Public health by any other name…

By Steve Senior, Siobhan Farmer and me

In a recent blog, David Buck and Toby Lewis gave some thought to how ‘population health’ and ‘public health’ can work best work together. Here we respond to some of the issues they raise.

We are grateful to Toby and David for clearly describing some risks we worry about: the imbalance in funding and capacity between public health and healthcare; the risk of reinventing failed models or forgetting about the piles of evidence we already have; and the risk of focusing on the health and care system and its crises to the exclusion of work to provide the building blocks of a healthy society. Their blog also rightly points to the essential role of wider local government in this work, to which we would add that of the voluntary, community, and faith sector, as well as the essential role of the private sector.

There are some points on which we are less clear. When it comes to trying to capture spending on ‘prevention’ it’s not obvious how that could be sensibly defined. Prevention can mean different things to different people, and most public spending that prevents illness is not primarily intended to prevent illness. Examples include spending on unemployment benefits, education, and public transport. Each can have profound benefits for health, but each is also a means to a different, entirely legitimate end.

Another example is “bringing health care expenditure into play beyond the narrow confines of healthcare delivery”. We’d be the first to agree that some rebalancing between treating disease and promoting health is long overdue. But this too easily shades into heating bills on prescription, fruit and veg on prescription, and so on. The NHS paying for these things is a sign of failure of other systems, medicalises basic human needs, and makes already exhausted GPs and other clinicians gatekeepers to any public help. The only thing worse than a healthcare system meeting these basic needs is that they not be met at all.

Shifting NHS resource away from providing care and towards meeting such wider needs is not straightforward when NHS services are under a level of strain that is contributing to excess deaths. As important partners and large economic actors in local systems, NHS organisations will always have a big role in tackling the causes of inequalities in health. But their first responsibility must be to make sure its services are working well and reducing – not widening – inequalities in health. Areas to focus on might include addressing the inequitable distribution of GPs and some other clinical staff, gaps in uptake of vaccines and screening services, ensuring routine equity audits of care pathways, and tackling the unequal experience of care felt by people from deprived and ethnic minority communities, those who identify as LGBTQ+, and other inclusion groups. 

These are symptoms of a deeper confusion: we have not been persuaded that population health is anything different than public health. The King’s Fund’s excellent vision for population health could just as easily be a vision for public health. Much has been written about this and we do not intend to rehearse the arguments here. Greg Fell and Andrew O’Shaughnessey wrote the sceptics’ case in 2017.

We think this long-standing lack of agreement about whether public health and population health are different things underlies any confusion and friction. We suggest the risk of competing narratives that David and Toby rightly point to exists precisely because of a failure to recognise that public health and population health are the same thing. We are all engaged in the same enterprise, pursuing the same end: better health for everyone. Some of us are just using different tools.

Recognising the wide range of tools available for building health has always been part of public health. Specialism exists within the public health profession, reflecting the different tools available to the profession. These include communicable disease control, commissioning services like smoking cessation and weight management, through to working with partners to improve the environments we live in. Those of us working in local government public health would happily agree that some of our colleagues across the council, such as in planning, children’s services, or economic development, can do more to improve public health than we can. We’re enthusiastic about working with them to maximise their benefits to health – “opening the room” to use Toby and David’s phrase – while also recognising they may have other legitimate goals and priorities, as well as different skills and professional identities. 

A question of professional identity lurks behind the debate about population health. Without for a second questioning the professionalism of those in population health roles, population health itself is not defined as a profession. We suspect any attempt to define it would produce something very similar (if not identical) to the public health profession, which has developed and evolved over more than a century and a half. This includes clear training pathways, professional qualifications and registration, and regular appraisal and revalidation required of people in senior public health positions. The equivalent standards do not exist for even the most senior population health roles. The appointment of a number of former directors of public health to senior population health roles in Integrated Care Systems is a welcome recognition of the value of the broad knowledge and experience they bring to such a senior public health (in all but name) role. However, we would suggest that these roles should explicitly require the same professional standards to be met as for Consultants and Directors of Public Health.

For its part, the public health profession needs to avoid defensiveness and assuming it has all the answers or expertise. This shouldn’t be too hard: we don’t assume we’re experts in patient care, town planning, economic development, or any of the other myriad of things our partners do. Where we do hold expertise, we are always keen to share. It isn’t a lack of generosity, as suggested in Toby and David’s blog, that is the biggest barrier to sharing what expertise we have, but a lack of people and time created by a more than a decade of underinvestment.

Toby and David also argue against “an artificial division of labour where population health leaders simply work on better NHS healthcare rather than the roots of wellbeing and healthier lives”. We are not convinced that a division of labour between the various organisations and professionals who aim to improve health is a bad thing. The complexity of the problems and the breadth of skills needed to tackle them makes a division of labour almost inevitable, and there is nothing wrong with different organisations focusing primarily on what they have responsibility for, expertise in, and influence over. The alternative is confusion about who is doing what, and which organisations are best placed to meet various needs. This will almost certainly lead to duplication and inefficiency as multiple organisations try to solve the same problems while others go neglected. 

It may seem pedantic or obstructive to (still!) be spending time questioning the usefulness of the term ‘population health’ when there are pressing public health and healthcare problems to be getting on with. But improving poor health and inequalities in health are wicked problems that arise from complex systems. Problems like these need coordinated responses across many different levels and organisations using many different tools. Integrated Care Systems offer a potential vehicle for the coordination of this diverse array of work, but we worry the term ‘population health’ is becoming an obstacle, by creating confusion over roles, responsibilities, accountability and whether we are all involved in the same enterprise after all. Where ‘population health’ roles exist, we in public health will of course continue to work closely with them. But perhaps the longer-term approach is not to keep trying to reinvent the wheel, but rather to invest properly in the public health profession and thus allow a greater dispersal of these highly skilled professionals across the system.

As ever, agree or disagree, you can let me know on Twitter.