Currently, public health is the responsibility of a mix of national and local organisations, in which national direction and support on policy priorities is as essential as local delivery of interventions. The dissolution of PHE creates a need for public health and health improvement functions to become the responsibility of an alternative national body or local function. We anticipate the publication of an options paper exploring these proposals further, however there are several considerations for a new public health system, regardless of where responsibilities sit.

Recognising the importance of local expertise and collaboration

The response to COVID-19 has been centrally coordinated, but interventions to support people with COVID-19, either socially, medically or financially, have been delivered locally. The national social distancing restrictions, coronavirus testing, and the vaccination programme have been enabled by local delivery, but there have at times been tensions between the centralised coordinating role, and the desire of local leaders to have enough flexibility to meet the needs of their communities.

It is in this context of active learning from the pandemic as it evolves, that the NIHP will emerge. The timing of the creation of this new body may represent a government response to an increased focus on health protection in the current climate and a reaction to historical lack of sufficient resource and focus on this area of public health. However, it is critical to the success of the future public health arrangements that these reforms are not just reactive and expedient but are founded both on the needs of the population, in response to lessons learned from the pandemic, rather than short term priorities.

Successful public health interventions rely on a synergy between national enabling policy direction, local leadership and coordination, and place-based delivery of services and interventions that support the health of diverse communities. This is the case not just during health crises such as the pandemic, but across the range of public health priorities overseen by PHE and executed at a local level, in partnership with local government, health and social services, and the voluntary sector.


Successful public health interventions rely on a synergy between national enabling policy direction, local leadership and coordination, and place-based delivery of services and interventions that support the health of diverse communities.


While there are benefits to a sharp focus from government on managing disease outbreaks, including a nationally consistent directive and framework for a coherent and consistent local response, the 'local' element of this dynamic has not been consistently supported, and local leaders have not always felt empowered to lead the local response to the virus and support their communities. The effectiveness of the national coordinating role has not always been underpinned with the necessary supportive local flexibility. Where the government has attempted to operate large-scale programmes, it has often been hampered by a lack of detailed local data and operational challenges, for example, local authorities trying to coordinate local support and contact tracing efforts have struggled to get the data they need from NHS Test and Trace. In its inquiry into the development of NHS Test and Trace, the National Audit Office (2020) noted that "local government stakeholders expressed concern that they had not been sufficiently engaged on the design and implementation of test and trace services", and that government had not considered alternative options to the national system such as a hybrid of national and local capacity for contact tracing.

The success of the vaccination programme has offered a future path out of lockdown, and the first signs of the programme beginning to take effect can be seen in declining COVID-19 mortality among the highest priority groups. It underlines what the health system can achieve with a clear national directive, and local flexibility to deliver. But it also highlights the need for local organisations such as provider trusts and primary care to be given more flexibility to meet the needs of the communities they serve. The delivery of the programme, with its independent prioritisation process, nationally coordinated supply chain and delivery schedule, has taken longer to be fully tailored to local communities and their diverse circumstances.

For example, health professionals working in deprived parts of the country raised early concerns that the Joint Committee for Vaccination and Immunisation priority groups did not take account of health inequalities which might lead people under the age of 70 in deprived areas to be faced with the same risk of serious complications of COVID-19 as more affluent 80 year olds – healthy life expectancy (The King's Fund, 2020) in these areas is 19 years lower than in the least deprived parts of the country, meaning people experience the health problems that could make them more vulnerable to the virus younger than elsewhere. Now, new modelling has highlighted the need to consider wider determinants of health when assessing COVID-19 risk among different demographics and the guidance on who should shield has been updated, meaning more of those who are at a higher risk of complications of the virus will be vaccinated sooner, and will have their risk status communicated to them.

COVID-19 mortality was higher in more deprived local authorities, and the factors influencing this include existing health inequalities (The Health Foundation, 2020), overcrowded housing, and the fact that lower paid occupations are higher risk for exposure to the virus including caring professions and other frontline key worker roles. Local leaders also have a role to play in helping build trust in the vaccine, and promote take up of the vaccine when it is offered – this is especially importance given confidence in the vaccine among Black, Asian and minority ethnic communities is lower, while risk of severe COVID-19 illness in this group remains high due to inequalities.


The success of the vaccination programme has offered a future path out of lockdown, and the first signs of the programme beginning to take effect can be seen in declining COVID-19 mortality among the highest priority groups.


These issues all raise critical questions for the future of public health, population and prevention functions: whether responsibility for public health functions should sit within the NHS or local government, and subsequently, what the correct balance between centralised control and local agility and autonomy. NIHP will need to work hand in glove with local partners, and maintain strong links to local government public health teams, in order to take advantage of the value these experts bring in engaging with communities, convening wider public services, including housing, justice, parks and leisure, as well as public health services, social care, and education. While health protection is comprised of a specific set of functions and will benefit from focused leadership to drive the health protection agenda, these must not become divorced from the wider context in which people live their lives, and all the wider factors which influence health, and subsequently vulnerability to the direct and indirect impact of health threats.


The need for sufficient funding and investment

Recent figures from the Local Government Association estimate that councils could face a funding gap of £5.3bn by 2023/24 which could increase to £9.8bn due to uncertainty around the impact of COVID-19. The public health grant, which is paid to local authorities to deliver public health services, is now 22% lower in real terms (The King's Fund, 2020)  compared to 2015/16.

