The Governance of Prevention in the United Kingdom

Alice Borghini,¹ Andrea Poscia,¹ Maria Benedetta Michelazzo,¹ Umberto Moscato^1
1 Institute of Public Health – Section Hygiene, Catholic University of the Sacred Heart, Largo Francesco Vito, 1 – 00168 Rome
Edited by: L. Palombi, E. De Vito, G. Damiani, W. Ricciardi

Background

The healthcare system in the United Kingdom was instituted in 1948. It is a national system (National Health Service – NHS) supported through taxation and freely available to all citizens that use public health services. The United Kingdom government directly finances the healthcare system in England while allocating block grants to Scotland, Wales and Northern Ireland, which decide their own policy for healthcare.

The National Health Service Reorganisation Act 1973, in England and Wales, saw, in 1974, the creation of regional health authorities, area health authorities and Family Practitioner Committees, in order to integrate three different types of service: acute, community and preventive. In 1980, health authorities were reorganised from area to district health authorities to improve their efficiency. In 1990, the National Health Service and Community Care Act, approved by Government, separated purchasing (“commissioning”) from the provision of healthcare services in the country. The aim of this change was to improve the efficiency and quality of services.

In 1997, the National Institute for Health and Clinical Excellence (National Institute for Health and Care Excellence (NICE) from 2012) and the Commission for Health Improvement (Care Quality Commission (CQC) from 2009) were introduced, supporting new national standards and targets and acting as inspection and regulation bodies. The Health and Social Care Act (2012) was recently introduced in England, and became operative on 1 April 2013. This Act abolishes primary care trusts (PCT, administrative bodies, responsible for commissioning primary, community and secondary health services from providers) and strategic health authorities (SHA, responsible for enacting the directives and implementing fiscal policy of the Department of Health at regional level) and replaces them with clinical commissioning groups (CCGs) and commissioning support units (CSU). NHS England was established to be the purchaser of primary care and some specialist care while Public Health England (PHE) oversees the improvement of public health. The Care Quality Commission and NICE gained new responsibilities. Furthermore, the Health and Social Care Act introduced Local Health and Well-being Boards as well as national and local Healthwatch England groups. Local government is required to take responsibility for commissioning public health services.¹

Health System Organisation for Prevention

The most important institutions involved in the public health organisational structure are:

• Department of Health and Social Care (DHSC);
• National Health Service;
• Public Health England;
• Local Authorities (LA) (including the Health and Wellbeing Boards);
• Clinical Commissioning Groups.

The DHSC is responsible for some United Kingdom-wide health regulatory matters and international collaboration where it represents the whole United Kingdom (e.g. in dealings with EU or UN agencies). The Department of Health also regularly meets with its counterparts in the devolved administrations in Scotland, Wales and Northern Ireland.¹ The Department is also directly responsible for issues specifically concerning the health system in England. In fact, it is responsible for setting policies for the health and social care system in England. Moreover, the Secretary of State for Health (the head of the Department of Health, holding responsibility for the National Health Service) has overall financial control and oversight of all NHS delivery and performance, and is accountable to Parliament for the health system, including Public Health England. Following the 2012 Health and Social Care Act, the Department is no longer responsible for the direct delivery of NHS services. Instead, its focus is on:¹

• setting national priorities and monitoring the performance of the whole system so as to ensure it delivers what patients, people who use services and the wider public need and value most;
• setting budgets across the health system, including for PHE;
• setting objectives for PHE;
• supporting the integrity of the system by ensuring that funding, legislation and accountability arrangements protect the best interests of patients, the public and the taxpayer;
• accounting to Parliament for PHE’s performance and the effectiveness of the health and care system overall.²

In the context of the DHSC, there are some bodies that have a regulatory role, namely the Care Quality Commission (CQC) and Monitor in England, the National Institute for Health and Clinical Excellence (NICE), and the Medicines and Healthcare Products Regulatory Agency (MHRA). Another highly relevant agency in the structure of the English public health system is Public Health England, created in 2013 as an executive agency within the Department of Health. PHE’s role in public health management is defined in the document “Strategic plan for the next four years. Better outcomes by 2020” published in April 2016.³ It serves an important advisory role to the Government and runs the national health protection service (also coordinating the response to defined emergency situations). It also supports the public in improving their own health, conducts research on public health problems and shares its expertise with the NHS, local authorities and industry so they can contribute to improving population health.¹

A Chief Executive appointed by the DHSC Permanent Secretary is responsible for leading PHE. He is supported by an Advisory Board and has established a National Executive to support him in delivering PHE’s objectives. A Senior Departmental Sponsor (SDS) acts as PHE’s designated point of contact within the DH. The SDS is currently the Director General for Public Health and is responsible for setting PHE’s priorities. Basing on these stated priorities, PHE prepares a three-year corporate plan that describes its longer-term aim and objectives, sets out a strategy for achieving them, provides a framework for monitoring their progress and forms the agreed basis for detailed planning. PHE has a relationship with NHS providers through its roles on data collection (e.g., registration and surveillance of disease) and quality assurance of services (e.g., cancer and non-cancer screening programmes).²

In England, the local authority (or local council, the most common type of authority) is responsible for directly buying or providing the public health and promotion services at local level.⁴ The day-to-day running of the authority is the responsibility of the paid employees, that is, the chief executive, the directors of each service area and the council officers.

