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Rapid response to:

Editor's Choice

Investing in public health is our best route to sustainable healthcare

BMJ 2021; 375 doi: (Published 18 November 2021) Cite this as: BMJ 2021;375:n2812

Rapid Response:

Investing in public health is our best option for meeting current and future health challenges.

Dear Editor
Godlee is quite right to raise the issue of the paucity of good evidence for public health interventions during the pandemic.(1) Lockdowns, school closures outdoor socialising and face masks all needed more investigation. The lack of quality research is a real missed opportunity.

We strongly believe that any new interventions should be based on the best available evidence and when public health interventions which have little or low-quality evidence are implemented then it is vital that there is rigorous evaluation. Included in this should be an adequate assessment of the balance between potential benefits and harms.(2)

There have been many tremendous public health successes in the past and even just looking at the 20th century, one can see numerous notable achievements.(3-8) The impacts were on early death, illness, and disability.(3) These resulted in less pressure being placed on our health services. The lessons of public health history are considerable and still relevant today.(8)

Godlee briefly highlights the current crisis in staffing within our NHS,(1) and the Institute of Health Promotion and Education has also in the past described the critical workforce issues for example in relation to nursing(9) and general practice.(10,11) We believe this current crisis has implications for the health of patients, health of staff and the future of the NHS. Solving this crisis will not be easy and will require significant financial investment. We need to increase the numbers of staff including doctors and nurses so that, at least, we have similar numbers to comparable countries.

Another area that needs considerable and urgent funding is public health.(12-17) Successive governments have failed to provide an effective response to improving health and tackling health inequalities. The Covid-19 pandemic has highlighted the valuable roles to which directors of public health and their multidisciplinary teams are committed.(17) Moreover it has allowed them to improve the links with many organisations and individuals within their local communities. It is time to create a robust public health system that is capable of improving health outcomes for all.

Directors of public health are independent advocates for public health, with unique knowledge and expertise about their communities, and with sufficient resources they will promote health and wellbeing across many sectors including councils, the NHS, schools and workplaces.(18-20) It is important that their voices are also heard at national level. They have expertise to share in developing and promoting good policies across key agendas such as accident prevention, alcohol and drug treatment, clean air, early years, healthy economic growth, mental health, obesity, sexual health, smoking cessation, and violence prevention.

We now need investment for the long term and with a reinvigorated public health system, the country will be in a good position to promote the health of individuals and families which will also lessen the strain on our overburdened NHS.(1,12-17) Directors of public health need more resources to enhance their capacity to be masters and champions of public health for their communities.(18,19) We must help our policymakers to recognise the centrality of public health and its critical role in rebuilding the health of the nation, including levelling up.

1) Godlee F. Investing in public health is our best route to sustainable healthcare. BMJ 2021; 375:n2812 doi:10.1136/bmj.n2812

2) Hanna E S, Dingwall R, McCartney M, West R, Townsend E, Cassell J et al. Sociocultural reflections on face coverings must not ignore the negative consequences. BMJ 2020; 371:m3782 doi:10.1136/bmj.m3782

3) CDC. Ten Public Health Achievements of the Twentieth Century - United States, 1900-1999. MMWR Weekly 1999;48(12):241–3

4) Tones K, Tilford S. Health promotion: effectiveness, efficiency and equity. Cheltenham: Nelson Thornes, 2001.

5) Gray S, Pilkington P, Pencheon D, Jewell T. Public health in the UK: success or failure? J R Soc Med 2006;99: 107-11.

6) Hemenway D. While We Were Sleeping. Success Stories in Injury and Violence, Berkeley: University of California Press, 2009.

7) Middleton J. Public health at 170. What’s needed now is a big birthday present. BMJ 2018;362:k3653.

8) Donaldson L and Rutter P. Donaldsons' Essential Public Health (4th Edition). Boca Raton: CRC Press, 2018.

9) Watson MC and Thompson S. Nursing crisis: Missed opportunities in promoting the health of the country. British Medical Journal Rapid Response 12th December 2019.

10) Watson M C, Owen P. General practice on the brink: three key solutions the government must implement. BMJ 2021; 373 :n1482 doi:10.1136/bmj.n1482

11) Watson M and Lloyd J. Time to put GPs first by investing in general practice. BMJ 2019;365:l4158

12) Watson M C and Lloyd J. Need for increased investment in public health BMJ 2016;352:i761.

13) BMA. Funding for ill-health prevention and public health in the UK. May 2017.

14) Watson M C and Thompson S. Government must get serious about prevention. BMJ 2018;360:k1279.

15) Finch D, Marshall L and Bunbury S. Why greater investment in the public health grant should be a priority. London: The Health Foundation, 2021.

16) Taylor K, Bhatti S, Ferris K and Avhad P. Overview – Narrowing the gap: Establishing a fairer and more sustainable future for public health. London: Deloitte, 2021.

17) Taylor K, Bhatti S, Ferris K and Avhad P. Identifying the gap: Understanding the drivers of inequality in public health. London: Deloitte, 2021.

18) Watson MC and Lloyd J. Re: BMJ briefing: meet the new masters of public health. British Medical Journal Rapid Response 8th July 2013.

19) Watson M and Tilford S, 2016. Directors of public health are pivotal in tackling health inequalities. BMJ 2016;354:i5013.

20) The Association of Directors of Public Health. What is a Director of Public Health (DPH)? London: ADPH, 2016.

Competing interests: No competing interests

25 November 2021
Michael Craig Watson
Trustee, Institute of Health Promotion and Education.
Professor Sylvia Tilford, Trustee, Institute of Health Promotion and Education.
Institute of Health Promotion and Education, PO Box 7409, Lichfield WS14 4LS, UK.