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The COVID-19 crisis has demonstrated the extreme vulnerability of the human being and the importance of care within the framework of a social state. This crisis has also brought pre-existing inequalities to light, showing that it is mainly women who continue to take up the tasks of care as they have always done. Indeed, care work has always been carried out by women and this dedication has contributed to diminishing the exercise of other rights, so it is essential to take on the tasks of care by the family and the State in a co-responsible manner. This problem has been taken into consideration by the studies on constitutional reform in Spain in order to prepare a text that includes the right to care, and the rights of caregivers as well. The purpose of this work is to highlight this need and to make proposals to improve the Spanish constitutional framework.

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There is a crisis of public health in the UK. Although public health measures are known to be effective and cost-effective, UK government has shown a reluctance to adopt those measures. Reasons for this reluctance include: the wide-ranging agenda involved in dealing with the social determinants of health; a governmental decision bias against prevention; a similar bias against precaution; the problems of interorganisational collaboration and cross-government working; and the need for political leadership. However, the reluctance also reflects a dominant libertarian way of thinking about the role of the state, which needs to be replaced by a new social contract for responsible government.

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A Manifesto for a New Social Contract

A public health crisis is gripping the UK. Improvements in life expectancy have stalled, health inequalities have widened, obesity and alcohol misuse are placing an increasing strain on health services and urban air pollution is now widely recognised as a serious health hazard. COVID-19 revealed the weaknesses of the UK's public health system, once thought to be among the best in the world.

Against this background, this book examines the organisational and political barriers to an effective public health system showcased through the UK. It urges that what is needed is a new social contract, in which health policy is truly public.

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The fundamental question at the heart of public health policy is how it can be that cost-effective measures to promote the health of the population are not more vigorously implemented. The question has become more urgent as the pressures on the NHS have increased. Behind the implementation deficit, this chapter examines the role that a dominant public philosophy of libertarianism has played. That public philosophy is plagued with a number of problems, and in its place this chapter argues for a philosophy of social individualism in which the role of government-provided public goods is central to creating the conditions for effective individual choice and fulfilment. The chapter concludes with a manifesto of practical public health measures.

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With the demise of Public Health England came the establishment of the UK Health Security Agency and the Office for Health Improvement and Disparities. This new settlement poses issues of process and policy. Separating health protection and health improvement poses its own problems, given the association between poor health status and susceptibility to infection. More generally, the new bodies will have to cope with the complexity of public health evidence which is essential to scientific integrity, as well as the need for independence from politically partisan control. Political leadership will be essential, and there needs to be a ruthless focus on implementation.

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Devolution is a notable constitutional change in the UK. The devolution of health responsibilities has been associated over time with the establishment of public health responsibilities in the home nations other than England. Public Health Scotland, Public Health Wales and the Public Health Agency in Northern Ireland have acquired responsibilities, though the precise configuration varies among them. These differences suggest that there is no one right way of organising public health responsibilities, although it is notable that all the devolved governments have brought together health protection and health promotion. Important policy initiatives, like the minimum unit pricing of alcohol, are independent of organisational questions.

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This chapter explores the organisation of public health responsibilities in England between 2013 and 2020. The establishment of Public Health England was widely welcomed in bringing together health protection and health promotion. During its lifetime, Public Health England encountered problems in addressing some health promotion issues, like vaping, as well as ensuring cross-departmental working in government and forming relations with local government. Its funding was also cut. At its abolition in 2020, long-standing issues about the lack of priority to be given to public health to protect the NHS and promote the health of the population remained unresolved.

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