What should we do?

#10 Re-design our
public health system

John Clarkson and Carol Brayne

The pandemic is forcing us to change direction, to rethink what we do
and how we do it.

We ask our experts:
where should we go from here?

Re-design our public health system

by Professor Carol Brayne CBE and Professor John Clarkson

COVID-19 has highlighted debilitating flaws in England’s public health systems decades in the making. Carol Brayne and John Clarkson from Cambridge Public Health, a new interdisciplinary centre, argue that a radical rethink is long overdue. They recommend bringing a ‘systems approach’ to the challenges, to help make our public health system fit for the future – for everyone.

This will be a particularly challenging winter. Health services across the UK are braced for the resurgence of COVID-19, with most caring for increasing numbers of people with the complications of COVID infection. We know more about the virus and the disease this time around, but the remobilisation of healthcare resources along with normal winter pressures are already disrupting services, including both social and health care. Meanwhile, the backlog of non-COVID-19 care is growing larger.

The pandemic has shone a spotlight onto areas that have long been a concern to the public health community. People in the UK have been living longer than ever before but, even before the pandemic, the steady increase in life expectancy had been stalling. At the same time, the gap between life expectancy and healthy life expectancy is widening, particularly in those with most disadvantages. Added to this, the pandemic has taken its heaviest toll on the older population, on those with disabilities, on black and minority ethnic communities, and on people living in deprivation.

All of this follows a major reorganisation of the NHS within England, brought about by the Health and Social Care Act (2012). This led to a fragmentation of the system – the Act abolished primary care trusts and strategic health authorities and transferred funds to hundreds of clinical commissioning groups that are heavily dependent on outsourcing to the private sector. It also moved public health infrastructures out of the NHS in England altogether – with the establishment of Public Health England – and Directors of Public Health into local authorities.

From the outset, people warned that this made the system acutely vulnerable – and it did. The changes weakened communications, undermined independence of advocacy for the population based on the balance of evidence, blurred accountability, fragmented a key skill base of the NHS and made it harder to coordinate efforts for population health across all the necessary areas.

"The public health community has long been articulating deep concerns about the fitness of the system to care for the population. This wasn’t translated into sufficient action despite strenuous efforts of those in the fragmented but weakened system."

Professor Carol Brayne

Now that the pandemic has brought the growing inequalities in health outcomes into sharp relief, we must not miss this opportunity to overhaul the system. A re-design of services should draw on existing evidence, multi-sectoral and multi-disciplinary working, historical knowledge and the evidence that will emerge from experiments already under way across the UK.

Escaping the bunker

Public health entails an intimidating and wide array of issues and activities. It represents society’s organised efforts to improve health across an entire population and across the entire life course, for present and future generations. While it may not always appear so on the surface, everything in public health is connected.

So, during the pandemic, although the UK’s hospitals made superhuman efforts to respond to government directives, it is now manifestly clear that efforts were not sufficiently joined up with local authorities and care in the community. Among other tragic outcomes, this resulted in insufficient testing and protection of care home workers, the movement of COVID-infected patients into vulnerable care home settings and perhaps thousands of preventable deaths.

"Without joined-up thinking, the system will continue to suffer from a severe lack of resilience. Such resilience has to be designed in, and that takes time and multi-disciplinary expertise."

Professor John Clarkson

Resilience also takes deep working with communities and trust in those relationships. Identifying these connections and working out how to improve the overall system is one of the central aims of Cambridge Public Health, a cross-University initiative to bring those working for population health and wellbeing together whatever their disciplines.

Cambridge Public Health is for the whole University but hosted in the School of Technology, with Co-Directorship from the Clinical School. With this emerging strength of collaboration, we are exploring how engineering principles – and especially a ‘systems approach’– can be used to overcome the problem of too many people trying to fix problems in individual bunkers. Knowledge of what’s going on in the bunker next door often changes how you think. This is very aligned to public health thinking, with the latter bringing in further disciplines such as social science and beyond.

Put simply, designing an efficient system means taking into consideration how one part affects all the other parts, each of which might be constantly changing depending on the pressures it is working under. Cambridge has an abundance of research strengths relevant to current and future population health, and Cambridge Public Health aims to harness these in a coordinated way to tackle Grand Challenges, an urgent need reinforced by the pandemic.

Where should we go from here?

In designing systems better able to tackle health and wellbeing challenges to global societies, what should we prioritise? Here are our top recommendations with an emphasis on our research pillars of Lifecourse and Ageing; Inequalities; Global Health; Sustainability; and Public Mental Health.

Be better prepared for future pandemics. The Scientific Advisory Group for Emergencies (SAGE), or its future incarnations, should be constantly assessing the risks posed by infectious disease, thinking through the challenges and putting systems in place before they unfold. For its part, the government needs to accept the need to maintain sufficient investment in these systems to ensure we are always ready for the worst. Such work must be contextualised by the detailed understanding gained by the public health systems based in localities and working with communities, and take into account our deep knowledge of the relationship of other areas of health and environment to the playing out of infections.

We need greater and sustained funding for urgent inter-disciplinary research to design effective systems. This pandemic has arisen because of a lack of attention to existing knowledge about how to prepare for pandemics; as well as a disregard for the pressures for human societies created by inequalities, increased life expectancies, global mobility and economic models and destruction of our ecosystems. All of us can learn from the flexibility that the pandemic has demanded to break out of silo working, exchange expertise more widely, and promote more connected systems approaches, building on work led by the Royal Academy of Engineering on 'Engineering Better Care' and the many involved in public health from Cambridge highlighting these challenges.

