The House of Commons Health and Social Care Committee has launched a major new inquiry into preventative healthcare. Unusually, they are staging their call for evidence. In the first step they are inviting researchers and people working in health prevention to suggest what specific topics should be explored.
This is sensible as the subject is vast, including the classical issues of smoking, alcohol and obesity, but also broad issues, such as mental health and healthy environments. Even with such a varied list, they accept it is not exhaustive and they are welcoming proposals that cover other areas in prevention. Their aim is to advise government on where prevention should be in 2030. The closing date for this call is Wednesday 8 February, but there will be a second call when the areas to be investigated have been chosen.
We have submitted a proposal that addresses the organisational issue of where and how our national efforts to prevent disease should be coordinated.
Our recent NIHR ARC South London research project explored the circumstances surrounding the closure of Public Health England. It stimulated a series of questions regarding national arrangements to improve public health.
How should we think about the organisational design, policy paradigm and public philosophy that makes for effective, reliable and robust public health policy?
One of our central conclusions is that structural reorganisations, like the one that led to the creation of the UK Health Security Agency and the Office for Health Improvement and Disparities are never enough. Although such reorganisations can be attractive to politicians, they can also obscure more fundamental questions about the principles and policies that should inform public health and beyond them questions of governance and the capacity of the UK state to meet its public health responsibilities.
How far can the UK’s new public health system establish the policies and processes that meet the challenges of public health in the 21st century?
Public health is not just a matter of health policy, especially when it comes to addressing the social health determinants of health and tackling health inequalities. It concerns whole systems, cross-sectoral inter-departmental matter, which the WHO has termed Health in All Policies. As prevention lies at the heart of public health, we suggested to the Committee that they investigate how well these cross-sectoral arrangements are working in UK government. A recent report from the National Audit Office noted the breadth of cross-departmental responsibilities.
We invited the Committee to:
While this “whole system” approach is not novel, achieving it has proved very difficult to implement in practice.
As WHO and others have said, in many countries ministries of health are generally weak when it comes to cross-government working and unable to provide the required leadership. Unless finance ministries are on board, then public health generally gets ignored or down-played.
There are different models to achieve this coordination, for example, the Health Committee Inquiry in 2016 (House of Commons Health Committee, Public Health Post-2013. Second Report of Session 2016-17, HC 140) did look at the issue of having a Cabinet sub-committee for public health (see paras 85-87, pages 39-40). The Committee's conclusion was that it was not persuaded that having a sub-committee had been a key driver for change or that it should be re-established. They did recommend that a minister in the Cabinet Office be given specific responsibility for embedding health in all policies across government, working closely with the Minister for Public Health in the Department of Health (para 94, p.41).
In its response to the Committee's report, the Department of Health (2016, Government Response to the House of Commons Health Committee Report on Public Health Post-2013, Cm 9378) agreed that 'a Cabinet sub-committee is not the most effective way to achieve that unity [for central government as a whole]' (para 10, pages 8-9). But it also believed that creating a second ministerial post with similar duties to the Minister for Public Health in the department 'would run the risk of duplication and inconsistency', so was not in favour of this suggestion.
We proposed that in its report on prevention the Committee consider that governmental public health policy coordination could be modelled on the Office of Budgetary Responsibility, as proposed by the UK Public Health Network. While there are arguments for and against any particular arrangement, the Committee could determine how well the current arrangements that are supposed to be in place are working, and then alternatives could be canvassed if deemed necessary.
With the NHS at breaking point, prevention is likely to be scrutinised very closely in the next few years as one way to address the challenges. This inquiry, if it gets it right, could make a significant contribution to restoring faith in the NHS.