5. Provision of services
ublic Health England, Health Protection Scotland, Public Health Wales and the Public Health Agency for Northern Ireland exist in their respective nations to strengthen and coordinate health protection. The key elements of public health in the United Kingdom are: health protection programmes, health improvement programmes, and reducing health inequalities.
Primary care in the United Kingdom serves three main roles: it is the first point of contact when a person has a health concern; it provides ongoing care for common conditions and injuries; and it serves as a gatekeeper to more specialized care, which is generally provided in hospitals. Most NHS secondary care is provided by salaried specialist doctors and others who work in state-owned hospitals. Tertiary services offer more specialized care, and are often linked to medical schools or teaching hospitals. Tertiary care services often focus on the most complex cases and on rarer diseases and treatments. Across the United Kingdom there has been a move to concentrate specialized care in fewer centres in order to improve quality.
Patient pathways are fairly similar across the United Kingdom, with comparatively more emphasis on choice of provider in England. The GP is usually the first point of contact, although there are other primary care pathways, including telephone services and walk-in centres. Recent policies have focused on reducing demand for emergency care through public information campaigning and broadening access to urgent care services. It is hoped that improving the integration of health and social care should also reduce demand for emergency care services and unnecessary hospitalizations.
5.1 Public health
The Department of Health or its equivalent is in charge of public health in England, Scotland, Wales and Northern Ireland respectively, and the Chief Medical Officer of each of the four departments leads in setting and monitoring public health measures. The key elements of public health are: health protection programmes (immunization, etc.), health improvement programmes (smoking cessation, etc.) and reducing health inequalities. Public Health England, Health Protection Scotland, Public Health Wales and the Public Health Agency for Northern Ireland exist in their respective nations to strengthen and coordinate health protection.
Services are delivered through the NHS, local authorities and other groups. The Health and Social Care Act 2012 moved responsibility for commissioning (i.e. purchasing) public health services to local authorities in England. People whose work contributes to public health include: specialists (such as senior management figures and senior scientists); the wider community (teachers, social workers, doctors, etc.); and public health practitioners (health visitors, consultants in public health medicine, and those who use research, science or health promotion skills in specific public health fields). The United Kingdom Faculty of Public Health maintains professional standards and oversees the quality of training and professional development of public health specialists and revalidation methods for public health workers, who no longer also need to be medically qualified.
Public health priorities for all of the United Kingdom include: alcohol harm reduction, childhood obesity, health inequalities, infant mortality, response to sexual violence, sexual health, teenage pregnancy, tobacco control, vaccination and immunization, and the mental health and psychological well-being of young people. Some interventions have been introduced across the United Kingdom as a result of separate decisions by each administration, for example smoking bans in public places and raising the minimum age for tobacco sales to 18. However, Scotland, Wales and Northern Ireland have produced their own sets of goals and health priorities in addition to those listed above. For example, Scotland aims to improve healthy life expectancy, which has historically been below the United Kingdom average, and to break the link between early life adversity and adult disease.
Scotland, Wales and Northern Ireland may also focus on different factors in public health; the Scottish government passed a Public Health Act in 2008 in response to modern threats to public health such as food production and environmental changes. Scotland has also been at the forefront of policies to tackle alcohol consumption through the suggested introduction of minimum prices per unit, which was agreed to in principle in 2012 but has not yet been implemented due to a legal challenge (Steel & Cylus, 2012). Wales intended to put forward a Public Health Bill in 2015 which would include action to reduce the harms to health from smoking, alcohol misuse and obesity.
The Joint Committee on Vaccination and Immunization is a standing advisory committee, independent of the Department of Health, with statutory responsibility to advise the Secretary of State (i.e. minister) for Health. Immunizations are not compulsory in the United Kingdom, but they are strongly encouraged. Health care professionals who work with immunizations and vaccines receive special training in those areas. The MHRA monitors vaccine quality under their remit. Immunization programmes cover children, older people and people with particular conditions or lifestyles, as well as health care and laboratory staff.
The United Kingdom National Screening Committee (NSC) recommends programmes that screen for potential problems or diseases in all of the United Kingdom. In determining which screening programmes will be most effective, the NSC takes into account the standard criteria: condition (it should be a serious and detectable condition, and one for which cost-effective prevention has been used as much as possible first); test (the test should be simple, safe, precise and validated); treatment (treatment should be effective, and there should be evidence for which people should receive treatment); and screening (there should be strong evidence that screening reduces mortality or morbidity, and that the benefit outweighs the physical and psychological harm of the screening itself). The NSC recommends systematic screening for adults, children, newborns and pregnant women. England, Scotland, Wales and Northern Ireland adopt the NSC’s recommendations for their own screening programmes, with some local variation. Private sector health screening is widely available in England, including some screening tests that are not recommended by the NSC. Such tests are regulated by the CQC.
In August 2020 the UK government announced the creation of a new National Institute for Health Protection. This will initially incorporate:
• Health protection responsibilities of Public Health England (PHE), including the Centre for Radiation and Chemical and Environmental Hazards;
• The Joint Biosecurity Centre, responsible for monitoring and analysis of Covid-19;
• NHS Test and Trace, responsible for testing and contact tracing during Covid-19;
There is an aspiration for it to be responsible for local health protection teams, and emergency planning and preparedness. It will have a remit primarily within England, but will also take on UK-wide responsibilities currently held by PHE to support the four chief medical officers of the UK nations, and international infectious diseases work.
These changes appear to end PHE in its current form. PHE was created in 2012 to bring together various bodies and programmes as an “executive agency” with limited independence from government and civil service. The changes are seen to be linked to criticism of PHE over aspects of handling of Covid-19, though its role and responsibilities remain disputed. The NIHP will not be “formalised” until Spring 2021. It is unclear at this stage how health improvement responsibilities previously held by PHE, (e.g. obesity, smoking, alcohol, and substance misuse), will be allocated.
Public Health Scotland became operational as a reorganized national special health board on 1 April 2020, created under existing statutory powers to consolidate functions (https://www.legislation.gov.uk/ssi/2019/336/pdfs/ssipn_20190336_en.pdf). Although accountable to Scottish Ministers, it uses a distinctive model of being jointly sponsored by the Scottish Government and the Convention of Scottish Local Authorities (COSLA), an independent representative body for local government. This effectively means shared decision-making, planning and performance management. Scottish Government Ministers appoint its board, but COSLA are consulted and manage a merit based selection process to appoint two local councillor members to the board (https://www.gov.scot/publications/consultation-new-national-public-health-body-public-health-scotland/pages/4/).
The organization works across health protection, health improvement, and health care improvement. It primarily plays a leadership and coordination role, rather than service provision and delivery which remain mostly with local bodies. Its functions include:
• Linking, improving and analysing data and intelligence on health and health care, working with NHS and local bodies.
• Playing a general leadership role across Scottish local and national bodies whose responsibilities relate to public health, and supporting partnerships at different levels.
• Compiling evidence, and producing advice and guidance to national government, NHS organisations, and local government.
• Research, development, training and education relating to public health.
• Provide national overviews and analysis of public health plans by partnerships of local bodies.
Its strategic remit is currently based around six priorities for public health in Scotland agreed between COSLA and the Scottish Government in 2018 (https://www.gov.scot/publications/scotlands-public-health-priorities/). There is a three year strategic plan (https://www.publichealthscotland.scot/our-organisation/a-scotland-where-everybody-thrives-public-health-scotland-s-strategic-plan-2020-to-2023/).