By Karen Taylor and Samrina Bhatti, Deloitte Centre for Health Solutions

Over the past seven months, we have been developing a series of reports examining the current challenges and future requirements for a resilient public health system in the UK. This week we launched the first report in the series, Narrowing the gap: A fairer and sustainable future for public health.¹ This report is an executive overview highlighting the key findings from a series of deep dive reports into the crucial challenges facing public health. This week’s blog provides highlights from our overview report and a taster of what to expect from our report series which we will launch over the next few weeks.

Why public health matters?

Public health is defined as ‘the art and science of preventing disease, prolonging life and promoting health through the organised efforts and informed choices of society, organisations, public and private communities and individuals’.² Public health is concerned with improving the physical , mental health of a defined population and involves shifting the focus from treating illness to promoting greater health and wellbeing in a sustainable way, strengthening services and reducing health inequalities.³

Our research, including a survey of 1,500 front line staff and interviews with 85 public health experts and other key stakeholders, was carried out between March and July 2021, against the backdrop of the third wave of COVID-19. As most of us are aware, the pandemic has exposed the impact of long-standing health inequalities and lack of progress in addressing the social determinants of health. However, it has also highlighted the serious shortcomings and gaps in public health funding and confusion over the roles, responsibilities and accountabilities of a beleaguered public health workforce. Furthermore, it has increased awareness of public health in the eyes of the public and created opportunities for innovation and new ways of working.

We acknowledge that public health challenges are highly complex, interdependent and constantly evolving, and that tackling these challenges requires a combination of specialist public health skills and cross functional responses, including more effective collaboration between stakeholders.  Moreover, activities to improve health outcomes need to be managed in way that helps achieve the overarching objectives of closing the health inequalities gap, reducing avoidable disabilities and premature deaths, and improving the wider outlook for health and society.

What were the challenges facing the public health system pre-COVID-19?

Traditionally, the success of a public health system has been gauged by its impact on reducing health inequalities, measured by life expectancy at birth, and healthy life years. While the UK has seen year--on-year improvements in life expectancy over the past century, these improvements have stalled in recent years. Moreover, the number of people living longer but with more years in ill-health has increased. Importantly, there is now widespread acceptance that access to healthcare only partially impacts life expectancy, and that health inequalities are shaped by a complex array of inter-linked social, economic, political and environmental factors, known as the social determinants of health.

Our survey respondents identified the increasing demands of a growing and ageing population, tackling health inequalities and keeping pace with the rising complexity of the needs of an ageing population as the most frequently mentioned challenges that public health faced pre-pandemic. The most frequently identified challenges mentioned by our interviewees were: funding cuts, difficulties in reducing deep-seated health inequalities and fragmentation and silos within and between services (see Figure 1). Our interviewees also highlighted concerns that the health protection system was too fragmented with far too few people in the workforce and that there had been a lack of vigilance in preparing for pandemics including inadequate surveillance and unclear accountabilities.

Figure 1. Prior to the COVID-19 pandemic, what were the top three challenges the UK was facing to create an effective public health system?

What was the main impact of COVID-19 on the public health system?

The pandemic has amplified the challenges pre-pandemic including the full extent of the social gradient on health outcomes; as well as exposing the inadequacy of investment in the health protection infrastructure, such as test, track and trace. Moreover, the pandemic has changed irrevocably how the public perceives health threats. This has added to the concerns that were already evident before the pandemic about:

• the capacity and capabilities of public health organisations to meet the growing needs for services and reduce health inequalities
• the workforce challenges evident before the pandemic and the need for more innovative, flexible and sustainable workforce solutions
• the lack of access to relevant health data (especially in the first wave of the pandemic)
• the fragmentation of the public health infrastructure
• the need for longer term certainty and an increase in funding and investment, commensurate with the growing public health needs.

However, our interviewees also noted how the pandemic prompted many bold and innovative responses and demonstrated the agility, skills and talent of the public health workforce, including the impressive development and rollout of COVID-19 vaccines. They also identified an enhanced appreciation of the role of the voluntary and charitable sectors as well as partnership working with stakeholders.  Moreover, the pandemic has exposed the link between health and productivity and has shown how population health and workforce wellbeing are crucial assets for economic recovery and growth.