Public Health England, in the person of the Chief Executive who is the Accounting Officer, provides a public health grant to local authorities to support every authority in fulfilling its duty to improve the public’s health. Moreover, PHE provides evidence and knowledge on local needs to support local authorities and can promote national actions when appropriate for specific public health situations. A specialist director for public health (DPH), appointed from the local authorities jointly with the Secretary of State for Health, in practice Public Health England, is accountable for the delivery of the services required from local authorities. The director of public health, who also has a role on the Health and Wellbeing Board, must be a public health specialist, with highly developed technical skills, and with access to a range of public health expertise in his or her team. In general, the statutory responsibilities of the DPH are designed to match exactly the corporate public health duties of the local authority. The exception is the annual report on the health of the local population – the DPH has a duty to write a report, whereas the authority’s duty is to publish it.⁵ The DPH leads a specialist public health team.

Since the introduction of the Health and Social Care Act in 2012, primary care services have been attributed to 221 Clinical Commissioning Groups, led by general practitioners, which replaced the primary care trusts. These new bodies have more control over decisions about spending, as GPs see patients more regularly than other healthcare providers and so theoretically have a better understanding of their needs.

Clinical Commissioning Groups (CCG) deal with urgent and emergency care, elective hospital care, community health services, mental health services, pharmaceuticals, maternity, newborns, and children’s healthcare services. These services are commissioned to a range of providers such as public hospitals and community and mental health providers, including those from the voluntary and private sectors, provided these are registered with a regulating body. Where clinical commissioning groups commission primary care services, in order to avoid conflicts of interest, they do so with NHS England, as local GPs are both purchasers and providers. Part of the budget assigned to the CCG is not ascribed to a specific field of expense, so there is an incentive to reduce costs. There are also a number of bodies that serve as support for CCG in purchasing, such as commissioning support units, strategic clinical networks and multi-professional advisory groups (Clinical senates).

Finally, the UK National Screening Committee advises ministers and the NHS in the four UK countries about all aspects of screening and supports implementation of screening programmes.

Delivery of Prevention Health Care Services

The delivery of health services is the responsibility of NHS England. This executive non-departmental body oversees the delivery of NHS services and is responsible for the contracting and purchasing of primary care health services, as well as some nationally-based functions previously undertaken by the Department of Health.¹ The NHS performs a critical role in the delivery of some important public health services, in strict cooperation with PHE. This includes ensuring that the prevention of diseases and improvements in the nation’s health are systematically addressed across services.

Public Health England works to improve and manage health protection. The central elements of public health are: health protection programmes (immunisation, etc.), health improvement programmes (smoking cessation, etc.) and reducing health inequalities. Public health priorities for all of the United Kingdom include: alcohol harm, childhood obesity, health inequalities, infant mortality, response to sexual violence, sexual health, teenage pregnancy, tobacco control, vaccination and immunisation, and the mental health and psychological well-being of young people.¹

Health promotion and health protection, among others, are the responsibility of local authorities: these entities are required to provide a small number of mandated services, but are otherwise free to set their own priorities, working with local partners, through Health and Wellbeing Boards.²

The Government intends to mandate a small number of steps and services, as follows:

• steps to be taken to protect the health of the local population;
• ensuring NHS commissioners receive the public health advice they need;
• appropriate access to sexual health services;
• the National Child Measurement Programme;
• NHS Health Check assessment.

In particular, local authorities are responsible for immunisation and screening programmes that are performed in schools, such as human papilloma virus vaccination (under the local authority but performed by the NHS), chlamydia screening (which can be performed in colleges or sexual clinics, which are under local jurisdiction) and the National Child Measurement Programme (one of the six screening programmes aimed at children in the antenatal and postnatal period).⁶ Moreover, local authorities work closely with all the other actors involved in public health. The Health and Wellbeing Boards, established by the Health and Social Care Act, are a focus for improving the health of the local population and closing the gap between health and social care. These Boards are created by local authorities and also include representatives from the NHS, public health, adult social care, children’s services and Healthwatch. These local groups can in fact best address the needs of the population.¹

In the specific field of public health, the NHS is responsible for delivering, through CCG and GPs, the majority of immunisations for children and adults.⁶

As regards screening programmes, every person regularly registered with a GP is automatically contacted at the stated age to enter appropriate programmes, based on lists derived from the local register of individuals who are registered with the NHS. The registers are known as the Exeter system.⁷

Specific screening offices are responsible for the invitation letters and screenings are performed both in the community health setting and in hospitals.

