Refocusing upstream – three decades of public health: a personal reflection

Reflecting on public health policy helps highlight areas for future change.

Roberta Jacobsen of University College London Institute of Health Equity considers the key lessons to be learned in public health practice from the last 30 years.

The last three decades provide important insights into where ‘upstream’ change is needed for the future of public health. There are inevitable paradoxes. Successive governments have misunderstood the need for action both at a population and individual level, focusing instead on individual ‘lifestyle change’.^1–3 Furthermore, achieving action in the three overlapping domains of public health – health improvement, service improvement and health protection ⁴ – has been hampered by successive reorganisation and marketisation since 1979. It has been argued that because most health is gained or lost outside the healthcare and social care sector, public health leadership needs to come from outside the National Health Service (NHS) and Department of Health. ⁵ Unfortunately, this has increased the isolation of health improvement from its equally vital contributions to healthcare and social care, particularly relevant to an ageing population.

The closest possibility of such integration occurred in the first decade of the new century, associated with significant increases in real spending in the NHS – a consolidation of public health influence across healthcare and social care and creation of effective ‘whole health economies’ in parts of the country. Joint budgets and pump priming in deprived areas allowed regeneration schemes to thrive alongside healthcare developments. ⁶ This contributed, for example, to a significant fall in both overall teen pregnancy and its social inequalities, ⁷ action across local health economies ⁸ and reduction in infant death rates. ⁹ Multidisciplinary expansion occurred in public health. This flowering needed at least a generation of consistent pursuit to bear fruit. But after 2010, further system reform, together with cuts across the NHS and local authority systems, caused extensive disruption to both policy and practice.

The National Institute of Clinical (and later on Health and Care) Excellence (NICE), created in 1998, is one of the few institutions that has retained the same leadership for many years and survived further multiple reorganisations of the health system. ¹⁰ It has largely earned independence from government interference, in contrast to the more recently created Public Health England that is part of government. NICE has done much to set the bar for evidence-based practice, with international replication of its work. Its pathways of care have illustrated the route to better integration of health promotion and healthcare guidance. ¹¹

The impact of this progress has been weakened by problems arising from the growth of the parallel universes of academe and frontline practice. This is almost unique compared with other disciplines. Progress in any service depends on new knowledge emerging from research into practice. Yet too many public health academics have been locked into the study of causation and the monitoring of outcomes, leaving a black box of intervention in between. Public health research policy priorities have marginally shifted the balance by prioritising intervention research, despite slim allocation of resources. ¹² This has frustrated frontline public health specialists whose task it is to turn research evidence into improved practice, in a climate of constant system change and reduced NHS/local authority funds. The gap between theory and practice has remained wide, although there are honourable exceptions. Academic input into training is vital, but has too often been seen as a marginal activity requiring very little time and effort.

Health policy, like all public policy, will always be subject to political interference. There is a fundamental incompatibility between the time it takes for public health measures to have a positive impact and the short termism of politicians. This can result in jettisoning the baby and the bathwater with every newly elected regime. Good examples of ‘slow-cooked’ public health policies include tobacco control, which took more than a generation to implement and in the teeth of fierce tobacco industry opposition. ¹³ Securing change on discrete issues has also been successful, such as seat belt legislation, accident prevention and communicable disease control, while public health interventions have been less effective on the underlying issues of inequalities in material wealth. Action on health inequalities, obesity and alcohol depends on government departments outside health.

Public health hasn’t always been adept at managing the delicate balance between independent advice on population health while remaining a trusted and effective part of the local and national corpocracy. With the increasing emphasis of the performance culture in the health system, academe became the last bastion of independent public health advocacy. A recent example was the vocal, united front by academics against the widely criticised 2011 health ‘reforms’. ¹⁴ NHS public health practitioners who added their voices, by contrast, did so at risk to their future.

Lessons to be learned from the last 30 years include the following. First, both leadership and sufficient resources for public health need to be vested in the Secretary of State for Health, rather than being submerged at a junior ministerial level. Second, the punishing performance culture needs to be exchanged for a genuine, learning culture, punctuated by the supportive peer review that practitioners have espoused for decades. Third, we need to mend bridges broken by taking public health out of the NHS. This does not need further reorganisation but a change in the role of the Director of Public Health so that it is jointly shared by NHS and local authorities and influences the decisions of the whole health economy. This would help to catalyse the vital cooperation needed between public health, planning and the built environment to implement local solutions to the pressing challenges of obesity and alcohol. Finally, there is safety in numbers. A strong multidisciplinary, expert public health workforce – uniting academe and practice – can maximise influence in changing practice and in equipping the next generation of public health professionals for the future.