Why health improvement needs to be the focus of the UK’s future

It would not be an understatement to say that COVID-19 has tested every aspect of how we organise our lives, our services and our society. In the moment of crisis, citizens, services and professions have flexed and innovated to protect the most vulnerable and to ensure that those who need urgent care and support receive it.  

Crucially though, COVID-19 has exposed gaps in our pandemic preparedness and in our knowledge of how to respond appropriately to minimise harm. Some of these gaps were unimaginable, such as the precise nature of effective intensive care to save lives. Some were avoidable, such as a lack of planning for critical care beds, morgue capacity and personal protective equipment. We have the prospect of a national inquiry ahead of us to understand and learn lessons. 

Right now, we are facing a difficult winter with a second wave of COVID-19 as well as seasonal flu. And we are now acutely alert to how easily a novel virus can take a hold and cause havoc. For these reasons the Secretary of State has announced that he is creating a new National Institute for Health Protection (NIHP).  

The NIHP will bring together the health protection responsibilities discharged by Public Health England (PHE) with the capabilities of NHS Test and Trace, and the Joint Biosecurity Centre ‘to ensure we have the best infectious disease control capability and is a global leader on dealing with pandemics or health protection crises.’ There is much to debate and question about the plans and the timing – and whether staff can maintain a focus on the issues of today amidst the uncertainty of where they will be working tomorrow. 

However, leaving aside the NIHP, what has been left unclear is what is to happen to the other functions of PHE, such as health improvement and its knowledge and intelligence functions. In his speech to the Policy Exchange, the Secretary of State said, ‘levelling up health inequalities and preventing ill health is a vital and a broad agenda. It must be embedded right across government, across the NHS, in primary care, pharmacies, and in the work of every local authority.’ 

Many would argue we were already on the way to embedding this agenda. Tackling inequalities is now a central plank in the NHS long term plan; public health sits squarely within local government; and the formation of integrated care systems has facilitated true place-based partnership working. PHE has played a vital role, evidencing the breadth of causes of health inequalities, from early childhood development through to the quality of our homes and communities, and producing practical frameworks to support local action.  

Some have argued that PHE has lacked the independence to speak truth to power. But it has held the unique position of speaking both to national government and to local systems, providing the data and analysis to demonstrate where inequalities exist, and publishing the evidence for the policy decisions that will have the greatest impact on wellbeing and health. Without a dedicated national public health agency, how will national and local government, the NHS and other actors access the data and the evidence they need to make decisions that will address all the determinants of health, narrow inequalities and achieve the levelling-up aspiration? 

There has been a disinvestment in public health nationally and locally over the last few years. The King's Fund estimates that local government spend on public health has decreased from £2.7bn in 2014-15 to £2.5bn in 2019-20. This represents a fall in real terms of 25% per person over the past five years. COVID-19 has exposed the impact of this disinvestment across the public health disciplines: on the one hand a lack of investment in health improvement has given rise to the poor levels of health in the population that have contributed to the UK’s high death rate from the virus. And on the other hand, our health protection teams were woefully underprepared in terms of the systems and equipment necessary to tackle the virus. The risk now is that health protection is prioritised at the expense of health improvement.  

COVID-19 has demonstrated that those in poorer health and those living in poorer circumstances are the most vulnerable to the impacts of infectious disease. We knew this back in the days of cholera and tuberculosis, but it is a hard lesson to learn again in today’s society. We must do more as a country to improve our health status and the wider conditions in which we live. 

Next year will mark the start of the UN’s Decade of Healthy Ageing, to which the UK is a signatory. What better to way to prepare than to announce plans and investment for health improvement to mirror those announced for health protection? That way, we can ensure that we have the best health improvement capability and that we are a global leader on dealing with health inequalities.