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Phil Swann: Public health needs a reset between NHS and councils

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“We spent all our time saying it wouldn’t work. Five years down the line it’s the best thing for pubic health and for local communities and residents.”

“The complexity of the work is not yet fully understood … we are still influencing from the side.”

“Gaining more traction with the NHS is absolutely key. If we don’t get that right we’ll have a narrow version of public health focusing on place without any traction with the wider health system.”

These three quotes, from interviewees for a report commissioned by the County Councils Network and published this week, capture the range of perspectives on the impact of the transfer of public health to local government.

The core conclusion of the research, carried out by Shared Intelligence, is that the transfer is on course to deliver the ambitions of the ministers who instigated it in 2013. Public health teams in local government are beginning to influence the wider determinants of health through collaboration with their new local government colleagues on planning, transport, employment and skills, children’s services and housing.

Our report, based on unattributable interviews with directors of public health, health and wellbeing board chairs, chief executives and health partners in 14 county areas, concludes that public health services have benefited from councils’ procurement and commissioning expertise. Before the transfer many directors of public health were nervous about the politics of local government, but they now see councillors as powerful advocates for public health within councils and communities.

As the second quote citing complexity suggests, however, more progress is being made in some places than others. Our research shows that the position of public health in a council is important. The report paints two pictures.

In one picture the public health function sits at the corporate core of the council. The task of marshalling the wider determinants of health is centre stage. This is an aspirational place-based function.

In the other picture public health is seen as a people service, sitting alongside adult and children’s services. The focus of activity is often on commissioned services. This is a setting in which financial pressures tend to be central.

Yet the real challenge facing public health is encapsulated in the third quote on gaining traction with the NHS.

Most of the people we spoke to in the NHS were critical of the transfer, highlighting fragmentation of service provision and a perceived gulf between public health teams and the health service. They are also sceptical about the extent to which action on the wider determinants is happening or is having an impact on the ground.

Many of the directors of public health we interviewed were concerned about the development of a gulf and highlighted the steps they are taking to maintain and develop effective relationships with their NHS colleagues and organisations. Personal links are critically important, as are a variety of staffing arrangements, including basing public health staff in NHS organisations, jointly-funding posts and co-locating staff.

These findings must be looked at alongside the focus of prevention in the NHS long-term plan. It is significant that the plan talks about the NHS complementing, not taking over, the important role of local government. This research shows why that is important.

The core conclusion of this research is that in 2013 the then government was right to be ambitious about the potential of local government to take the lead in improving health locally, working closely with local partners and exploiting the full breadth of its remit.

But if the government’s objectives for health and care integration and prevention are to be achieved it is vital it builds on the wider place-based role of county councils and their district partners, not simply their role as social services authorities and commissioners of public health and care services.

This will require a fundamental reset of the relationship between health and local government, including on the role of public health.

Phil Swann, executive chair, Shared Intelligence

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