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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.
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.
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.
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.
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.
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.
The concluding chapter considers the ways in which the NHS has been viewed and evaluative in previous anniversaries, noting enduring themes. The four analytical axes are then reviewed in the light of evidence presented in this edited collection. Finally, a summative assessment of the NHS is offered which points to issues that the NHS will face in the future.
This chapter discusses the health policies of the United Kingdom’s devolved nations. These are placed in their historical and contemporary contexts, with due attention paid to the respective particularities of Wales, Scotland and Northern Ireland alongside an acknowledgement of commonalities within the UK as a whole. Even before the crucial decade of the 1990s, administrative devolution allowed for divergence in health policy, especially in Scotland. Political devolution, in principle at least, reinforced this trend, and a further component of the chapter is an attempt to explain why this should be so, and what this might mean for all the constituent parts of the UK.
Although NHS anniversaries have been widely celebrated, adult social care has tended not to receive the same attention. As a result, the history of adult social care is largely overlooked – and even people working in adult social care may know little about the origins and evolution of their current services and roles. Using the four analytical axes set out in the introduction to this book, we explore the different forms of governance (hierarchies, markets and networks) which co-exist within adult social care; the mixed economy of care; relationships between the centre and localities; and relationships between the state and professionals (including the position of the bulk of the workforce, who might not meet standard definitions of a ‘profession’). In each case, adult social care is very different to the NHS, making attempts to integrate care – while laudable – extremely difficult to achieve in practice.
As the NHS marks its 50th anniversary, questions about the financial sustainability of a tax-funded, free at the point of use service are being raised once more. The pressures on the health service are intense. Spending increased to deal with the COVID-19 pandemic, following a decade of historically low funding growth. The decade of austerity left the NHS with limited capacity to manage the health shock. COVID-19 exposed and magnified the risks associated with prioritising short-term efficiency and cost control over resilience. Over the next decade building a resilient health service which is able to both reduce the care backlog and respond to a rapidly ageing population with rising health need will require funding to increase by more than inflation and GDP. But the NHS can’t go it alone, it needs to be part of a health eco-system that includes better funded public health and social care services. This raises profound questions about the size of the state and levels of taxation.