Rebuild our caring systems. Social care has to be considered as important as hospitals with our ageing populations and those in younger age groups with complex needs. To do this requires deep knowledge of our populations across the lifespan and for particular ages, such as those conducted by the Department of Public Health and Primary Care. In 2019, as COVID-19 swept through our communities and care homes, it wasn’t possible to fix a system that was broken on so many levels, while needing to give so much emergency care. Going forward, we must think more carefully about how to build a seamlessly integrated system where people can provide ongoing levels of care in the community right through to end of life.

We must ensure that our public health system listens and responds to individual and community journeys, and in doing so takes far greater account of evolving inequalities. Resilient services need to deliver robust support that is flexible to the needs of the individual, beginning with the premise that it is normal to be different. These must integrate mental and physical health, and our journeys across life with extraordinarily different societal influences at each key transition, as well as intergenerational relationships.

We need to work out how to exist in a way that doesn’t degrade the natural environment and condemn millions of people to poverty, pollution, famine and disease. Scientists, historians, engineers, architects and researchers from many other disciplines all need to work much more closely together to create the evidence base which we’ll need to make lasting and effective change. This will need to involve far greater collaboration with the Global South in a way that harnesses multi-directional learning with trusted relationships.

We need to rebuild secure and sustainable long-term relationships of trust between the population and its civic infrastructures, which have been systematically broken down over the last decades. It was an extraordinary achievement to get homeless people into safe housing at the start of the pandemic. In very little time, the authorities managed to join things up because they had to, urgently. Hotel rooms had to be allocated and medication supplied. But will all of this be reversed or will we simply slip back into tolerance of a societal scandal that we didn’t use to have? We can’t let it, we need to build the future in a way that doesn’t see us racing to the worst practices in unequal societies, including families with children going hungry – something unthinkable even a couple of decades ago.

Rethink the role of business. The business community has a largely unrecognised beneficial potential role to play in public health improvement, but we need to curb ill-judged outsourcing and wasteful experiments with taxpayers’ money. Early in the pandemic, for instance, the government called on companies to design new ventilators – this was with hindsight an unhelpful distraction. We didn’t need new designs, we just needed to make more of the ventilators that we already knew worked well. At the same time, businesses need to step up to help promote healthy lifestyles and wellbeing both as creators of new healthy products and, as employers, healthy workers. COVID-19 has brought about an extraordinary enforced experiment in homeworking, ending the daily commute for many people and challenging the normal work-life balance in the new home-office.

Harness innovation. The future of public health will benefit enormously from the appropriate use of technology, both existing and new, to develop new ways of capturing, analysing and using data. Personal and wearable electronics, combined with home sensors and smart algorithms, will transform our knowledge of those people who want to engage with this technology, informed by population analytics. This raises the need for our own capacity and whether we want to own and share information about ourselves, our health and our care needs. But these also need to be ‘handled with care’.

What’s next?

We cannot let 2020 happen again. We must not squander the opportunity to learn from its harshest of lessons. We must now work together to design resilience into our public health systems with the full force of joined-up thinking.

The aim here is not ‘simply’ to make GP surgeries, hospitals and care homes more resilient at times of crisis – crucial as this is – but to make our entire population more resilient in good times and bad.

Our research is aimed at developing a bold population-level, cross-sectoral approach to addressing equalities, adverse environments, obesity, poor mental health, multi-morbidities, addiction and other threats to health and wellbeing in a way that is sustainable for future generations. This will only be possible if researchers from a wide range of disciplines, clinicians and policymakers work together.

Our ultimate goal must be the prevention of poor health and improving both quality of life and healthy life expectancy for all. To get there, we must go beyond current investments focused on early diagnosis, prediction, treatment and management of specific disorders. This requires societal action on inequalities at the whole population and community level, as well as attention to health and social care systems.

Carol Brayne is Professor of Public Health Medicine affiliated with Cambridge’s Clinical School. She is Co-Chair of Cambridge Public Health. Carol is a medically qualified epidemiologist and, since the mid-1980s, her main research area has been longitudinal studies of older people following changes over time in cognition, dementia natural history and associated features with a public health perspective. She is lead principal investigator in the group of MRC CFA Studies, which inform national policy and scientific understanding of dementia in whole populations. Carol holds the positions of Faculty of Public Health, Academic & Research committee Chair, Royal College of Physicians special advisor, NIHR Senior Investigator PH SIG co-lead, SPHR member PI, and CLAHRC theme lead. She was awarded a CBE for her services to public health medicine in 2017. She is a Fellow of Darwin College.

Professor John Clarkson is Director of the Cambridge Engineering Design Centre (EDC) and Deputy Chair of Cambridge Public Health. John’s research interests are in the general area of engineering design, particularly the development of design methodologies to address specific design issues, for example, process management, change management, healthcare design and inclusive design. As well as publishing over 800 papers, he has written and edited a number of books on medical equipment design, inclusive design and process management. The Healthcare Design group in the EDC seeks to embed a systems engineering culture in the UK Health Service and its suppliers. John is currently leading a team with the Royal Academy of Engineering, the Royal College of Physicians, The Royal College of Anaesthetists and the Academy of Medical Sciences to develop Engineering Better Care, a systems approach to health and care redesign and improvement, and an accompanying toolkit for Improving Improvement. He is a Fellow of Trinity Hall.

More about Cambridge Public Health

Further reading

Oyebode, O, Ramsay, SE and Brayne, C (2020) Public health research in the UK to understand and mitigate the impact of COVID-19 and COVID-19 response measures, J Epidemiol Community Health

Brayne, C and Hickman, M (2020) Building back better for population health and wellbeing, The BMJ Opinion

Editor: Tom Almeroth-Williams
Artwork: Balvir Friers
Series Editor: Louise Walsh

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