UK Public Health Systems

by

David Hunter

• LAST MODIFIED: 28 October 2020
• DOI: 10.1093/obo/9780199756797-0200

Introduction

Within the UK there are four public health systems covering each of four countries making up the UK: England is the largest country, followed by Scotland, Wales, and Northern Ireland. There are many commonalities between the systems in terms of their functions and workforce terms and conditions as well as the challenges each faces. But in keeping with the devolved systems of government enjoyed by each country, the public health systems are organized differently and their structures and priorities reflect the differing contexts in which they are located. Drawing on the three domains outlined by Griffiths, Jewell, and Donnelly in their seminal 2005 paper and comprising health protection, health improvement, and health service delivery and quality, UK public health systems exist to protect and promote health improvement and well-being in the population and do so through devising policies and strategies and providing services as well as contributing to the evidence base in regard to what works to improve health. The definition of a public health system is clearly contingent on the definition and scope of public health. The UK public health systems have adopted the definition of public health advanced by the UK Faculty of Public Health and other bodies and first produced by a former Chief Medical Officer for England, Sir Donald Acheson, in 1998: “Public health is the science and art of preventing disease, prolonging life and promoting health through organised efforts of society.” A slightly extended version appeared in a review of public health carried out for the UK government by its appointed independent adviser, Sir Derek Wanless, in 2004: “Public health is the science and art of preventing disease, prolonging life, and promoting health through the organised efforts and informed choices of society, organisations, public and private, communities and individuals.” These definitions share important characteristics including: public health is both a science and an art, essentially and always a combination of knowledge and action; the core purposes of public health are to prevent disease, prolong life, and promote health; public health is an organized societal function. Several aspects of these definitions can be highlighted as being especially pertinent to public health systems. Notable among these is the desire for closer links across health and the environmental sector; addressing social and political determinants of health as an essential and legitimate public health action; and the importance of health systems for public health improvement. Given these definitions with their whole-of-society focus, a public health system is wider and more inclusive than a health system. An effective public health system can be judged by the extent to which relevant groups, organizations, and sectors work effectively together on specific issues.

General Overviews

There are few general overviews which focus specifically on the UK public health systems but three sources worth mentioning are: the Oxford Textbook of Global Public Health, the European Observatory on Health Systems and Policies Health in Transition Series (HiTS), and a four nations study conducted by academics based at the School of Health and Related Research (ScHARR), University of Sheffield. Although not focusing exclusively on the UK, many of the chapters in the Oxford Textbook of Global Public Health are relevant to developments in its public health system. While earlier editions of the textbook are worth consulting—their publication began in 1984—the fourth (2002), fifth (2009), and sixth (2015) editions are the most useful. The WHO HiTs reports covering the UK (Cylus, et al. 2015) and its constituent parts (Boyle 2011 for England; Steel and Cylus 2012 for Scotland; O’Neill, et al. 2012 for Northern Ireland; and Longley, et al. 2012 for Wales) provide useful descriptions of the four systems operating in the UK and identify the key challenges facing policymakers and practitioners. Barnes, et al. 2018, the ScHARR four nations study, is perhaps the most useful overview since it focuses entirely on public health in contrast to the WHO HiTs reports which include health care services. It is also the most up-to-date overview in terms of covering the shared challenges the four systems face.

• Barnes, A., S. Baxter, C. Beyno, et al. 2018. Four Nations Study: A Comparative Systems Review and Thematic Policy Analysis of Public Health across the Four Constituent Countries of the UK. Research Report. ScHARR: Univ. of Sheffield, The Health Foundation and the Association of Directors of Public Health.

  The starting point is the absence of knowledge about the extent of divergence across the four nations and what can usefully be learned from the ‘natural experiment’ of national devolution as it affects public health. The study includes a systematic review of the published literature relating to the four public health systems. This covers organizational structures and systems, ways of working, influencing factors and outcomes, and system-wide impacts.

• Boyle, S. 2011. United Kingdom (England): Health system review. Health Systems in Transition 13.1: 1–48.

  The profile notes that the NHS provides preventive medicine, primary care, and hospital services to all those in need. Despite successive reforms to the health system, both before and since the publication of this review, basic features of the English NHS remain unchanged. The most significant change affecting the public health system occurred in 2012 when responsibility for public health was removed from the NHS and returned to local government.

• Cylus, J., E. Richardson, L. Findley, M. Longley, C. O’Neill, and D. Steel. 2015. United Kingdom: Health system review. Health Systems in Transition 17.5: 1–125.

  The Health in Transition (HiT) volume covers the whole health system in the UK and includes a section on public health. Supporting the UK volume are four separate HiTs for the four countries making up the UK: England, Scotland, Northern Ireland, and Wales. Each volume is organized around the following topics : organization and governance, financing, physical and human resources, provision of services, principal health reforms, and assessment of the health system.

• Detels, Roger, Martin Gulliford, Quarraisha Abdool Karim, and Chorh Chuan Tan, eds. Oxford Textbook of Global Public Health. 2015. 6th ed. Oxford: Oxford Univ. Press.

  Comprises three volumes covering respectively the scope of public health, methods of public health, and practice of public health. Chapters written by respected authorities in their field cover many issues from a global perspective, including the development of the discipline of public health, determinants of health, public health policies and functions, and prevention and control of public health hazards. A comprehensive index for each volume guides the reader to the content of most relevance to the UK.

• Longley, M., N. Riley, P. Davies, and C. Hernandez-Quevedo. 2012. United Kingdom (Wales): Health system review. Health Systems in Transition 14.11: 1–84.

  Like Scotland and Northern Ireland, Wales abandoned the internal market in health care. The health system continues to face some structural weaknesses that have proved resistant to reform. Life expectancy has continued to increase and health status has improved although health inequalities have resisted improvement and remain high.

• O’Neill, C., P. McGregor, and S. Merkur. 2012. United Kingdom (Northern Ireland): Health system review. Health Systems in Transition 14.10: 1–91.

  Northern Ireland has operated an integrated health and social care system since the devolved administration was established in 1998. Like Scotland, there is less emphasis on competition and market forces. The stated aim of the health and social care system is to improve the health and social wellbeing of people in Northern Ireland. Health inequalities are evident in some areas of health although evidence suggests they have narrowed in recent years.

• Steel, D., and J. Cylus. 2012. United Kingdom (Scotland): Health system review. Health Systems in Transition 14.9: 1–150.

  This profile notes how Scotland’s health system has increasingly diverged from that in England. Scotland has pursued an approach stressing integration and partnership as opposed to one in part driven by market forces. There have been fewer structural changes. Good progress has been made in terms of population health although a number of challenges remain. More progress is needed to close the gap in health status between Scotland and other developed countries.