Views & Reviews If I Ruled the NHS

We need a Public Health Act fit for 21st century

BMJ 2015; 350 doi: (Published 19 February 2015) Cite this as: BMJ 2015;350:h616
  1. John R Ashton, president, Faculty of Public Health
  1. Johnrashton{at}

If I ruled the NHS, strengthened public health and primary and community care would go further than the currently fashionable talk of integration, to re-embrace housing and town planning and the “hidden lay healthcare system” that accounts for most care.

Other challenges I would tackle include bringing back robust local public health intelligence, no longer provided by the public health observatories, and a new approach to workforce development that recognises the importance of practical nursing and the reservoir of untapped young talent in our communities. It is lunacy to reject well qualified domestic applicants to medical school while plundering the output of schools in the developing world.

So, here are some of my solutions to the failures of the past 30 years. The Department of Health should be recast as a department of public health, with a secretary of state in the cabinet supported by a minister for the NHS and advised by a national director of public health, and with meaningful two way links to each other’s government department.

We need a new Public Health Act to succeed the last principal one in 1936. This should provide a framework for policy, legislation, and action fit for the 21st century and committed to devolution. In any steps taken, the principles of structure following function and subsidiarity with additionality, in which local policy and action is the default position, should be paramount.

The democratic deficit of NHS governing bodies and the cloning of non-executive boards should be replaced by directly elected boards of health and hospital and other service providers. They should be provided with independent advice by local directors of public health, who would have the same independence of mind and voice as local financial auditors.

Nationally, I would review Public Health England’s scope and purpose. The US public health service model of command and control, which influenced its origins, may have its place in public health emergencies such as bioterrorism, Ebola, or pandemic flu, but the principle of Occam’s razor applies here: the starting point should be the most parsimonious list of functions needed in London to protect the public’s health. In his Five Year Forward View NHS England’s chief executive, Simon Stevens, acknowledged that the future of health depended on a radical upgrade in prevention and public health. This is refreshing, heady, and welcome stuff—if it is not yet another false dawn.

My final action would be to establish a national network of public service staff colleges to provide joined-up public service leadership, fit for the 21st century and encompassing all public services. These would be freed from the recent hegemony of private and commercial sector ideology.


Cite this as: BMJ 2015;350:h616


  • Competing interests: None declared.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

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