Improving population health is outlined as a central goal for the future of the health and care system. But while NHS policy documents often describe the aims of public health, they say far less about the specialist workforce required to deliver them.
Population health can only be delivered with meaningful input from a skilled public health workforce capable of analysing need, shaping strategy, influencing resource allocation, and leading interventions across an increasingly complex system. If that workforce is pushed to the margins, the consequences will go beyond the profession to impact communities who always bear the brunt of poor decision-making.
Without consistent access to accredited public health expertise across the NHS, the system risks poor decision-making across pathway design, prioritisation, resource allocation, and equity, and is less able to act on health inequalities. This affects the quality of health protection responses and prevention initiatives, with potentially dire consequences for communities who miss out on opportunities for intervention. As demand increases, overlooking public health expertise is an unaffordable risk.
Across England, health outcomes remain unequal and improvements in life expectancy have stalled. Meanwhile, the NHS is undergoing significant reform intended to shift from treatment to prevention and strengthen action on the unfair differences in health outcomes across communities. However, as these structures are redesigned, there is a risk that public health expertise becomes diluted precisely when it is needed most.
To understand the issue, the Association of Directors of Public Health undertook a joint review with The Faculty of Public Health to examine how public health is described across legislation and national policy, and conducted interviews with senior leaders across NHS England, Integrated Care Boards (ICBs), local authorities (LAs), and provider organisations.
The findings are concerning. Across the 21 documents reviewed, none explicitly mandate the employment, governance, or resourcing of accredited public health specialists to lead population health work inside the NHS. This responsibility is assigned to system leaders and neighbourhood teams or diffused between population health functions without naming the specific professional department or roles to take it on.
This was reflected in the interviews with senior system leaders where public health expertise was consistently valued when present but often described as poorly embedded within decision-making. In various settings, system leaders also described public health specialist roles being substituted with broader workforce functions or used in an advisory capacity, rather than being integral to planning. Notably, we found that specialist public health capability was best described across advocacy or other professional organisation strategies, while the documents carrying the greatest authority over NHS structures described the role the least.
Without consistent access to accredited public health expertise across the NHS, the system risks poor decision-making across pathway design, prioritisation, resource allocation, and equity, and is less able to act on health inequalities. This affects the quality of health protection responses and prevention initiatives, with potentially dire consequences for communities who miss out on opportunities for intervention. As demand increases, overlooking public health expertise is an unaffordable risk.
Addressing this workforce gap in practice requires a much clearer specification of roles, responsibilities, and resourcing across the system. First, there is a critical distinction between contributing to population health and holding accountability for it. Public health leadership should be defined across four levels: national, regional, Integrated Care System or ICB, and local, including being rooted within neighbourhood teams.
Second, accredited public health specialists should be embedded within core structures responsible for population health. This includes leadership roles within ICBs, local government, and larger provider organisations such as Integrated Health Organisations.
Third, we need to strengthen specialist workforce development. A substantive healthcare public health placement should be a mandatory requirement within public health specialty training, supporting exposure to the NHS. In addition, post-CCT development should be explicitly defined, with mentorship and leadership development expectations comparable to the standard of other senior medical professions. Lastly, professional standards should align with the Faculty of Public Health's March 2026 statement, supporting consistency across public health roles. This would, in turn, reinforce accountability across the system.
Crucially, the report states that these recommendations should be seen as a single requirement to make public health a genuine mechanism for improving population health. Because realising improvements in population health and reducing inequalities requires the public health specialist workforce to not only be visible in policy but embedded within system design.
Greg Fell OBE, President of the Association of Directors of Public Health and Yvonne Doyle, Chair of the Health Services Committee at the Faculty of Public Health.
