By Louis Allwood
The pandemic will long be remembered for the disruption and loss which it has caused. For many of us, it will mark the beginning of challenging circumstances, brought about by sickness, isolation, poverty, bereavement, burnout or fear. National commitment to protect and promote good mental health across the population has never felt so important.
In this context, last month’s announcement by the Secretary of State that Public Health England (PHE) will be replaced by a new National Institute for Health Protection (NIHP) has been a cause for concern. In the short term, Public Health England continues to discharge its duties in relation to the public’s mental health: taking a national perspective and supporting other government bodies and departments, keeping a watchful eye on data around mental health and making analysis available to others, developing resources and social marketing campaigns to encourage individuals to look after their own mental wellbeing, and supporting local authorities to adopt evidence-based approaches to improving mental health in their communities. Where these responsibilities will rest by the middle of next year and beyond is less clear. We know that they will not be transferred to the NIHP along with other PHE functions such as infection control.
National commitment to protect and promote good mental health across the population has never felt so important
What, then, for national leadership on public mental health?
The Department of Health and Social Care policy paper on the future of public health gives some clues. This paper states the need “to establish the right future system and organisational arrangements” to “level up health”, “support future resilience” and move towards “greater focus on prevention in the delivery of local health services”. The Government commits to engaging experts and wider stakeholders during the process and confirms that final recommendations will be made in December.
The paper outlines four possible options for future arrangements.
- Devolving functions to a more local level such as local authorities and/or integrated care systems (ICSs)
- Creating a separate national organisation dedicated to driving progress on prevention, health improvement and, potentially, public healthcare services
- Retaining health improvement responsibilities within DHSC and/or other government departments
- Embedding health improvement responsibilities into existing health arm’s length bodies such as NHS England and NHS Improvement
Each of these options, and any combination of them, must be carefully assessed.
Firstly, an understanding of mental health, which impacts upon and is impacted by other health concerns, should be considered as a vital element of health improvement. National public mental health work such as suicide prevention, mental health promotion and mental health literacy programmes must be connected to wider health improvements and initiatives, such as smoking cessation and healthy weight management. This bidirectional relationship is not explicitly addressed by plans so far, and observers of the recent Government obesity strategy might comment that an understanding of mental health is too often absent at a national level. Additionally, as has been extensively evidenced during the current crisis, public mental health should be of significant concern during and after a pandemic. If the brief of the NIHP is to prepare for and manage pandemics effectively, it must collaborate closely with any new entity assigned responsibility for improving population health and wellbeing.
National public mental health work such as suicide prevention, mental health promotion and mental health literacy programmes must be connected to wider health improvements and initiatives
Secondly, our mental and physical health is influenced by a complex mix of environmental and social factors, most of which are beyond the reach of health services. A greater focus on prevention must involve looking at these broader determinants. Building new arrangements around traditional health services which specialise in responding to illness and injury might therefore be limiting. Health services can’t do this alone. Local councils are critical. They deliver public health and social care services alongside a broad range of activities which impact on mental health in communities, including children’s services, housing, community safety, culture, leisure, planning, youth services and licensing. National arrangements must work for local authorities.
our mental and physical health is influenced by a complex mix of environmental and social factors, most of which are beyond the reach of health services
There are many and varied approaches which demonstrate the promise and impact of local authorities in health improvement. However, resources are often limited. Local authority spending on public health has fallen over recent years amid repeated cuts to the Public Health Grant. Adequate resource must be made available to address longstanding gaps in funding and increase capacity in public health teams and communities to improve physical and mental health outcomes.
At the same time, the expertise and support which PHE provides across government, its analytical capacity, its ability to share intelligence and best practice to all local areas, and its national overview are all critically important. We know, too, that the active role of regional PHE centres within existing structures is highly valued by those working in local areas. These centres have the ability to assist local work, coordinate between areas, and connect communities to national programmes and strategies.
The alternative of devolving health promotion powers to integrated care systems (ICSs) presents some challenges. Evaluations of early models found that the contribution of local authorities can be ‘eclipsed’ within ICSs; that power and decision making could move towards regional structures dominated by health services (and usually large acute hospitals) and away from councils. This could hamper efforts to promote better mental health and prevent mental illness, especially within diverse communities and deprived neighbourhoods which should benefit most from the ‘levelling up’ agenda.
Adequate resource must be made available to address longstanding gaps in funding and increase capacity in public health teams and communities to improve physical and mental health outcomes
The transition from Public Health England to the National Institute for Health Protection and any other agencies or arrangements (TBC) creates opportunities too. The separation of health improvement functions from health protection and infection control could create greater transparency and accountability for tracking national investment in public mental health. A meaningful cross-sector engagement delivered over the next three months, as promised by the Department of Health and Social Care, could be pivotal in designing an evidence-based, system-wide approach to improving the public’s mental and physical health that delivers on ambitions to reduce health inequalities, integrate care and support more effectively, and reduce the growing burden on the NHS by helping more people before they become unwell. But this must not play second fiddle to the new health protection agency.
Importantly, and worryingly, this process will conclude after the Comprehensive Spending Review (CSR). This means, whatever the outcome of the consultation, financial constraints on a national programme for public mental health could already be set. The CSR must set new arrangements up for success by providing adequate resource for national and local initiatives and structures which improve mental health. In our representation to HM Treasury we have called for urgent investment in local authority public mental health services (following years of cuts) and a funded cross-government approach to better mental health. This should be a starting point for our national ambition for a mentally healthy society.
