The transition of public health back to local government responsibility was never going to be a simple ‘lift and shift’ affair, but it is a great chance to reshape healthcare, writes David Hunter

A great deal has been written about the challenges facing NHS leaders, but those facing public health leaders are at least as great. 

David Hunter

‘The transition of public health back to local government was never going to be a simple “lift and shift” affair’

Following the move of public health back to local government in April last year, the public health community has undergone significant change from which it is only just beginning to surface, although the future holds many uncertainties.   

The transition was never going to be a simple “lift and shift” affair and so it has been proved.

Out of the comfort zone

Apart from the disruption associated with moving organisations, the culture shift that the specialists in public health have undergone has been considerable.  

With few exceptions, directors of public health and their teams have had to familiarise themselves with a political culture vastly different from that in the NHS.

Whereas these directors saw themselves as leaders in the NHS, in local government it is the elected members who are the leaders. They decide priorities and what evidence to use to inform their decisions. 

Hardly surprising then that not everyone in the public health camp is happy about the move out of their NHS comfort zone.

It helps explain why the vacancies for public health directors remain so high and why many remain discontent with their lot.

‘Health and wellbeing boards are reliant on charm and persuasion’    

On top of the political realities of life in local government, there is the new organisational architecture that everyone working in local government is struggling to come to terms with.

Health and wellbeing boards have been heralded as potential system leaders, although fear lingers that they will be reduced to talking shops. 

Initially, their role was reasonably clear if ambitious. Namely, to improve the health and wellbeing of their communities and tackle inequalities. But their remit has rapidly expanded and the new HWBs find themselves in the vanguard of efforts to secure integrated care via the better care fund

And as if that was not enough to keep HWBs busy, they also have oversight of the reconfiguration of the NHS from being hospital focused to community focused.

But HWBs have no powers other than to produce health and wellbeing strategies that clinical commissioning groups are expected to align with their strategies while being under no compunction to do so

In terms of levers to influence outcomes, HWBs are reliant on charm and persuasion.

The ‘mission creep’

Demonstrating effective relational leadership is uppermost on their agendas but building trust and establishing relationships takes time which is at a premium.  

Given that most HWBs have memberships of 20-30 people and meet every two months for a couple of hours or so, making a difference is going to be hard.

‘Building trust and establishing relationships takes time and it is at a premium’   

The biggest casualty of the “mission creep” HWBs are experiencing is likely to be public health and wellbeing. Just as it was marginalised by primary care trusts, it could well be that despite local government being a more natural home for public health, the political focus on integrated care will sweep all before it.  

With £3.8bn of NHS money being handed to cash strapped local authorities, how it is spent will be under intense scrutiny. 

Conceivably, there could be winners all round. Moving away from a narrow focus on the current ringfenced public health budget is in itself desirable since pooling resources from a range of bodies and sources, including other local government functions which contribute to public health, is arguably a more effective strategy to achieve public health goals than simply protecting a limited resource that is unlikely to remain protected.  

New skills for public health

To succeed in this new world will place different pressures on the public health workforce, and in particular on its skills mix, which needs to be overhauled to give greater emphasis to soft skills. 

Leaders with political astuteness are required to work across different organisations and cultures to embrace whole systems. They must have a more sophisticated appreciation of different types and sources of evidence to inform investment and disinvestment decisions. They need to be true servant leaders working through, and able to communicate with, a variety of audiences.     

Amid all this there is a question mark over the future of clinically qualified specialists in public health as being the natural leaders.

‘There is a question mark over the future of clinically qualified specialists in public health as natural leaders’  

It seems inevitable that with the pressures on local authority budgets, the public health workforce will soon look very different with clinically qualified specialists on tap rather than on top. Public health leaders will be those who display an understanding of how local government works. 

They may come from other parts of the local authority, including environmental health, and adult social services. 

This is an exciting time for public health and while there will be casualties, the opportunities to reshape public health and make an impact that it has largely failed to do over the past 40 years are considerable. They should be seized.

David Hunter is professor of health policy and management at Durham University