Trusts have a key role to play in driving public health and preventative approaches. For example, they look after the wellbeing of staff and patients, deliver some public health services such as smoking cessation, weight management and alcohol screening and are taking an increasingly active role in the health of the population that they serve as anchor institutions, contributing to local employment opportunities and establish healthy workplaces, and work collaboratively with partners in the health and care system to tackle to wider determinants of health. Trusts playing an active role in prevention are clear that it takes board-level sponsorship and integration into the 'core business' of the trust to work effectively. Our report, Providers deliver: New roles in prevention (NHS Providers, 2020) highlights the work trusts are doing to embed prevention and population health into their COVID-19 response and recovery, and their interventions are locally designed and tailored to local communities.

But there are still barriers to address. The way NHS services are commissioned does not always enable trusts to extend their reach beyond core services into wider preventative services. While there is an expectation that trusts will contribute to reducing health inequalities in the population, with increasing pressures there is little resource left to spare for work beyond those they are explicitly commissioned to provide. Changes to the payment system coupled with a more clearly defined role for the NHS in tackling health inequalities and improving population health will go some way towards strengthening trusts’ ability to embed population health and preventative approaches into the design of their services.


The case for a new approach to commissioning clinical public health services

Public health functions were transferred from the NHS to local authorities under the Health and Social Care Act 2012. This led to the formation of PHE in April 2013, and the creation of the statutory position of director of public health within local health and wellbeing boards. These reforms were part of a drive to develop a more joined up approach to tackle the wider determinants of health (like housing and education). In some areas, these arrangements have led to a more joined up approach. However, the transfer of public health functions to local authorities has also coincided with years of budget cuts and given rise to fragmentation between the NHS and the public health and prevention agenda.

The dissolution of PHE amid the pandemic and the title of the NIHP suggests that 'health protection' issues such as disease control will be led centrally (as currently). This raises important questions for a number of the functions PHE currently discharges in partnership with regional and local colleagues in the NHS and in local authorities to tackle the wider determinants of health and to promote a preventative approach to service delivery across the health and care system.


The transfer of public health functions to local authorities has also coincided with years of budget cuts and given rise to fragmentation between the NHS and the public health and prevention agenda.



The existing arrangements for public health service commissioning have introduced fragmentation between clinical public health services, such as sexual health services and drug and alcohol services, which currently suffer from a lack of coordination between parts of the system funded by the NHS, and those commissioned by local authorities. The transfer of public health funding and responsibilities to local government, while addressing the issue of public health not sitting close enough to the wider determinants of health, may in some areas have led to it being too far removed from the NHS.

Where these links between public health services and NHS services have been weakened, trusts describe challenges around the fragmentation and complexity of commissioning arrangements, funding, and communication between services. This leads to issues such as patients needing to visit multiple services for different elements of their sexual health or mental health needs, and care is less joined up, with an artificial divide created between services that are considered ‘public health’ and those which are considered 'healthcare'.

The challenges around public health funding, as well as funding for the wider determinants of health, and the impact of these challenges, are well documented. With many local authorities forced to reduce spending and cut services across these areas just to fund their statutory duties in respect of adult social care and social services, much has already been lost in the way of local authorities’ financial capability to support a holistic and tailored approach to population health. This has inevitably compounded existing problems and has created a situation in which local authorities struggle to sustainably fund the services they are responsible for delivering. Budgets are often small, and trusts holding contracts for these services often struggle to meet demand and deliver a sustainable service for the money they are being paid to provide it.

Regular re-tendering of contracts in a bid to increase efficiency and value for money has created instability in services and made it difficult for trusts holding these contracts to plan for the future or invest in and transform services. A dispute about who was responsible for funding the 2019/20 Agenda for Change pay uplift for NHS staff working for local authority commissioned services (largely in community trusts), while eventually resolved, underscored the impact of the current divisions between public health and the NHS.


Where these links between public health services and NHS services have been weakened, trusts describe challenges around the fragmentation and complexity of commissioning arrangements, funding, and communication between services.



In 2019, DHSC carried out an exercise to explore whether some public health services – sexual health, health visiting and school nursing – should be brought back into the NHS, as part of a long-term plan commitment to review whether the NHS should play a stronger role in commissioning these services. We argued at that time that the risk of disrupting these services during a period of instability and financial pressure in the NHS would outweigh the reward of doing so, despite the potential benefit of reducing fragmentation and enabling investment in services due to the NHS’s comparatively better financial position.

These benefits and risks remain relevant but in light of forthcoming changes to the health and care architecture, including the dissolution of PHE, the creation of NIHP, and plans in the NHS white paper to put integrated care systems on a statutory footing in 2021, there is now a need to reconsider how clinical public health services are commissioned and funded under this new structure, given the separation of health protection and health improvement and an increased focus on the role of the NHS in public health in the context of the COVID-19 pandemic. Among the proposals set out for the future public health system is the bringing of local authorities into the remit of the providers selection regime to simplify and strengthen joint working between the NHS and local government, and a consultation on these proposals also gives scope for public health to be brought into NHS commissioning, raising multiple questions about how future public health services are funded and commissioned.

There are benefits to the arrangements put in place in 2012, including the greater recognition of public health as a multidisciplinary, population-based approach to prevention and a greater ability to engage the full range of levers that local authorities can access to promote place-based planning and delivery of services. It will be important not to lose these benefits. We continue to emphasise that investment is needed wherever the funding and commissioning responsibilities sit, and that the NHS being responsible for these services will not alone be sufficient to resolve issues created by a lack of funding.

Bringing public health services back into the NHS, and the NHS budget, may afford services greater protection against the cuts in local government finances, which in many areas has led to disinvestment in services and erosion of budgets. Trusts which hold contracts for these services have seen their finances suffer in recent years, particularly community trusts. However, it will be important to avoid a situation in which the commissioning and funding of these services is brought back into the NHS’s remit without any additional funding – papering over the cracks in this way will not achieve the longer-term aim of putting public health services on a more sustainable footing.

Public health and the services provided by the NHS are inextricably linked. Any new system for public health, wherever services sit and whichever body funds them, must take account of this fact and ensure that nothing is lost in the transfer of responsibilities, including ensuring services are tailored to people’s needs, and connected with the wider determinants of health. There will also be a need to avoid over-medicalising’ prevention and public health, which in reality is an amalgamation of influences, of which healthcare is just one. However, a change to the way these services are commissioned may incentivise greater strategic focus on prevention at all levels of trusts’ activity, bolstering trusts’ contribution to prevention and public health and facilitating better joint efforts to tackle health inequalities, as well as enabling a stronger link between these services and the other services trusts provide.