Bridging the Divide: Integrating Public Health in Local Government with NHS Systems

In the evolving landscape of health and care in the UK, the disconnect between public health in local government and NHS systems remains one of the most persistent and damaging challenges. Despite shared ambitions to improve population health, reduce inequalities, and deliver preventative care, these two pillars of the system often operate in silos hampered by structural, cultural, and financial divides. The consequences are felt most acutely by the communities they serve: fragmented services, missed opportunities for early intervention, and a growing sense of public dissatisfaction. As we stand at a crossroads shaped by Integrated Care Systems (ICSs), neighbourhood health models, and renewed calls for collaboration, the question is no longer whether integration is necessary but how we make it happen. This blog explores the barriers, consequences, and most importantly, the solutions that can help bridge the divide and create a truly joined-up public health system.

1. Acknowledging the Problem

Despite shared ambitions to improve population health, reduce inequalities, and deliver preventative care, public health in local government and NHS systems remain poorly integrated. This disconnect is not merely administrative it has real and lasting consequences for individuals, families, and communities.

A joint report by the Local Government and Social Care Ombudsman and the Parliamentary and Health Service Ombudsman in July 2024 starkly highlighted the issue. Titled “People Not Structures: Putting People at the Heart of Integrated Care”, the report concluded:

“The evidence of our casework shows that a lack of communication between health and social care services is an issue that lies at the heart of many system failures. In some cases that lack of communication is life limiting: years of education lost that cannot be recovered, inadequate care in the last days of life, and families left in uncertainty at the start of young lives.”

One case involved a boy with complex medical and special educational needs who lost six years of education because local NHS and council services failed to agree on a joint support plan. In another, a woman with dementia received inadequate end-of-life care due to the absence of a joint assessment between her local authority and NHS Trust.

These failures are not isolated. A House of Lords report in December 2023 warned that patients are “constantly being inconvenienced, endangered, or denied opportunities to improve their long-term health” due to a lack of joined-up care between primary and community services.

The BMJ also reported that fragmented services lead to “substandard care, missed opportunities for home-based support, and increased risk of deterioration in chronic conditions”.

From a systems perspective, the King’s Fund noted that the 2013 reforms which moved public health teams into local government while beneficial for addressing wider determinants of health also created a perception that prevention was no longer the NHS’s responsibility. This led to “high-profile battles over who pays for prevention” and entrenched silos between treatment and public health functions. The consequences of this fragmentation are measurable:

• 59% of Britons were dissatisfied with how the NHS is run in 2024 the highest level ever recorded.

• 32% of the public believe the NHS is poor at keeping people informed about their care.

• Health inequalities persist and are widening, particularly in areas of high deprivation where ICSs were meant to make the biggest impact.

As Professor Sir Chris Ham of The King’s Fund put it:

“We are living in the century of the system. Individuals and organisations cannot solve the problems facing today’s society on their own. We must design new ways to work together across systems to make the best use of collective skills and knowledge.”

2. Understanding the Barriers

Efforts to integrate public health in local government with NHS systems are often undermined by deep-rooted structural, cultural, and policy barriers. These challenges are not new, but they remain persistent and complex requiring more than goodwill to overcome.

Structural and Cultural Differences

Local authorities and NHS bodies operate under fundamentally different governance, funding, and accountability frameworks. Councils are democratically elected, locally accountable, and funded through a mix of council tax, business rates, and central government grants. In contrast, NHS organisations are centrally commissioned, operate under national mandates, and are funded through general taxation via the Department of Health and Social Care. As Sir David Pearson observed:

“Local government and the NHS are two different worlds with distinct cultures and (it sometimes seems) languages.”

These differences manifest in everything from decision-making processes to organisational priorities. While councils often focus on prevention and place-based wellbeing, NHS bodies are driven by clinical outcomes and national performance targets. This misalignment can lead to confusion, duplication, and missed opportunities for joint working.

Resource Disparities

Public health teams within councils are frequently under-resourced compared to their NHS counterparts. The Association of Directors of Public Health (ADPH) has repeatedly warned that:

“Disparity in resource between NHS and local government must be acknowledged. This has previously created tension and will make it difficult for local authorities and NHS bodies to be truly equal partners within ICSs.”

Between 2015 and 2023, the public health grant was cut by £850 million, and councils lost nearly 60p in every £1 of government funding for services between 2010 and 2020. These cuts have left local public health teams stretched thin, limiting their ability to engage meaningfully in strategic planning and delivery within Integrated Care Systems (ICSs).

