Public health is in crisis, but it can be fixed
BMJ 2024; 384 doi: https://doi.org/10.1136/bmj.q760 (Published 27 March 2024) Cite this as: BMJ 2024;384:q760
Since 2010 a combination of austerity, Brexit, and the impact of covid-19 has considerably worsened the public’s health in England.123 Obesity levels have risen, fuelled by the consumption of unregulated ultra-processed foods, a chronic problem which successive governments have failed to tackle.4 Gains in life expectancy have stalled.5 Health inequalities, both between and within regions, are widening.6 Growing numbers of people are unable to work because of illness.7 The UK now has one of the worst health profiles of any high income country, especially among children,8 and its deteriorating health status is adding to pressures on the NHS. To secure social conditions that support healthy populations, we need the political commitment of governments to act for the common good and their investment in institutions that protect public health.
We know that ill health is tied to social determinants, and while governments alone do not shape those determinants, it is their job to produce policies that improve social conditions and protect health. To do this they need well resourced public health agencies that are strong and politically effective in influencing policies in transport, housing, planning, consumer affairs, and finance. But public health is in crisis in England, with the country’s core agencies weakened by a broken government that has no interest in rebuilding the public services and infrastructure it has done so much to hollow out.
After abolishing the principal public health agency, Public Health England (PHE),9 without warning midway through the pandemic in August 2020, the government replaced it with two new bodies. The UK Health Security Agency (UKHSA) is charged with health protection, and the Office for Health Improvement and Disparities (OHID) has responsibility for wider public health, including non-communicable diseases such as obesity. Set up in haste with no consultation, OHID lacks any of the (albeit limited) independence PHE had, being an opaque body scattered through the Department of Health and Social Care. Given its low profile and lack of a clear mission, it comes as no surprise that, despite denials from the government, it has recently been reportedly decimated under the guise of a “restructure.”10
OHID’s fate is in keeping with the government’s ongoing opposition to public health measures and fear of being accused of “nanny statism.” True to its neoliberal roots, the government is committed to the rhetoric of individual choice and to shrinking state support, which we refer to as “vulgar individualism.”11 Instead of this defunct philosophy, we urgently need a new social contract based on the principles of “social individualism,” a philosophy that recognises how the health and flourishing of populations depends on the right social conditions, and which is committed to using political authority for the common good.
A wake-up call
Many of the measures that could be adopted to tackle our public health challenges have a sizeable and robust evidence base, so there is no need for further reviews or inquiries. The weakening of OHID should serve as a wake-up call. The next incoming government should reset public health policy and restore serious national public health leadership. A good place to start is the Hewitt Review on Integrated Care Systems. Ignored by the government, the review argues for a major shift upstream towards prevention and for investment that prioritises public health.12
England urgently needs a national agency for public health that is respected, free from government interference, and able to speak truth to power. NICE may serve as a model here given its impressive longevity and the global respect for its work,13 which is largely due to its organisational stability, governance, and arm’s length relationship with government.
England could also learn from the devolved nations. Public Health Wales and, more recently, Public Health Scotland have made notable improvements to the health of their populations. In Wales, pioneering work has been conducted through health impact assessments covering topics such as the mental wellbeing of future generations and climate change,14 while in Scotland the introduction of minimum unit pricing for alcohol has reduced deaths directly caused by alcohol by 13.4% and related hospital admissions by 4.1%.15 Both bodies were established after consultation with key stakeholders and detailed attention was paid to their governance so that they have a degree of independence from government.
Revitalising public health in the UK requires three key changes. Firstly, the government should consider establishing a body like the Office of Budget Responsibility or National Audit Office, with a remit that allows it to independently report on the effect of government policies on public health.16 Secondly, a cross-government approach is needed to make progress in realising the new social contract we advocate for aimed at tackling the social determinants of health. Lastly, priority should be given to restoring the funding cuts to local government17 and to public health whose funding has been reduced by 27% in real terms since 2015/16.18
Investing in the public’s health is not a cost but an investment in a more productive society. However, fixing public health also means reforming our broken political and public policy system.19 Missing above all from the UK government’s approach to the public’s health is the political will and competence to act. But for policy to stick these are essential prerequisites.
Footnotes
Competing interests: None declared.
Provenance: Commissioned; not externally peer reviewed.