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The Public Health System in England: a Scoping Study

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The Public Health System in England: a Scoping Study View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Edinburgh Research Explorer The Public Health System in England: a Scoping Study David J Hunter Linda Marks Katherine Smith Centre for Public Policy and Health November 2007 School for Health Contents 1. Introduction ___________________________________________________________ 1 Part 1: The State of the Public Health System in England: its evolution between 1974 and 2004 ________________________________________________________ 4 2. Background ___________________________________________________________ 4 3. The Nature of the Public Health System____________________________________ 5 3.1 Whole systems approach______________________________________________________ 5 3.2 Approaches to defining public health systems______________________________________ 8 4. Public Health After 1974: the End of the Beginning or Beginning of the End? ___ 17 4.1 What is public health? _______________________________________________________ 21 4.2 Who does public health? _____________________________________________________ 25 4.3 The emergence of the ‘new’ public health ________________________________________ 27 4.4 Local government and public health ____________________________________________ 36 4.5 Non- governmental organisations and public health ________________________________ 38 4.6 Health protection ___________________________________________________________ 39 4.7 Other developments _________________________________________________________ 40 4.8 How far have things changed? _________________________________________________ 41 5. Conclusion to Part 1 ___________________________________________________ 44 Part 2: The State of the Public Health System in England: the impact of policy and organisational changes since 2004 _______________________________________ 47 6. Background __________________________________________________________ 47 7. Approach and Methods ________________________________________________ 48 8. The Changing Policy Landscape in England Post-2004 ______________________ 51 9. The Public Health System and its Capacity to Meet Public Health Challenges____ 58 9.1 What is a ‘public health system’? ______________________________________________ 58 9.2 What is ‘public health’? ______________________________________________________ 60 9.3 Comparing the ideal public health system with what already exists ____________________ 65 9.3.1 Engaging with local communities __________________________________________ 65 9.3.2 Leadership ____________________________________________________________ 66 9.3.3 A focus on shared values, and goals_________________________________________ 67 9.3.4 Evidence-based policy and practice _________________________________________ 68 9.3.5 Organisational issues ____________________________________________________ 69 9.3.6 Public health timeframes and resources ______________________________________ 72 9.3.7 Local flexibility ________________________________________________________ 74 9.4 Policy connectivity and coherence______________________________________________ 75 9.5 Progress in public health _____________________________________________________ 77 10. Impact on the Organisation and Management of the Public Health System of Arrangements for Commissioning, Partnership Working, and Public Involvement _ 79 10.1 Commissioning for health and well-being _______________________________________ 80 10.1.1 The development of a workforce equipped with the requisite skills _______________ 82 10.1.2 The provision of sufficient resources _______________________________________ 83 10.1.3 The achievement of more collaborative working ______________________________ 83 10.1.4 The provision of a coherent and supportive policy context ______________________ 84 10.1.5 Organisational and policy stability_________________________________________ 85 10.1.6 The use of available evidence in making decisions about commissioning___________ 86 10.1.7 Increased public awareness, and therefore involvement in and support for, commissioning for health and wellbeing__________________________________________ 86 10.2 Partnership working ________________________________________________________ 87 10.2.1 The extent to which partner organisations (and individuals) have historically worked together ___________________________________________________________________ 88 i 10.2.2 The level of trust / antagonism between partners ______________________________ 89 10.2.3 Coterminosity of boundaries across organisations _____________________________ 89 10.2.4 Shared targets, incentives and performance assessment arrangements _____________ 90 10.2.5 Arrangements relating to resources ________________________________________ 90 10.2.6 Joint DsPH ___________________________________________________________ 92 10.2.7 Public health outcomes__________________________________________________ 93 10.3 Public involvement ________________________________________________________ 94 11. Markets and Choice __________________________________________________ 98 11.1 Specific concerns about the impact of the choice agenda on health inequalities __________ 99 11.2 General concerns with the choice agenda ______________________________________ 100 11.3 Positive comments about the choice agenda ____________________________________ 102 12 The Changing Public Health Workforce _________________________________ 103 12.1 To what extent is the public health workforce now multi-disciplinary? _______________ 104 12.2 Workforce morale and issues relating to recruitment______________________________ 107 12.3 Perceived gaps in training and issues relating to the current mix of skills within the public health workforce _____________________________________________________________ 109 13. Looking to the Future ________________________________________________ 111 13.1 How the public health system was likely to develop over the next five years ___________ 111 14. Commentary________________________________________________________ 113 14.1 The changing policy landscape ______________________________________________ 115 14.2 The nature of public health and a public health system ____________________________ 116 14.3 The impact on the public health system of commissioning, partnership working and public involvement _________________________________________________________________ 118 14.3.1 Commissioning_______________________________________________________ 118 14.3.2 Partnership working ___________________________________________________ 118 14.3.3 Public involvement____________________________________________________ 118 14.4 Markets and choice _______________________________________________________ 119 14.5 The changing public health workforce_________________________________________ 119 14.6 Looking to the future ______________________________________________________ 121 15. Conclusion _________________________________________________________ 121 Appendix 1: NHS Reorganisation – 1975-2007 ______________________________ 125 Appendix 2: A time line of key public health policy statements since 2004________ 130 Appendix 3: Interview Schedule___________________________________________ 131 References_____________________________________________________________ 136 ii The Authors David Hunter is Professor of Health Policy and Management and Director of the Centre for Public Policy and Health (CPPH) in the School for Health and Wolfson Research Institute at Durham University. He led the scoping review, oversaw its progress and is main author of the report. Linda Marks is Senior Research Fellow in the CPPH, School for Health and Wolfson Research Institute at Durham University. She was co-applicant for the scoping review, contributed to its content and structure and devised the interview schedule. Katherine Smith is Research Assistant in the CPPH, School for Health and Wolfson Research Institute at Durham University. She undertook a brief review of literature relating to the public health system in England since 1974, which fed into Part 1 of this review, and conducted, analysed and wrote-up the 28 interviews on which Part 2 is based. Acknowledgements We wish to thank all those who agreed to be interviewed for the scoping review and gave so generously of their time. We are grateful, too, to those who provided comments on Part 1 which formed the interim report produced earlier this year, and to two external referees who commented on the final report. Many of their helpful comments have been incorporated into this revised version. We would also like to thank JHTS for transcribing the tapes in record time, and Christine Jawad for assistance with finalising the presentation of the report for submission. Finally, we thank the SDO for commissioning this scoping review and are grateful to the support received throughout its conduct, especially from Stephen Peckham who also commented on earlier drafts. Any errors of fact or interpretation remain the responsibility of the authors. November 2007 iii 1. Introduction The specific purpose of this scoping study of the public health system in England is to provide essential, and hopefully helpful, background and context for the National Institute for Health Research Service Delivery and Organisation’s (NIHR SDO) new public health research programme. It is intended to be of use to the successful proposals selected for funding (for summaries of the studies visit www.sdo.lshtm.ac.uk ) and to avoid individual research teams having to rehearse much of the background
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