Policy Misalignment

National reforms have often disrupted local partnerships rather than strengthening them. A 2024 BMC Public Health study found that:

“National policymakers risked undermining their own reforms. Organisational restructuring to establish ICSs caused major disruption, with unintended effects on the partnership working it aimed to promote.”

The study revealed that while local leaders were committed to collaboration, they were hampered by unclear policy aims, inconsistent funding, and a lack of alignment between national priorities and local realities. This “perverse influence” of national policy has made it harder not easier for local systems to work together effectively.

3. The Consequences

The failure to integrate public health in local government with NHS systems has far-reaching consequences not just for service delivery, but for public trust, operational efficiency, and population health outcomes.

Trust and Satisfaction

Public confidence in the NHS has reached historic lows. According to the British Social Attitudes Survey 2024, only 21% of British adults were satisfied with the way the NHS is run, while 59% expressed dissatisfaction the highest level recorded since the survey began in 1983.

This erosion of trust is closely linked to poor communication and fragmented care. As the BMJ editorial noted:

“One of the strongest drivers of satisfaction with the NHS is how well it communicates with patients… yet 32% of the public think the NHS is poor at keeping people informed about what is happening with their care and treatment.”

This dissatisfaction is particularly acute among younger people, with 28% of those under 65 reporting poor communication experiences compared to 17% of over-65s.

Inefficiencies

Poor communication and lack of coordination between NHS and local government services lead to inefficiencies that waste time, money, and human potential. A King’s Fund report found that 1 in 5 patients received appointment letters after the appointment date, contributing to missed visits and delays in care. Missed appointments alone cost the NHS nearly £1 billion annually, enough to fund the salaries of over 26,000 nurses. These inefficiencies are compounded by administrative failures, siloed digital systems, and a lack of shared data infrastructure.

Missed Prevention Opportunities

Perhaps the most damaging consequence is the loss of preventative potential. Without joint assessments and shared data, preventable conditions go unmanaged, and vulnerable individuals fall through the cracks.

A report by the Health Services Safety Investigations Body (HSSIB) found that poor information sharing between NHS, social care, and local authorities leads to delays in treatment, duplication of services, and even serious mistakes. Patients are often forced to repeat their stories to multiple professionals because their records are not shared across systems.

“We discovered that poor communication was the sole cause of patient-safety incidents in over one in ten cases and contributed to causing incidents in one in four cases.” International Journal of Population Data Science

The lack of integrated data systems also hampers efforts to tackle health inequalities. A study by Imperial College London and Kent County Council concluded that “few examples exist of routine cross-sectoral data linkage across ICSs,” despite its critical role in population health management.

4. Exploring the Solution

While the barriers to integration between public health in local government and NHS systems are significant, they are not insurmountable. The 10-Year Health Plan, the evolution of Integrated Care Systems (ICSs), and renewed calls for strategic commissioning offer a roadmap for change. Below are four key areas where solutions are emerging.

A. Neighbourhood Health Models

The NHS’s 10-Year Health Plan places neighbourhood health centres at the heart of its vision for reform. These centres are designed as one-stop shops for care, integrating GPs, nurses, care workers, mental health support, diagnostics, rehabilitation, and social care referrals under one roof. They aim to shift care from hospitals to communities, and from reactive treatment to proactive prevention.

“Neighbourhood health services will bring diagnostics, mental health, post-op, rehab and nursing to people’s doorsteps… freeing up hospitals to focus on cutting-edge care.” Prime Minister Keir Starmer

The government plans to deliver 250–300 Neighbourhood Health Centres over the next decade, operating extended hours and designed to reduce pressure on A&E departments.

“Any positive shift towards neighbourhood working is critical but must be built on strong relationships between local government, health and voluntary and community sector leaders.” Local Government Association

B. Strengthening ICSs

Integrated Care Systems (ICSs) are central to delivering joined-up care. The Association of Directors of Public Health (ADPH) has issued ten key recommendations to strengthen ICSs, including:

• Equal Partnership: Councils and NHS bodies must be treated as equals.

• Co-terminosity: Align ICS and council boundaries to reduce duplication.

• Clear Governance: Define roles and accountability across ICS partners.

• Resourcing Public Health: Directors of Public Health must be adequately resourced to participate meaningfully in ICSs.

“ICS infrastructure should not supersede local government infrastructure. All ICS partners should be understood, respected, and sufficiently resourced.” Helen Atkinson, ADPH spokesperson for ICSs

C. Strategic Commissioning

Integrated Care Boards (ICBs) are being asked to focus their remaining resources on strategic commissioning using population health data and lived experience to guide decisions. According to the NHS Confederation, 95% of ICB leaders are concerned about cost reductions impacting their ability to deliver priorities, yet remain committed to strategic commissioning.

