Reform of Public Health England: what next for public mental health?

Location: England

4th Sep 2020
Influencing policies
Antonis Kousoulis

Dr Antonis Kousoulis

Former Director of England and Wales

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This content mentions depression, which some people may find triggering.

Here we take you through our thoughts on what the reform of Public Health England means for the future of public mental health.

Public Health

Public health is what we build together as a society when we shape our communities so that everyone can achieve optimal health. Public health is largely understood as a modern term, but its origins can be traced to over 2,000 years ago.

The ancient Greeks were the first to debate the supernatural conceptions of health and illness that had until then dominated human societies. Led by Hippocrates, they developed a new school of thought, proposing that maintaining good health and tackling illness depends on the interaction between our internal physiology, our social environments and our behaviours.

In recent decades, public health as a discipline was allowed to develop and flourish through concentrated efforts to stop infectious disease outbreaks by focusing on their causes and their distribution. And as it was shown that the distribution of various illnesses was consistent across lines of geographies, wealth and race, the notion of the social determinants of health was named and strengthened.

We are now clear that the conditions in which we are born, grow, live, work and age are directly influencing how illness emerges. These conditions are in turn shaped by our social and physical contexts and health services, which are further affected by the distribution of money, power and resources at global, national and local levels.

These principles have been readily applied to mental health so that today we can define public mental health as the art and science of improving mental health and well-being and preventing mental health problems through the organised efforts and informed choices of society, organisations, public and private, communities and individuals.

Window of opportunity

Back in 2018, we wrote to the British Medical Journal to clearly say that the window of opportunity to improve public mental health was open and called for action through coordinated health leadership, tackling of inequalities, better measurement of impact, and sustainable funding.

This window of opportunity in the past few years has brought about some impressive progress. We saw a consultative and comprehensive review of the Mental Health Act, a Long Term Plan for the NHS with a clear role for prevention, a Prevention Green Paper from the Government and a wider interest in having conversations about mental health at a societal level, including the influential Royal Family. We found that our Mental Health Awareness Weeks have been bigger in reach and impact each year and that more funding than ever before was flowing towards mental health, through the Research Councils, the Wellcome Trust, the National Lottery Community Fund and others.

We also saw charities and organisations working on issues of physical health stepping forward and wanting to invest more efforts and resources into the interaction between physical and mental health. Businesses, workplaces, schools and universities found a new interest in protecting the mental health of their employees and their students and whole city approaches (like Thrive LDN and Thrive West Midlands) started influencing system-wide change and investment.

Last but not least, the education landscape has been changing. In the course of just a few short years, curricula of mental health studies were updated to include training in prevention and those of public health studies were updated to include streams dedicated to mental health. Many clinical psychology and psychiatry trainees looked for placements in public health and Local Authority settings and new undergraduate, postgraduate and online courses specialising on public mental health and well-being emerged. There is a whole new generation of professionals trained in public mental health ready to go out and work in our world.

Public mental health during the Coronavirus pandemic

This interest in mental health did not go away since the emergence of the Coronavirus pandemic. This has been the first pandemic during which the public, politicians, professionals and researchers have also been interested in mental health. Various programmes and research have focused on understanding and addressing the impact of the pandemic and associated measures on mental health.

The abolition of Public Health England

The announcement by the government of the abolition of Public Health England (PHE) last month and the uncertainty around the future of some of its functions, outside of the new National Institute for Health Protection, threatens to undermine some of the incredible progress we’ve seen in recent years.

The replacement of PHE with a body which focuses on infectious disease control leaves us without a clear future for PHE’s public mental health functions. In the absence of any reassurance to the contrary, we are concerned that PHE’s valuable public mental health work may be deprioritised.

The focus on infectious disease control also carries the risk that professionals and the public may be led to believe that public health is only about infectious diseases. In the developed world, noncommunicable diseases, including mental health problems, make up the majority of years lived with a disability. Not only do these diseases cost the economy billions of pounds, but they also intersect with infectious diseases, potentially worsening the impact of pandemics. Depression remains the leading cause of disability in the world.

It is already clear that COVID-19 is exacerbated by a range of pre-existing conditions, including obesity and respiratory conditions, as well as other factors such as race and poverty. The direct and indirect consequences of the COVID-19 pandemic also have repercussions for the nation’s mental health, which need to be addressed as part of a recovery plan.

A fully integrated model of public health, which covers communicable and noncommunicable diseases (and the social and environmental factors that interact with them) is necessary to respond to these challenges and build a healthy, prosperous and productive society. The new National Institute for Health Protection is a part of that, but it is not enough on its own.

The Mental Health Foundation is a charity dedicated to the prevention of mental health problems and the promotion of good mental health for all. At the end of last year, while the new coronavirus was emerging in China, we published our new strategy declaring that we want to be a sustainable and potent force for change, positioning us as the UK mental health charity focused on prevention and good mental health. The COVID-19 pandemic has made this mission even more urgent than before.

Today, we have a clear statement: it is not acceptable to lose public mental health as a key national priority, especially at this time.

The future of national public health functions

Public health functions are best delivered directly and effectively through regional organisations (such as Local Authorities), who have a more nuanced understanding of the needs of the populations that they serve. However, local structures are not enough to improve the population health of whole societies. A national body providing thought leadership and oversight is essential, as is a related infrastructure for data, evaluation and human resource. Thus, it is not acceptable to lose the home of the national public mental health function without a clear replacement.

It is important that public mental health remains a key part of discussions about the future of public health in this country. In many ways, we were facing a mental health crisis even before the COVID-19 pandemic, and we already knew that it is not possible to treat our way out of this crisis. However, public health funding in local authorities had already seen cuts year-on-year.

Alongside the new National Institute for Health Protection, the country needs a national world-class organisation dedicated to issues of population health – with a particular focus on mental health. We expect to see parity in funding and focus between physical and mental health and a national plan well integrated with local action.

As part of the transition from Public Health England to the new National Institute for Health Protection, we have written to the government asking that they provide:

  • a commitment to maintaining and improving on PHE’s core public mental health functions, including details of where these will be hosted and how they will be funded
  • new home for the “Every Mind Matters” campaign
  • a clear future for Fingertips and the rich data sources that PHE hosts
  • a commitment to retaining a focus on suicide prevention as a public health priority rather than solely an issue for acute services
  • a remit for the new National Institute for Health Protection which includes mental health as part of its planned response to infectious diseases
  • a new public health strategy which sets out how the National Institute for Health Protection will work with the rest of the public health sector to deliver an integrated and comprehensive response to all public health challenges
  • a commitment to tackling health inequalities as a public health priority

Investment in prevention and in addressing the social circumstances that clearly lead to mental ill-health is one of the most important tasks of any modern government because so much of a country’s potential is dependent on its citizens’ collective well-being. We are expressing our concern and our strong motivation for retaining a national public mental health function for the sake of the well-being of the people of this country.

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