The delivery and organization of public health in England: setting the research agenda

Summary

The publication of Best Research for Best Health highlighted the need for the NHS Service and Delivery Organisation (SDO) Programme to develop a programme of research on public health service delivery and organization. This paper reviews the need for this research by reviewing recent policy documents and public health research activity. The paper outlines the role of the SDO Programme in relation to other current developments and discusses how these respond to the need to develop research on public health and what the research priorities are.

Introduction

The re-organization of primary care trusts (PCTs) and strategic health authorities in England in the autumn of 2006 has highlighted their important strategic public health role. In addition, recent changes to the quality outcomes framework (QOF), which provides financial incentives for undertaking specific activities¹ in general practice, have focused attention on developing health promotion and prevention activities in primary care. Similarly, in Scotland and Wales, public health continues to be a key focus on health policy and political debate, although without the added complication of major organizational upheaval. However, despite the growing significance of public health as a policy priority, the Healthcare Commission's annual ‘State of healthcare’ report² identifies the prevention of illness and the reduction of health inequalities as one of the four areas where further action is needed, arguing that healthcare organizations should give ‘sufficient priority to investment in the promotion of health and well-being—notwithstanding the current pressures on NHS finances’ (p. 13). Possible reasons for the lack of priority include the following: an evidence base in regard to public health delivery and organization that remains weak and undeveloped compared with other areas of healthcare delivery; and a failure to apply evidence even where it does exist for reasons not fully understood and themselves in need of research. The future capacity and capability of the public health function (health protection, health improvement and health service quality improvement) will depend crucially on being underpinned and informed by appropriate investment in research and development (R&D) and by an ability to exploit its potential to improve health and tackle health inequalities.

Since 1997, numerous developments in the area of public health have attempted to stimulate research and strengthen research capacity, address health inequalities, develop organizational workforce capacity, and strengthen the public health workforce and develop its skills.3, 4, 5 None of these initiatives has strengthened research capacity significantly. There is no disagreement that public health and the reduction of health inequalities are now key public policy goals and central to the achievement of an effective health service.6, 7, 8 However, research has tended to concentrate on descriptions of health states and socio-economic inequalities in health rather than on the impact and cost-effectiveness of interventions to reduce them. The publication of ‘Best research for best health’⁹ in 2006 renewed the attention on developing and expanding research on public health service delivery and organization. The need for such research was highlighted by Derek Wanless in his second report reviewing the state of public health.⁷ He was critical of the absence of research on the effectiveness of interventions and on how services should be organized to ensure their effective delivery.

This article examines the development of public health research following publication of the Department of Health's 2001 public health research strategy developed in response to concerns about research and the evidence base raised in the Government's 1999 White Paper on public health, ‘Saving lives: our healthier nation’.¹⁰ The focus is on England but much of the wider context relating to the position and development of public health research is relevant to the UK in general and possibly beyond, since issues of funding and weak infrastructure are not unique to the UK. It argues that little research has addressed the delivery and organization of public health despite the increasing use of targets and performance measures to direct public health activity. In ‘Best research for best health’, the Government signalled its intention to address the research deficit in this area by directing the National Health Service's Service Delivery and Organization (SDO) R&D Programme to commission research on public health.⁹ This article will consider the context behind this move and outline how the SDO Programme is responding to ‘Best research for best health’ and where this fits into current developments in public health research and health services research more generally following publication of the review by Cooksey in late 2006.¹¹