The Strategic Commissioning Framework outlines a four-stage approach:

1. Understanding the context – using linked, person-level data.

2. Developing long-term strategy – co-designed with local partners.

3. Delivering through the payor function – allocating resources strategically.

4. Evaluating impact – tracking outcomes and adjusting accordingly.

D. National-Local Partnership

The Local Government Association (LGA) is calling for a national-local coalition to deliver neighbourhood health models focused on prevention and place-based care. This partnership would unlock cost-effective, integrated interventions, reduce health inequalities, and create better outcomes across the country.

“Health does not begin in hospitals – it begins in homes, streets, parks, and schools. The NHS cannot deliver a healthier society on its own.” Cllr Louise Gittins, LGA Chair

The LGA urges ministers to ensure:

• Effective integration across NHS and local government.

• Strengthened public health leadership.

• Elimination of service duplication and cost-shunting.

5. Case Studies of Success

St Helens Cares

Launched in 2018, St Helens Cares is a nationally recognised integrated care partnership that brings together NHS providers, St Helens Borough Council, housing, police, fire, probation, and the voluntary sector. It operates under the vision:

“One Place, One System, One Ambition – Improving people’s lives in St Helens together.”

The model has:

• Reduced emergency admissions for self-harm and suicide.

• Increased uptake of preventative services like pulmonary rehabilitation and wellbeing support.

• Embedded public health priorities across the life course: Start Well, Live Well, Age Well.

• Won the MJ Achievement Award for Care and Health Integration in its launch year.

Cheshire & Merseyside ICS – Fuel Poverty Dashboard

Faced with rising fuel poverty, the ICS developed a Fuel Poverty Dashboard using the CIPHA platform, integrating data from 2.6 million residents. The first project, Warm Homes for Lungs, targeted patients with severe COPD living in cold, damp homes.

• 1,317 vulnerable individuals were identified and supported.

• Over £106,000 in household support payments were distributed.

• Patients received warm home packs, vitamin D vouchers, and referrals to wellbeing services.

• Community nurses reported transformative outcomes:

“We’ve never changed lives like this. It’s hard not to cry when you see the impact.” Diane Green, COPD Nurse

Doncaster & Hertfordshire

In Doncaster, public health acts as a strategic bridge between the council and NHS, leading on integration strands such as falls prevention and data analysis. The Director of Public Health is also the executive lead for the Health and Wellbeing Board, ensuring alignment across services.

In Hertfordshire, public health teams influence planning policy through Health Impact Assessments (HIAs) and guidance for developers. Though not statutory consultees, they shape healthy environments by embedding wellbeing into spatial planning and development strategies.

6. Data Snapshot

Life Expectancy

• England average: 79.1 years (men), 83.0 years (women).

• Gap between richest and poorest areas:

  • Men: 10.3 years (Blackpool: 73.4 vs Hart: 83.7)

  • Women: 8.3 years (Blackpool: 78.4 vs Hart: 86.7).

• Healthy life expectancy: 61.5 years (men), 61.9 years (women)   meaning many spend over 20 years in poor health.

Smoking Mortality

• Estimated deaths attributable to smoking in 2019: 74,600.

• Post-pandemic data: Difficult to estimate due to disrupted reporting; new methodologies are in development.

ICS Confidence

According to the NHS Confederation:

• 4 in 5 ICS leaders are confident they can fulfil their four core purposes.

• 95% of ICB leaders are concerned about cost reductions but remain committed to strategic commissioning.

• Most confident in understanding local context and developing population health strategies.

7. Conclusion: From Vision to Action

To truly integrate public health in local government with NHS systems, we must move beyond structural reforms and policy rhetoric. The real work lies in building trust, sharing resources, and co-creating solutions that reflect the lived realities of communities. Integration is not a technical fix it’s a cultural shift. It demands humility, partnership, and a commitment to place-based leadership. The future of health lies in collaboration, not competition. Councils and NHS bodies must stop working in parallel and start working in partnership. That means aligning priorities, pooling data, and designing services together not just consulting after the fact. It means recognising that health begins in homes, schools, parks, and workplaces not just in hospitals.

As Cllr Dr Wendy Taylor of the Local Government Association rightly said:

“Effective integration across the NHS and local government is essential to deliver for communities. With major change in both sectors, we must commit to rewire together, not turn inward into silos.”

The opportunity is clear. The tools are emerging. Now is the time to act.