PHOENIX: An investigation of the public health system in England

This research is being led by a team within the Policy Research Unit on Commissioning and the Healthcare System (PRUComm), on behalf of the Department of Health. Is it a 33-month study, commencing in April 2013.

The public health system in England has undergone substantial reorganisation with a wholesale transfer of public health responsibilities from local NHS organisations to local authorities and Public Health England (PHE) – a new organisation which subsumes a large number and wide range of former bodies. At the same time, health service leadership and commissioning have been transformed through the creation of NHS England – at ‘arm’s length’ from Government – and clinical commissioning groups (CCGs). These structural changes have enormous implications for the way in which the public health function is approached, organised and delivered. Under the new system, the NHS will remain critical to protecting and improving the population’s health. It will be charged with delivering certain public health services, and with promoting health through all its clinical activity. However, outside the clinical arena, the key responsibility for improving the health of local populations – including reducing health inequalities – will rest with democratically accountable upper tier and unitary local authorities.

There is an expectation that local authorities will be better able to deliver health improvements in local populations than the NHS has been. According to the Department of Health, “integrating public health into local government will allow greater co-ordination and effectiveness – services will be planned and delivered in the context of the broader social determinants of health, like poverty, education, housing, employment, crime and pollution” (DH 2012: Public Health Outcomes Framework for England 2013-16, p.4). Whilst this research will not be able to answer definitively whether that is the case, it will examine changes in the public health system as a whole, the impact of the reforms on the system, and some of the key facilitators and barriers to realising that expectation.

The overarching aim of this research project is to examine the impact of structural changes to the health and care system in England on the functioning of the public health system, and on the approaches taken to improving the public’s health. A key focus will be to explore the impacts of structural changes at national, regional and local levels on the planning, organisation, commissioning and delivery of health improvement services.

The project will use an examination of public health strategies to tackle obesity obesity as a focal issue, and will examine the response of public health systems to the issue of obesity/weight management: the approaches taken by key actors; how commissioning decisions are made; what the resulting spectrum of services/activities looks like; and whether there is any change in the balance of interventions delivered, ranging from individual level tier 4 services to high level upstream population approaches.

The project aims to identify the extent to which, how and why: key opportunities within the new system are being realised; key challenges are being overcome; and key concerns are addressed. As a result the project aims to provide transferable learning to enable organisations at all levels within the public health system to work together more effectively in their efforts to improve health.

Key objectives:

1. To conduct a critical analysis of the impact of recent structural reforms on the public health system and its likely ability to improve population health and tackle obesity (as an example of a complex problem).
2. To develop a clearer understanding of the relationships between different components within the public health system at national and local level.
3. To identify the ways in which commissioning organisations within the public health system are approaching the commissioning of health improvement interventions (by focusing on their approaches to tackling obesity).
4. To examine commissioning decision-making processes within 4 case study sites, with regards to the commissioning of obesity/weight management services, to identify influences on decision-making and relational influences on health improvement.
5. To identify difficulties and opportunities facing actors within the new public health system in progressing the public health agenda, and specifically in relation to preventing/managing obesity.

Study design

Within an overarching collaborative and participatory approach to the research, this study will incorporate multiple methods, including key informant interviews, document analysis, local case-studies and national surveys. It will incorporate a scoping review, two annual national surveys of key agents within local public health systems (e.g. DPH, Chair HWB, Chair CCG), four in-depth geographical case studies, and four further ‘lighter-touch’ geographical case studies in order to capture different organisational arrangements in local government and the NHS.

PHOENIX: Public Health and Obesity in England – the New Infrastructure Examined

This report is the fifth and final report for the project. It should be considered alongside a first interim report (Gadsby et al 2014), focusing on our scoping study phase; a second interim report (Peckham et al 2015) focusing on our phase one case study research and first national survey; a first survey report (Jenkins et al 2015) and a report of the second survey (Jenkins et al 2016). The research commenced in April 2013 and involved three phases of interviews – a scoping study with key informants in 2013 and two phases of interviewing in five case study areas in 2014 and 2015. In total we conducted 108 interviews for the main phases of the research reported in the final report (Peckham et al., 2016) and 23 initial scoping interviews reported in our first interim report (Gadsby et al 2014). In addition we undertook two national surveys in 2014 and 2015 of Directors of Public Health and lead councillors for health. This final report incorporates the findings of our phase two case study research and second national surveys of Directors of Public Health (DsPH) and councillors who lead on public health issues. It also draws on the findings of the previous two phases of the research.

The Role of Local Authorities In Health Issues: A Policy Document Analysis

Prior to the passing of the Health and Social Care Act 2012 the Communities and Local Government (CLG) Select Committee conducted an investigation into the proposed changes to the Public Health System in England. The Committee considered 40 written submissions and heard oral evidence from 26 expert witnesses. Their report, which included complete transcripts of both oral and written submissions, provided a rich and informed data on which to base an analysis of the proposed new public health system. This report analyses the main themes that emerged from the evidence submissions and forms part of our preliminary work for PRUComm’s PHOENIX project examining the development of the new public health system.