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Health systems everywhere are experiencing rapid change in response to new threats to health, including from lifestyle diseases, risks of pandemic flu, and the global effects of climate change but health inequalities continue to widen. Such developments have profound implications for the future direction of public health policy and practice.

The public health system in England offers a wide-ranging, provocative and accessible assessment of challenges confronting a public health system, exploring how its parameters have shifted and what the origins of dilemmas in public health practice are. The book will therefore appeal to public health professionals and students of health policy, potentially engaging them in political and social advocacy.

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Author: David J. Hunter

This chapter highlights the need for partnership working, which has been a long-standing objective of health and social policy. For many years, the National Health Service (NHS) and local authorities have been attempting to deal with ‘wicked issues’. Issues such as homelessness, disaffection of young people, and the ageing society that have complex multiple causes require joined-up approaches by the statutory and third sectors at national and local levels. In 2012, at the time when Public Health responsibilities were transferred from the NHS to local authorities, health and wellbeing boards (HWBs) were established in England. With few exceptions, HWBs punch below their weight and are not the powerful system leaders that were hoped for. Evidence of their value and impact is negligible, with poor-performance indicators, and the difficulties in overcoming deep-seated departmentalism and a silo approach prevalent in government and public services, leaving ‘wicked issues’ as deep-seated as ever.

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Author: David J Hunter

As in the case of other parts of the UK wider health system, it has been a turbulent time for public health since 2010. Not only has the function undergone major structural and cultural change following its return to local government from the NHS, where it had been located since 1974, but it has had to confront new challenges in public health arising from lifestyle behaviours and a widening health gap between social groups. All of this has occurred during a period of unprecedented financial austerity affecting public services in general but local government in particular. This chapter reviews the state of public health in the lead up to the changes announced by the Coalition government in 2010. It then summarises the reforms before offering an interim assessment of their impact. Finally, it discusses the evidence to date concerning the reforms and speculates on likely prospects in the years ahead.

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This book sets the scene for the series by comprehensively assessing and critiquing the current 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. This chapter introduces the various issues that will be tackled in subsequent chapters.

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This chapter reviews the policy and organisational changes that have occurred since 1997 following a change of government. New Labour sought to accord a high priority to the health of the public and was strongly committed to putting both health improvement and health inequalities back on the policy agenda. An important symbol of this new policy emphasis was the appointment of the UK’s first ever Minister for Public Health. The chapter presents and assesses the various policy developments from 1997 to the present day, including the two public health White Papers of 1999 and 2004 respectively. It also examines other developments affecting public health within this period, including changes in the structure of the NHS, the relaunching of commissioning under the heading ‘world class commissioning’, and the policy shifts towards markets and choice in the provision of health and health care.

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This chapter is structured around a series of issues that have currently come to the fore in the public health system, all of which have their roots in the history of public health charted in the preceding chapters. These issues represent the key policy and practice challenges facing the public health system as it moves through the twenty-first century. The discussion focuses on the following issues: the nature of policy formation relating to the health of the public; markets, competition and choice; commissioning for health and wellbeing; public health through partnership; and public involvement.

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This chapter looks ahead to some of the key threats to the health of the public and the challenges facing a public health system in future. These include climate change and environmental concerns; the need for a concern for health and wellbeing to permeate a far wider range of policies, tasks and activities than at present and to become a priority for those working in fields that would not normally be considered relevant to public health; and the thorny and persistent subject of health inequalities, which, arguably, is more a matter of social justice than health policy. The discussion suggests that a strong and confident public health system will contribute effectively to meeting these challenges. The global economic crisis could also provide an opportunity to find new ways of making progress that does not compromise sustainability.

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This chapter considers in more detail definitions of public health and how these in turn influence conceptions of a public health system. It does so in the light of the varying, and often contested, views and assumptions as to what public health is, what its guiding values are and who actually conducts public health. The latter is connected to a consideration of the debates surrounding what is an increasingly diverse and complex workforce employed by, and working in, a variety of organisations and institutional arrangements. Public health activities give rise to political and ethical tensions, which are reflected in debates over the boundaries of ‘stewardship’, defined as the collective responsibility that governments assume for protecting the health of their populations.

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This chapter charts in some detail the evolution of the public health system in England from 1974 to 1997, noting key features and policy developments. It presents an analysis of key shifts in the way that public health was understood, including the emergence of the ‘new’ public health in the 1970s and 1980s, following a series of international initiatives emanating from the World Health Organization (WHO), notably the Alma Ata Declaration, Ottawa Charter and Health for all strategy. The chapter assesses the dominance of public health medicine for much of this period and the challenges it faced from those who subscribed to political and ecological models of public health. These various perspectives underlay moves within this period to establish a multidisciplinary workforce embracing the breadth and range of public health concerns.

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