The public health system in England

202 Pages·2010·5.713 MB·English

by  David J Hunter, Linda Marks, Katherine E Smith

Evidence for public health practice series
The public
healTh sysTem
in england

david J. hunter, linda marks and Katherine e. smith
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THE PUBLIC HEALTH
SYSTEM IN ENGLAND
David J. Hunter, Linda Marks and Katherine E. Smith

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This edition published in Great Britain in 2010 by
The Policy Press
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Contents
List of boxes and figures iv
Acknowledgements v
List of acronyms vi
About the authors viii
one Introduction 1
two Public health and a public health system 17
three The evolution of the public health function in England (1): 49
1974–97
four The evolution of the public health function in England (2): 63
1997–2009
five Current issues in the public health system in England 103
six Looking to the future 149
Appendix: NHS reorganisation – 1975–2009 161
References 167
Index 189

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The public health system in England
List of boxes and figures
Boxes
2.1 Evidence-based policy and practice 31
4.1 Health protection on the move 63
4.2 Health Action Zones 70
4.3 The Wanless scenarios 73
4.4 Marmot review’s tasks 78
4.5 Public health networks 84
4.6 NGOs and the public health workforce 89
Figures
2.1 The main determinants of health 26
2.2 Global determinants of health 27
2.3 The intersectoral public health system 29
A.1 The pre-1974 NHS 161
A.2 The 1974 NHS 162
A.3 The 1996 NHS 164
A.4 The 2004 NHS 165

iv
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Acknowledgements
This book grew out of a scoping study of the public health system in
England commissioned by the National Institute for Health Research
(NIHR) Service Delivery and Organisation (SDO) programme in
2007 to provide important background information for its new public
health research initiative, which subsequently spawned seven studies.
These studies will provide the material for the forthcoming books in
the public health series. We are grateful to the NIHR SDO programme
and to Stephen Peckham in particular, at the time academic adviser to
SDO, for their support and encouragement throughout the scoping
study and its transition to a book. The final report of the scoping study
was greatly strengthened following comments and suggestions from
several external reviewers and we are grateful for these. In addition, we
received additional material from Mala Rao in personal discussion. At
the time she was working in the public health group in the Department
of Health leading on public health workforce issues.
The second part of the scoping study was based heavily on a series
of interviews conducted with a variety of public health managers,
senior executives/stakeholders across the NHS, local government and
third sector. We wish to thank them for their frank and honest views,
which have greatly enriched both the original study and now the book.
Finally, we wish to thank Christine Jawad, who provided invaluable
administrative support to the study at various stages.
Inevitably in a book of this nature, there are many other public
health advocates, researchers and practitioners who have influenced our
thinking over many years. They are too numerous to list here and many
have since retired or moved on. But much of our historical analysis
and selection of key themes to explore has been shaped by their work
and views and ou r interaction with many of them over the years. We
should like to record our indebtedness to them as well, even though
they are, for the most part, unwitting contributors.
Of course, all the views expressed in what follows remain entirely our
own and are not necessarily shared by the NIHR SDO programme,
Department of Health or anyone else.
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The public health system in England
List of acronyms
AHA area health authority
ASH Action on Smoking and Health
CAA comprehensive area assessment
CEO chief executive officer
CMO Chief Medical Officer
CSCI Commission for Social Care Inspection
DH Department of Health
DHA district health authority
DPH director of public health
DsPH directors of public health
FCTC Framework Convention on Tobacco Control
FHSA family health service authority
FPC family practitioner committee
HA health authority
HAZ health action zone
HIA health impact assessment
HiAP Health in All Policies
HPA Health Protection Agency
IA impact assessment
IDeA Improvement and Development Agency
IfG Institute for Government
IOM Institute of Medicine
JSNA joint strategic needs assessment
LAA local area agreement
LGA Local Government Association
LINks local involvement networks
LPSA local public service agreement
LSHTM Lon don School of Hygiene and Tropical Medicine
LSP local strategic partnership
MDPHF Multi-disciplinary Public Health Forum
MoH Ministry of Health
MOH medical officer of health
MOsH medical officers of health
MPH Master of Public Health degree
NGO non-governmental organisation
NHS National Health Service
NICE National Institute for Health and Clinical Excellence
(formerly National Institute for Clinical Excellence)
NIHR National Institute for Health Research
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List of acronyms
PbC practice-based commissioning
PCG primary care group
PCT primary care trust
PH public health
PSA public service agreement
RDPH regional director of public health
RDsPH regional directors of public health
RIPH Royal Institute of Public Health
RSH Royal Society for the Promotion of Health
RSPH Royal Society for Public Health
SDO Service Delivery and Organisation programme
SHA strategic health authority
SOLACE Society of Local Authority Chief Executives
STBOP Shifting the Balance of Power
UKPHA UK Public Health Association
WHO World Health Organization

