The UK public health system: fit for purpose,fit for the future The Edinburgh seminar,October 2017

Preamble

This statement has been prepared under the auspices of the UK Public Health Network. The UK Public Health Network comprises 20 organisations with a generic remit for public health across the four nations of the UK. The statutory public health agencies participate as observers to Network meetings but take a full part in all discussions. The Network meets every six months to exchange knowledge and experience on the strategic issues that affect the public health system and the public’s health and wellbeing.

The Network convened a seminar in Edinburgh on 17 October 2017 to identify the governance factors involved in ensuring the UK public health system is both fit for its current purpose and for future demands. Present at the Edinburgh seminar were Chief Executives, Chairs, Presidents and senior staff of the following:

To the seminar’s knowledge, this was the first time that all elements of the UK public health system had come together to discuss its governance and differing accountabilities. All four nations have experienced much change since 2009 with the creation of new statutory bodies and the restructuring of local public health teams in local authorities in England. Three of the four statutory public health agencies (Public Health England, Public Health Agency NI and NHS Health Scotland/National Services Scotland) are currently experiencing some element of internal restructuring, change in governance or, in the case of Scotland, creating an entirely new public health agency. The Edinburgh seminar provided a unique opportunity to inform the process of restructuring by sharing knowledge and learning between statutory agencies and non-government bodies. The seminar focused on the systemic factors that could be either supporting or inhibiting the delivery of improvements to public health and wellbeing across the whole country.

The considerable experience and expertise of seminar participants generated both a clear understanding of the present UK public health system and consistent agreement on the factors making a system fit for purpose. However, the views and decisions held in this statement will need to be balanced against any findings from systematic research.

The following six attributes emerged from the Edinburgh seminar. These are defined as the VALUES principles and were considered to be essential factors in a unified, effective and collaborative public health system.

Vision

Current annual planning cycles may work for organisational budgets but a more future-oriented strategy is required to achieve generational improvements in health. A public health strategy that takes a 10–20 year view would enable the UK public health system to deliver more systematic health gains with measurable performance against priorities on a 3–5 year cycle. Lessons should be learned from the Wellbeing of Future Generations (Wales) Act and the Community Empowerment Act (Scotland) both of which create a longer-term common vision and purpose in those nations.

The Edinburgh seminar felt that the UK public health system should be more aspirational. Current planning cycles do not support the delivery of generational improvements in public health and wellbeing.

Accountability

Accountability should be a two way process. It should not be restricted to monitoring performance but should enable reporting on outcomes as well. Disconnects currently exist, particularly in England where the national agency shares public health system leadership with local government. The differing accountabilities of national and local government challenge the effectiveness of this system. Any system re-design could avoid re-creating this issue. There may be lessons to learn from the devolution agenda in England and how Manchester delivers on improvements in public health in particular.

The Edinburgh seminar felt that current accountabilities may be hindering the ability to deliver sustained, long-term improvements in the health and wellbeing of the public. Accountability arrangements should address the present gap in responsibility for public health outcomes and targets not being met and enable effective shared leadership.

Language

The UK’s greatest economic asset is the health of its people. Speaking about health in language that is understood locally is of the greatest importance. Priorities should be locally determined but cross-cutting so that all government departments are included. Broadening the way that the public health community speaks about health to include social justice and a right to the highest attainable levels of health will also bring agencies and government departments together.

The Edinburgh seminar felt that the public health system should reflect local needs in its language as well as reaching out to other agencies to tackle wider determinants of health by changing the way it speaks about the public’s health and wellbeing.

Unity

The system needs further design to encourage Directors of Public Health to work together more cohesively and systematically. Interdependency needs to be built in so that longer term improvements to public health and wellbeing are a collective, cross-government responsibility. Collective action provides power to the system. This must include the third sector and non-government organisations alongside statutory agencies.

The Edinburgh seminar felt that shared leadership is essential to the UK public health system so that the system is able to identify and tackle the big issues together effectively.

Engagement

Building relationships with parliaments helps ministers to invest in creating a healthy population both within each nation and across the UK as a whole. Learning lessons from current governance issues, such as that around the Grenfell Tower fire, means that the system will know who makes the decisions, when, where and why. If the public health leaders do not even know where to look for the answers, then the system is working very imperfectly.

The Edinburgh seminar felt that the public health system needs to engage more effectively and systematically with the political and legislative environments.

Sustainability

Lessons need to be learned from Public Health Wales which – accepting that Scotland intends to change – has experienced the longest period of stability of the four nations since it was established in 2009. The Welsh Government policy of taking ‘the long view’ appears to allow its public health agency to set longer-term priorities which it is working to achieve through a variety of partnerships and collaborative arrangements. Such partnerships in England, for example, England’s Public Health System Leaders Group, are in their infancy.

The Edinburgh seminar felt that partnership working is fundamental to the delivery of improvements in public health and wellbeing. Sustainable mechanisms need to be further nurtured across the UK to support this approach.

Recommendations

The Edinburgh seminar believes that the VALUES approach would enable the various parts of the system to work more closely together, including the cross-government working that is so essential to addressing the wider determinants of health. Incorporating these six attributes into the design of the UK public health system should establish greater flexibility in the system; improve its accountability in delivering health gains at local, regional, national and UK levels; and, most importantly, encourage it to evolve to meet future needs.