We have argued that there is a fundamental puzzle at the heart of the public health crisis that now faces the UK. Although the problems are large, there are many policy measures capable of addressing them that are highly cost-effective and for which there is robust evidence. The importance of these measures has been recognised for decades by informed commentators on health services, the latest example of which has been the creation of integrated care systems (ICSs) and the proposals from the Hewitt Review for government to give a lead in prioritising preventive measures. Unless government implements these measures, the burdens on the NHS will increase, forcing an increasing rationing of medical care among the sick. To be sure, the administrative and governance barriers to action can be formidable. The measures require interorganisational collaboration, never easy for any organisation let alone governments, and an ability at the heart of government to think long-term. The measures also require being explicit about the trade-offs, including the trade-off between more private consumer spending and greater public health protection, that are involved in making health truly public. They require addressing the commercial determinants of health, strengthening and supporting those commercial activities that promote health and regulating and disincentivising those commercial activities that harm health. In short, the challenges of public health require a relentless focus on implementation and policy learning, with firm political leadership to ensure that measures are put into practice and the organisational barriers to public policy coordination overcome.

In this context, the focus on finding one right organisational structure displayed in the abolition of Public Health England (PHE) is inadequate. The view, expressed by Matt Hancock as Secretary of State, that the creation of the UK Health Security Agency (UKHSA) in place of PHE would be sufficient to avoid a repeat of the failures to upscale testing and tracing on the part of PHE was an example of naive ‘if only’ thinking, resting on the assumption that if only PHE had been like the Robert Koch Institute all would be well. Yet distinguished witnesses to the Covid-19 Inquiry, like Sir Chris Whitty and Sir Patrick Vallance, suggested the failures of PHE were the results of successive public underfunding, such that the UK was left without adequate stocks of personal protective equipment or the facilities to manufacture vaccines.