How might the ‘wicked problems’ of public health be tackled?

A crucial development is the wave of innovation in digital tools, which together with disruptive technologies (such as machine learning, digital reality, blockchain and the cloud) provide a more cost-effective opportunity to improve public health services. Going forward, health services will need to institute more equitable access to validated digital tools and develop initiatives to improve the digital literacy of the population.

Expert opinion on how best to improve public health emphasises the importance of empowering communities to drive and shape health in both direct and indirect ways Importantly, all communities have health assets provided by the public, private, voluntary, community and social and technology enterprise sectors. By drawing on their collective strengths, communities can improve the health and wellbeing of all their members, but also target those most in need of help and support. Public health teams have a crucial role in harnessing these assets and orchestrating their effective deployment

The establishment of ICSs as statutory bodies provides an opportunity for public health to influence a broader range of stakeholders to tackle the social determinants of health and create an enabling infrastructure in which local communities can thrive. Many of our interviewees emphasised that for this to be truly effective, public health needs to have a seat at the ICS table.  The creation of ICSs also provides an opportunity for public health teams to establish more collaborative, integrated, models of workforce deployment, optimising the use of the skills and talent of other stakeholders in the ICS.

What needs to happen to achieve a fairer and sustainable future?

COVID-19 has stress-tested the government’s ability to deal with unforeseen events and exposed the impact of the social gradient on the ever-widening health inequalities gap. It has shone a spotlight on the consequences for public health of poor and overcrowded housing, insecure employment and food insecurity. However, it has also shown that attitudinal shifts in health behaviour are possible.

Since inequalities in the UK are deep-rooted and complex, even well-designed policies could take years to have a meaningful effect and will need a long-term, multi-faceted approach, including more certainty of funding and longer commissioning cycles.

We now have an unparalleled opportunity to capitalise on the reorganisation of public health services and build on the public’s improved understanding of public health and the need to improve health outcomes for all and capitalise on the governments levelling-up agenda. Leaders need to focus on collaborative approaches to prevention and early interventions with a robust place-based, asset-based approach to deal with the root causes of health inequalities. 

Over the next six weeks we will publish our deeper dive reports on the future of public health, exploring the issues raised in our overview report in more detail including our primary research findings, case examples and relevant published literature.

• Identifying the gap: Understanding the complexities of public health
• Bridging the gap: Protecting the nation from public health threats
• Negating the gap: Preventing ill health and promoting healthy behaviours
• Removing the gap: Galvanising community assets to improve health outcomes for all
• Employers role in reducing the gap in public health: Improving the health and productivity of employees

Karen Taylor - Director, UK Centre for Health Solutions

Karen is the Research Director of the Centre for Health Solutions. She supports the Healthcare and Life Sciences practice by driving independent and objective business research and analysis into key industry challenges and associated solutions; generating evidence based insights and points of view on issues from pharmaceuticals and technology innovation to healthcare management and reform.

Email | LinkedIn

Samrina Bhatti, MRPharmS, PGDipGPP, Manager

Sam is a national award-winning pharmacist with local, national and international experience. Prior to joining the Centre, Sam was working alongside the Chief Pharmacist at Bart’s Health delivering trust-wide projects in service development and implementation. Prior to this Sam was the NHS England Chief Pharmaceutical Officers’ Clinical Fellow at Specialist Pharmacy Service, where she led various national projects on medicines use and digital healthcare. Sam is part of the global commonwealth health partnerships, an NHS England Clinical Entrepreneur, and a pre-doctoral fellow at Health Education England undertaking a PGCert in Healthcare Research Methods. Sam is also an associate of the Faculty of Clinical Informatics and Institute of Healthcare Management and has a Master of Pharmacy from King's College London and Diploma in General Pharmacy Practice.

Email | LinkedIn

______________________________________________________________________________

^{1 deloitte-uk-future-of-public-health-narrowing-the-gap.pdf}

^{2 Public health services, World Health Organization. See also: https://www.euro.who.int/en/health-topics/Health-systems/public-health-services}

 ^{3 Introduction to Public Health, Centers for Disease Control and Prevention. See also: https://www.cdc.gov/training/publichealth101/public-health.html}