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(Re-)visions of public health: how have our priorities changed?


Ahead of the launch of our new report A vision for population health at our annual conference, Lynsey Hawker looks back at the evolution of The King’s Fund’s work on public health.

We hear a lot today about integration and collaboration in health (and social care).

‘Historically it was perhaps inevitable that the main divisions of the health service – hospitals, public health and general practice – should have developed independently. The task of complete integration at the beginning would have been too great; but for many this remains the ultimate objective. Meanwhile, it has become increasingly clear that somehow better cooperation must be achieved if we are to make the best use of our limited resources’.

However, this introduction appears in Working together. a report from The King’s Fund written in 1968. This call for more integrated services resonates today, especially as The King’s Fund prepares to launch new work on population health. What has changed since this report’s publication exactly 50 years ago?

Working together is the first report from our archive that looks beyond hospital systems. It marks the beginning of a greater focus on public health and health inequalities within The King’s Fund.

Politically too, public health was prominent at this time and the next decade saw two seminal publications. Prevention and health: everybody’s business was published by the government in 1976. This White Paper aimed to highlight the importance of public education about the health-related effects of behaviours such as smoking, alcohol consumption, exercise and diet. Accepted as an important work, it was later criticised for putting too much emphasis on the individual.

The second report, Inequalities in health published the findings of the Working Group on Inequalities in Health, and is also known as The Black report, after Sir Douglas Black who chaired the working group. Inequalities in health was significant in highlighting the existence of health inequalities and the need to consider wider determinants of health when looking at the health of a population.

In this context, The King’s Fund contributed work on health inequalities during the 1980s and 1990s.

  • The Nation’s Health and the NHS (1980) compared causes of morbidity and mortality with health service use, highlighting differences in service provision among different communities.

  • The nation’s health (1988) (with a second edition in 1991) was a major report in three parts: key threats to public health (cancers, circulatory diseases, HIV/AIDS, road safety and lifestyle); health promotion; and priorities for public health policy for the 1990s.

  • Tackling inequalities in health (1995) reflected continuing priorities during the 1990s.

  • From the mid-1990s, increasing focus on specific populations was reflected in publications on improving health and access to health services for BME communitieshomeless peopleyoung people, and older people.

In 2004 the government published Securing good health for the whole population, a follow-up report by Sir Derek Wanless to his 2002 report on long-term health trends_._  This returned to a focus on prevention and the wider determinants of health, and engaging people in making healthy choices. The King’s Fund participated in the debate, asking how much (or how little) government intervention is appropriate when persuading people to adopt healthier behaviours – in Nanny or steward? The role of government in public health (2005). The following ’Kicking Bad Habits’ programme published a series of case studies exploring the effectiveness of different interventions from the provision of better health information to offering financial incentives to encourage healthier choices.

The Marmot Review in 2010 argued that health inequalities can be reduced only by tackling the wider social determinants of health – social environments, housing, education, income, standard of living, occupation and working conditions. The responsibility of improving population health therefore, the review argued, cannot sit within any one organisation or sector but requires better integrated health services across the NHS, local authorities and the voluntary sector. The coalition government’s White Paper Healthy Lives, Healthy People (2010) correspondingly gave more responsibility for public health to local authorities, supported by a new national body, Public Health England.

The King’s Fund responded by producing work that focused on the impact of these changes, including the impact of changes in the government grant, on producing material to support public health teams in local government and district councils, to support important sectors that affect health, such as housing, and on analysing some of the challenges these changes have introduced.

There is a history of policy initiatives advocating the importance of integrated care that can be traced back over half a century. In parallel, thinking about public health has also evolved over the past fifty years. The King’s Fund’s most recent work seeks to ‘join the dots’ between these two by highlighting the importance of population health systems in improving the health of the population.

Continuing to build on this, the Fund is publishing A vision for population health that we hope will guide future work in this area. The report will be launched at this year’s annual conference taking place at The King’s Fund on 27 and 28 November 2018.