The role of local government in supporting the population’s health and wellbeing is not confined to public health and adult social care, and encompasses a range of services related to people’s health and wellbeing including housing, education, leisure, green spaces, local transport and employment. These services are critical to the successful maintenance of the health of communities however financial pressures have led to reductions in spending across the board for many councils as they attempt to balance their books. For example, spending on planning and development, housing, culture and related services has been cut by more than 40% on average (Institude for Fiscal Studies, 2016), spending on social services by 20%.

The creation of a national body for health protection, or a redeployment of other public health functions, will not resolve issues with the public health system alone. COVID-19 has laid bare the impact of the lack of investment in public health over the years, with well-publicised inequalities in the impact of the virus on Black, Asian and minority ethnic communities, amongst others. A lack of resource and overly complex funding mechanisms have led to a fragmented public health infrastructure, and local authorities, having been largely stripped of their public health resources, were not empowered to play their pivotal role in meeting diverse communities’ needs during the pandemic. This, coupled with an apparent lack of preparedness for a pandemic - including the lack of suitability of the national stockpile of personal protective equipment (National Audit Office, 2020) - exposes a need to review the policy trend of deprioritising public health funding across the breadth of its functions.

The NHS may play a greater role in public health going forward, and if this is to be the case it must be supported by investment so that trusts are not asked to carry out vital prevention work without the resources they need to provide the services people need.


A continued focus on health inequalities and health improvement​

The advent of NIHP heralds a new focus on disease control and health protection, but this must not be at the expense of a sharp focus on prevention and tackling health inequalities – after all it is those who faced the worst health inequalities going into the pandemic who have borne the brunt of its impacts, and so any artificial distinction which is created by the separation of health protection and health improvement risks neglecting the fact that those responsible for tackling external health threats need to understand and respond to the factors which influence how those threats impact upon communities. The inequalities seen in outcomes from COVID-19, including case numbers, impact on employment and income, and mortality, do not occur in siloes but have emerged as a consequence of many years of pervasive structural inequalities, including racism and poverty, that render communities vulnerable to the worst effects of the virus.


The NHS may play a greater role in public health going forward, and if this is to be the case it must be supported by investment so that trusts are not asked to carry out vital prevention work without the resources they need to provide the services people need.


For example, the mortality rate in the most deprived areas was almost double that in the least deprived areas between March and July 2020 and followed trends seen in other conditions, suggesting COVID-19 risk is influenced by similar drivers to those of other conditions – inequalities we knew about before the pandemic (Health Education England,2020). Men who worked in elementary occupations or caring, leisure and other service occupations had the highest rates of death involving COVID-19 (Office for National Statistics, 2020), with 66.3 and 64.1 deaths per 100,000 males, respectively.

Not only are disadvantaged communities feeling a greater impact from the virus, but COVID-19 has also had a disproportionate impact of COVID-19 on people from Black, Asian and minority ethnic communities. After accounting for the effect of sex, age, deprivation and region, people of Bangladeshi ethnicity were twice as likely to die from COVID-19 as people of White British ethnicity. People of Chinese, Indian, Pakistani, Other Asian, Black Caribbean and Other Black ethnicity were between 10 and 50% more likely to die from COVID-19 when compared to people of White British ethnicity. Again, these statistics only serve to emphasise the impact of inequalities that were already deeply engrained in society. The causes behind these patterns are complex and interlinked because inequality snowballs out of structural racism to create inequality in housing, education, employment opportunity and ultimately, health outcomes. Deeply-rooted race discrimination has, over time, created systemic barriers to the conditions needed to live a healthy life, and the pandemic has now shone light on the tragic consequences of these inequalities.

More deprived communities also feel a stronger social impact of COVID-19. People in working poverty have been more likely to experience reduced hours/earnings, be furloughed or made redundant. 65% of people in working poverty have seen negative employment change compared to 20% (Legatum Institute, 2020) of those who were not. Crowded, multigenerational housing or more insecure income makes self-isolation more difficult or financially unfeasible, leading to a higher risk of exposure to the virus. More disadvantaged children were disproportionately harmed by closure of schools due to loss of access to learning time, access to online learning and resources, access to private tutoring and inequalities in the exam grading systems. Teachers in deprived areas were more likely to say their students were more than 3 months behind compared to teachers in the least deprived areas  (The Health Foundation, 2020). This demonstrates how health inequalities form a cycle – the impact of COVID-19 can harm the life chances of young people and worsen the poverty which can lead to poor health, leaving these communities even more vulnerable to the virus.

The creation of a specific body for health protection leaves many unanswered questions about the future of PHE’s other vital functions, and the implications of these reforms for the health sector. Among these, health leaders have raised concerns about risks for screening programmes, the national cancer registry, and public mental health functions, all of which depend on the national coordinating role of PHE to thrive. Several options have been set out for the future of health improvement, from embedding these functions into an existing national body such as the Department of Health and Social Care (DHSC) or NHS England and Improvement, creating a separate national organisation responsible for health improvement, devolving it fully to local government, or giving the NHS a greater role in public health, either through integrated care systems (ICSs) or some other mechanism (GOV.UK, 2020).

There is value in a national role driving a focus on health inequalities and health improvement, particularly at a time when the COVID-19 pandemic has affected communities unequally and shone light on the impact of the pervasive inequalities in society. An ongoing focus on addressing these inequalities is essential, both in the response to the pandemic but also in the wider economic and social recovery from the pandemic. This will take national leadership, with a focus on health inequalities at the centre of decisions made about health and other public services in the wake of the pandemic, and we would welcome clarity on where national oversight for prevention and population health will sit, as well as the delivery of services themselves. The lessons learned from the pandemic must not be forgotten or overlooked.