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The public health system in England
About the authors
David J. Hunter is Professor of Health Policy and Management and
Director of the Centre for Public Policy and Health, School of Medicine
and Health at Durham University, and a Wolfson Fellow in the Wolfson
Research Institute. He is also Deputy Director of the Centre for
Translational Research in Public Health. His research interests include
public health policy and its implementation, commissioning for health
and wellbeing, and getting knowledge into practice. He has published
widely in books and journals. His last book, The health debate, was
published in 2008 by The Policy Press. He has also produced reports for
organisations including The King’s Fund, UKPHA, UNISON and the
Local Government Association’s Improvement & Development Agency.
He has recently been appointed a non-executive director of NICE.
Linda Marks is Senior Research Fellow at the Centre for Public
Policy and Health, School of Medicine and Health, Durham University,
and a Wolfson Fellow in the Wolfson Research Institute. Her research
interests include commissioning for health and wellbeing, inequalities in
health, and public health policy. She has published in a range of journals,
including Public Health, Critical Public Health and the International Journal
of Prisoner Health, and has authored independent reports for The King’s
Fund, UNISON, the Health Development Agency, and others. She
has previously held posts as a Fellow in Health Policy Analysis at The
King’s Fund and as a primary care planner in an inner London health
authority, and is currently a non-executive director of Darlington
Primary Care Trust.
Katherine E. Smith is a Research Fellow in Applied Policy Research
in the School for Health, University of Bath. Prior to this, she worked
at the Centre for Public Policy and Health, Durham University, where
she spent 18 months exploring a variety of public health and social
policy issues and where she undertook (with the other authors) the
research on which this book is based. Katherine’s research interests
include health inequalities, the relationship between public health
research and policy, and corporate policy influence in Europe (and
its public health consequences). Recent publications include journal
articles on health inequalities in a devolved Britain in Social Science and
Medicine and Critical Social Policy.
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ONE
Introduction
Health systems everywhere are experiencing rapid change in response
to new threats to health arising from lifestyle diseases, risks of pandemic
flu, long-term conditions and the global effects of climate change and
other threats to sustainable development. Issues that were previously
viewed as distinct and separate are now regarded as inextricably
linked through their impact on health with the result that a significant
refocusing of policy is under way, albeit with varying degrees of success.
Such developments have profound implications for future public health
policy and practice. Public health, as a function embracing a wide range
of skills and expertise, is, or should be, at the forefront of this refocusing
of health policy and practice. If it is to succeed, public health needs to
adapt to the changing context and, in doing so, to address a number
of long-standing issues that have hitherto hampered the public health
function and prevented it from realising its full potential.
As the first decade of the 21st century comes to a close, this book
assesses the state of the public health system in England. It is the first
in a series of public health texts drawing on research largely funded by
the National Institute for Health Research (NIHR) Service Delivery
and Organisation (SDO) programme. The SDO launched its public
health research programme in 2007, funding seven studies examining
key aspects of contemporary concern and relevance to the organisation
and delivery of public health. The book series will provide a platform
for the findings from these studies. The purpose of this first book
is to set the scene for the series by comprehensively assessing and
critiquing the cur rent state of the public health system in England.
It places contemporary challenges and concerns in their historical
context, tracing the dominant influence of a medical paradigm on
the public health profession and exploring how this has given rise to
difficulties for those who subscribe to social or structuralist paradigms.
The history of public health is marked by struggles between these
competing perspectives and recent policy developments have pointed
in contrasting directions. While the public health profession has been
actively encouraged to embrace a multidisciplinary perspective, it has
simultaneously come under mounting pressure to contribute more
effectively to achieving targets through clinical interventions. In the
context of England, these long-standing tensions are informing ongoing
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