28 Jun 2022

The problem of design

How should public health governance be organised to be effective? The question is not easy to answer. Protecting public health means taking action against a wide variety of health hazards – for example, chemicals in the environment, climatic emergencies like a heatwave, or, as we have all discovered in the last few years, control of infectious diseases.

These organisational problems were thrown into sharp relief when, during the midst of the Covid-19 pandemic in August 2020, the UK government abolished Public Health England as a free-standing body and began the process of creating the UK Health Security Agency (UK HSA) (see blog: Gone and even forgotten). The restructuring did not resolve key issues of organisational design and these issues are still a matter for discussion and decision as part of the independent UK Covid-19 Public Inquiry, chaired by Baroness Hallett.

The Inquiry undertook a public consultation on its scope, following which the chair wrote to the Prime Minister with proposed changes to the Terms of Reference for the Inquiry, reflecting the recurring themes that emerged from the consultation.

Notably, one of the main themes to be added was that of organisational structure and concerned the collaboration between central government, the devolved administrations, local authorities, and the voluntary and community sector.

Jacqueline Johnson, Peter Littlejohns and Albert Weale

Expanding the Inquiry’s terms of reference reminds us that all major organisational restructurings, like that involving the abolition of Public Health England and the creation of the UK Health Security Agency, take place in a context, shaped by the existence of already existing bodies whose work touches that of the new one. The ship of state always has to be rebuilt at sea. Indeed, in the UK even to talk about the ship of state is misleading, since the devolved administrations of the home nations have public health responsibilities. This means that any change for England will also have implications for those in Scotland, Wales and Northern Ireland. We should really refer to a small fleet of ships rather than just one.

If there is to be further consideration of changes to public health governance in the UK, it therefore needs to take stock of the present situation. What boats does the fleet currently have and how are they related to one another? In this blog we offer a preliminary look at this question examining the existing distribution of responsibilities across Northern Ireland, Scotland, Wales and England. We have drawn the data from the publicly available sources on the websites of the UK HSA, Public Health Scotland, Public Health Wales, and Public Health Northern Ireland, all of which list the scope of their responsibilities.

How is public health governance currently organised?

Figure 1 (below) shows the division of public health responsibilities across the main public health bodies in the UK: the UK Health Security Agency, Public Health Scotland and Public Health Wales, as well as Northern Ireland. The UK HSA categorises some 215 responsibilities into four broad groups: exposure to chemicals, environmental health hazards, health emergencies, and infectious disease. Some of these responsibilities are shared by all four bodies; some are shared by fewer; and others fall just to one body.

Figure 2 (below) provides some detail about how these responsibilities are distributed across the four territories. The contrast between infectious diseases and chemicals is most striking. A large number of health hazards are included in each of these two categories. In the case of infectious diseases, the vast majority of the diseases fall within the responsibility of all three bodies. By contrast, UK HSA has responsibility for most of the chemical hazards. Presently, this data has been extracted from public sources, namely websites, and is in the preliminary stage of validation (any changes to data will be updated in a future version).           

The importance of collaboration across organisations and jurisdictions

An important implication of the same responsibility being shared among different organisations is that inter-organisational collaboration becomes important. When a new organisation is created, people often draw attention to the need to meld together the different cultural orientations of its different components, as has happened with bringing together Test and Trace and Public Health England in the new UK Health Security Agency. This is obviously a major challenge. However, given that health hazards do not recognise administrative and political boundaries, it is just as important that a territorially based organisation be able to work with similar territorially based organisations in other jurisdictions. For example, the UK HSA provided advice to the Chief Medical Officers in UK jurisdictions on the level of the Covid-19 alert in late May 2022 (see for example).

Further, the need for inter-organisational collaboration is also relevant in relation to the role of the Office for Health Improvement and Disparities, which was created in the process of setting up the UK HSA and sits within the Department of Health and Social Care. Though still under development, at present, it looks as though much of its work will be devoted to health promotion and issues such as obesity. However, it also has responsibility for air pollution. We know that exposure to the health hazards of urban air pollution has a clear social gradient. In principle, then, responsibility for such social inequalities should feed back into the scientific work of the UK HSA concerned to identify the pathways by which ill heath arises from pollution.

