Is England’s public health system still fit for purpose?BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g1102 (Published 29 January 2014) Cite this as: BMJ 2014;348:g1102
All rapid responses
It may come as no surprise to see a former regional director of public health bemoaning the demise of regional directors of public health (1). He raises the question of whether England’s public health system is still fit for purpose. Arguably, though, it has not been fit for purpose for several decades.
It is now forty years since the non-stop carousel of NHS reorganisations began. The 1974 reorganisation was supposed to end the tripartite division of NHS services between hospitals, GPs, and public health services based in local authorities. The latest reorganisation appears to have brought us full circle, with public health services once again based in local authorities. However, the new local authority public health directors have neither the stature, the independence, the authority nor the security of tenure of their pre-1974 predecessors, the Medical Officers of Health.
The structure was tinkered with in the 1980s, with the introduction of general management, and the experiment under the Thatcher government with the short-lived internal market, which quickly died a death, and was equally rapidly revivified under another name. However, the pace of reorganisation increased by an order of magnitude from 1994 onwards. Each reorganisation was greeted by its protagonists with initial euphoria, followed quite rapidly by disillusion and ultimately by a degree of realism setting in, only for the next wave of reorganisation to get under way. The current reorganisation is no different from any other, except that we appear to have skipped the initial wave of euphoria on this occasion.
It is too early to say what the eventual impact of these changes will be on the public health system, except to say that one of the lessons of the past forty years, and in particular of the last twenty years, is that reorganisation, whatever the intended benefits claimed by its promoters, is always disruptive. I share Dr. Scally’s anxieties about the future of the public health system, but it has already suffered from years of disruption, and there is really nothing new in this. The ‘responsibility deal’ is nothing more than window dressing. Many of the targets set are vague, and incapable of objective monitoring. All that claimed achievement of them will do is provide sound bites for annual reports of corporate organisations whose principal legal obligation will remain the maximisation of profits for their shareholders.
It remains to be seen if the new local authority public health departments can assemble sufficient expertise and authority to make any appreciable difference to the public health, and how they and the other new players in this area of activity, including NHS England and HealthWatch, can work together to achieve this.
Competing interests: No competing interests
Scally is right that the ‘responsibility deal’ with large private corporations has left England’s statutory Public Health ‘system’  in tatters. The consequences of this deliberate fragmentation of our ‘system’ and the abdication of Public Health oversight by Government have recently been reported in a national study by the Royal Society for Public Health. For example, less than 15% of professionals believed that this ‘transition’ was improving health outcomes. This Report concludes that ‘a key finding is the concern expressed by public health professionals over the perceived role of politics in health decisions’.
As BMJ has demonstrated for alcohol policy  but also for healthy decisions on, say, food or the environment: the ‘system’ is not fit for purpose. Narrow political interests linked irresponsibly to short term commercial lobbying will determine the health of whole communities.
The tenor of policy-making is shown by the recent fate of the Government’s behavioural team (the Nudge Unit). When this was set up it was closely linked to the responsibility deal. Now Cabinet Office minister Francis Maude has announced its commodification:
“This first spin out from a Whitehall policy team is one of the ways we wish to unleash the hidden entrepreneurs in the public sector.”
Most of us working for Public Health were not closet entrepreneurs longing for a quick profit… we were public servants looking for a healthier society now and for future generations.
1 Scally GJ. Is England’s public health system still fit for purpose? BMJ 2014;348:g1102
2 Royal Society for Public Health. The views of public health teams working in local authorities Year 1. London: RSPH, 2014.
3 Caan W. CAGE for the Cabinet (a smoke screen?) Rapid response 9 January 2014 http://www.bmj.com/content/348/bmj.g110/rr/680888
4 Wintour P. Nudge Unit to be spun off as mutual able to sell its services. The Guardian 2014; 5 February: 4.
Competing interests: I used to try to inspire students about Public Health