation and we will issue guidance to support ICSs to ensure they have the appropriate level of public health involvement.

Further, we are legislating to include a ‘Health and Care Partnership’ as part of the ICS, which would be tasked with promoting partnership arrangements, and developing a plan to address the health, social care and public health needs of their system. Members of the ICS Health and Care Partnership could be drawn from a number of sources including Health and Wellbeing Boards within the system, partner organisations with an interest in health and care (including Healthwatch, voluntary and independent sector partners and social care providers), and organisations with a wider interest in local priorities (such as housing providers).

Supporting and strengthening the central role of the local authority and Director of Public Heath

We will ensure that the local authority and Director of Public Health (DPH) remain at the heart of the public health system as leaders for public health at place level, and we will seek to strengthen their current public health responsibilities by ensuring that our reforms to other elements of the system serve to support their roles. As we design the UK Health Security Agency, the new national landscape for health improvement, and the regional public health tier, we are considering carefully how these entities can best meet the needs of local public health leaders.

While we are clear that the DPH role should remain at the heart of public health, we think there is more we and others around the system can do to better support them in their roles, and to ensure all areas learn from the best. That might mean considering whether local authorities and DPH would benefit from any additional powers, responsibilities or levers, to help them drive change in their areas. And it may mean looking further at how to improve local accountability and challenge, and at how local authorities can best draw upon support from other areas or partners to help them deliver improvement.

Reforming the regional tier

Regional public health teams, currently based in PHE, play an important role supporting local public health systems and leaders, facilitating collaboration, directly delivering health protection interventions, and helping to inform and translate national policy and priorities. We will strengthen the role of the Regional Director of Public Health as a cross-cutting system leader, able to convene partners across a region, influence and challenge, in order to drive more joined-up action. We will ensure that key functions which are currently delivered at regional level to support local systems are maintained, such as knowledge and intelligence services and strategic workforce support.

Building on our existing regional system leadership and health improvement capabilities, regional population health and prevention teams will work jointly across DHSC and NHSE&I, with a focus on broader recovery and health inequality, as well as health outcomes. Alongside this, detailed design work continues on the sub-national structures for health protection. We know that effective health protection requires strong local authority leadership, and that we need integrated local to national systems, processes and collaborative ways of working. At a local level this will require the UKHSA to work in partnership with local authorities and ICSs.

Nationally this means working with DHSC, NHSE&I, and the academic and life sciences sectors. This collaborative working is even more essential in a crisis and we will ensure that there are transition arrangements in place to protect the ongoing COVID-19 response.

How you can help us

To support our work on this, we are inviting feedback on the questions below. Please give us feedback by filling out this survey by 26 April 2021.

• Question 1: How can we strengthen the local authority and Director of Public Health role in addressing the full range of issues that affect the health of local populations?

• Question 2: How do we ensure that future arrangements encourage effective collaboration between national, regional and local actors across the system?

• Question 3: What additional arrangements might be needed to ensure that regionally focussed public health teams best meet the needs of local government and local NHS partners?

Next steps

We will use your feedback to inform the next phase of public health system reform as we progress towards implementation. There will be a further update on the reformed public health system and more detail on our plans and ambitions for improving the public’s health later in 2021.

Spring 2021

• UKHSA formally established
• Confirm future destination of all services and functions

Summer 2021

• Formal staff consultation, accompanied by a description of how the services and functions will be organised in their respective organisations
• Ongoing design work to shape the UKHSA in the long-term, under its new CEO
• Ongoing design work to develop the Office for Health Promotion and wider changes within DHSC
• Transition to new structures – PHE and NHS Test and Trace will continue to operate during this period

Autumn 2021

• Transfer of staff to new destinations complete
• UKHSA fully operational
• DHSC Office for Health Promotion established