Understanding how public health bodies relate to other parts of government

Concern about pollution suggests another set of organisational issues, namely how public health bodies relate to other public bodies whose responsibility falls within overlapping policy areas. Because health hazards are generated from a wide variety of sources, different parts of government are involved in regulation and policy making. Thus, hazards like air pollution in the environment will fall to the responsibility of environmental protection agencies or industry regulators. A recent review of the UK government’s air quality strategy by the National Audit Office  highlights breaches in implementation of air quality standards, but also identifies the key government departments responsible for implementation as Environment, Farming and Rural Affairs on the one hand and Transport on the other. As this shows, implementing policies to address a public health issue does not fall to bodies that have primary responsibility for public health.

This applies to other health hazards. Many sources of such hazards are the responsibility of a wide range of government departments, including those concerned with occupational health, traffic accidents, consumer product safety, poverty and poor housing, to name but a few. In short, once we move from policies to protect people from health hazards to policies preventing those hazards arising in the first place, we start to take in a broad range of government activity. We also see how health improvement needs to take note of what is being done, or not being done, to address the social determinants of health.

As a result of overlaps of responsibilities, in some parts of the UK a hazard will be the responsibility of the public health body, but in other parts of the UK, the responsibility, for example, of an environment agency. In Wales, for example, responsibility for drinking water falls to Public Health Wales, whereas in Scotland it falls to the Scottish Environmental Protection Agency. There is no reason to expect consistency in this respect. Different national governments will have different organisational arrangements for their various departments, and sometimes an already existing agency, like the Scottish Environmental Protection Agency, will have established a track-record in a particular area of concern.

Ensuring national and local public health bodies work together

So far we have considered organisational issues at the level of national governments. However, local authorities in the UK also have public health responsibilities and these interact in important ways with responsibilities at the national level. For example, Public Health Scotland is a special health authority, but it interacts with the 14 territorially based health authorities across Scotland. In England, the importance of this central-local interaction was illustrated by the difficulties of test and trace in the Covid-19 pandemic. Although Public Health England had a good grasp of the science relating to Covid-19, it had problems scaling up its test and trace capacity to the level needed, a problem that Test and Trace, when it was established as a separate body, did not solve. The successful tracing of contacts requires local knowledge. 

    So, if successful science, primarily a central responsibility, is to be translated into successful implementation at the local level, then national governments have to work with local governments. The union of scientific strength and local operational capacity requires organisations at these different levels to be able to work well together.

    Jacqueline Johnson, Peter Littlejohns and Albert Weale

    Two key lessons for the UK Covid-19 enquiry

    It is to the credit of the UK Covid Inquiry that it plans to take on board issues of organisational arrangements. Even our brief review here suggests some of the complexity of the issues that it will face. At this preliminary stage, however, two lessons stand out.

    First, there is a premium on inter-organisational collaboration given the adjacent functions and overlapping responsibilities that the organisation of public health protection inevitably involves. This can run against the grain of organisational routines, where silo thinking is the norm, not the exception. So public health functions will generate a need for protocols and processes of collaboration within agreed frameworks for the division of labour. These issues are just as important as creating the right internal culture in an organisation.

    Second, the complexity of organisational structures can create significant problems of policy accountability. Even experienced public administration professionals can find it hard to understand the scope of responsibilities of different bodies. What hope is there for the average citizen? A modest start would be a publicly accessible map of how the different organisations relate to one another and how they share their responsibilities.

    So, among the many other issues to consider, the Covid Inquiry inevitably prompts questions about governance. 

      Baroness Hallett has a once-in-a-lifetime opportunity to guide how public health agencies should be organised to ensure they are effective in their vital work.

      Jacqueline Johnson, Peter Littlejohns and Albert Weale

      Resources

      The Inquiry continues to emphasise its intention to be open and has made the following documents publicly available: 

      The NIHR ARC South London research collaboration was one of 20,000 individuals and organisations that responded to the draft T0Rs of the Independent Covid Inquiry.

      Acknowledgements

      We are grateful to David Hunter, emeritus professor of health policy and management, Newcastle University, and Professor Alison McCallum, Centre for Population Health Sciences, Usher Institute, University of Edinburgh for information and advice in connection with this blog. Naturally, content remains our responsibility.

      About the authors:

      • Jacqueline Johnson, executive master of public administration-global public policy and management, New York University and University College London
      • Peter Littlejohns, emeritus professor of public health, King’s College London, public health and multimorbidity theme lead, ARC South London
      • Albert Weale, emeritus professor of political theory and public policy, School of Public Policy, University College London