Currently, numerous efforts have been made in the field of primary prevention, where the NHS has launched a triple prevention strategy involving patients, staff and the public.⁸

Financing of Prevention Services

In the United Kingdom, the primary source of funding for health is public (79.4%). Private medical insurance and out-of-pocket payments, as co-payments or direct payments, cover the rest of the funding for health care. In 2016, out-of-pocket payments represented 15.1% of total health expenditure while voluntary health insurance accounted for 3.3%.⁹

Her Majesty’s Revenue and Customs (HMRC) collects most of the tax revenue, for example income tax, value-added tax (VAT), corporation tax, excise duties (on fuel, alcohol and tobacco) and National Insurance Contributions from the earnings of all employers, employees and self-employed people in the United Kingdom. After collection, the funds are pooled at national level. Taxes are not earmarked for a specific aim so National Insurance Contributions are not the only source of funding for the NHS, but about 10% of National Insurance Contributions are put towards NHS funding.^1,10

In England, the Department of Health allocates health funds to NHS England, which distributes them using weighted capitation to clinical commissioning groups, led by general practitioners, as well as to specialist and primary care services. The requirements of each clinical commissioning group population are established on the basis of input costs (such as staff and building expenses), age social factors (such as deprivation) and measures of health status as defined by the Advisory Committee on Resource Allocation.¹⁰ The Payment-by-Results system and Pay-for-Performance were introduced to improve quality and efficiency of healthcare. In England, clinical commissioning groups (CCGs) and the NHS are the third-party payers. The former purchase mental health and community health services from public and private service providers while the latter negotiates contracts for most primary care services and specialist services.¹

Local authorities are provided a ring-fenced grant from PHE. Local authorities have considerable freedom in terms of how they choose to invest their grant to improve the population’s health, although they must have regard to the Public Health Outcomes Framework.

As reported in “Statistical bulletin: UK Health Accounts: 2016”, Government spending funded about three-quarters (75.8%) or £7.8 billion of total prevention care spending in 2016. A further £1.3 billion was financed through out-of-pocket expenditure, with £0.8 billion spent through enterprise financing, mainly on occupational healthcare and hospital screening. Voluntary insurance accounted for £0.2 billion, mainly preventive dental activity such as check-ups and hygienist visits funded through dental capitation schemes. In 2016, expenditure on preventive healthcare was about £10.3 billion (5.4% of total healthcare expenditure in 2016), which shows an increase of 5.3% compared to 2015, when total expenditure on preventive healthcare was £9.8 billion.⁹

Workforce in Prevention Services

The NHS is the largest employer in the United Kingdom and in the last few years there has been a consistent increase in the health workforce as a consequence of increasing health demand.¹

PHE, the main public institution responsible for public health, delivered a broad range of products and services in 2016 and employed 5,522 staff, as described below:

• 2,272 in protection from infectious diseases;
• 486 in protection from environmental hazards and emergency preparedness;
• 1,010 employed in local centres and regions;
• 316 in the field of knowledge intelligence and digital and research;
• 319 in the national disease registration field;
• 273 involved in developing and assuring quality of screening programmes;
• 202 as national experts in public health evidence-based interventions in Health and Wellbeing and strategy;
• 10 in nursing;
• 65 in the health marketing field;
• 37 in global health, maintaining and developing relationships with the WHO and other international and national public health agencies;
• 532 business support professionals.

Furthermore, all the personnel who are involved in the delivery of prevention should be considered. This includes primarily the GP workforce and their co-workers, such as nurses, who are responsible for providing a number of prevention services to the population in cooperation with Local Health Authorities and other local institutions. In the same way, several actors are engaged in organising and delivering screenings, both in screening offices and in community health settings and in hospitals.

Conclusions and Outlook

“Prevention is better than cure” – this is the aphorism that seems to have inspired the DH and NHS England over the last few years, guiding their reforms and programmes in order to meet the progressive increase in health needs and demands in a context of financial constraints. Consequently, with a view to achieving fiscal sustainability for the health system, several moves have been implemented, such as the institution of Public Health England, an executive agency within the DH aimed at protecting and improving the nation’s health and wellbeing and reducing health inequalities, as well as a number of policies and programmes designed to increase public awareness about the importance of primary prevention. As a result, the United Kingdom seems to be more attentive to this theme now compared to the past, but a lot of work must be done in the next few years to ensure sustainability and a healthy population. However, is not clear who the actors involved in preventive services of United Kingdom are, and what their roles are in this situation, because, even with the accountability and transparency of English institutions, prevention activities are wide-ranging among different services and levels of care. This could be a strength in terms of an integrated system where the individual accountability of an organisation is substituted by accountability covering all service providers in a zone, with mutual, fixed responsibility over their population and capitated, pooled budgeting.⁸

References

1. Cylus, J., Richardson, E., Findley, L., Longley, M., O'Neill, C., & Steel, D. 2015. United Kingdom: Health System Review. Health Systems in Transition, 17 (5), 1-126.
2. Framework Agreement between the Department of Health and Public Health England. London: Public Health England; 2013.
3. Strategic Plan for the Next Four Years. Better Outcomes by 2020. London: Public Health England; 2016.
4. Eaton K, Varsamis, D. Joint Action on Chronic Diseases and Promoting Healthy Ageing across the Life Cycle Good Practice in the Field of Health Promotion and Primary Prevention United Kingdom (Other than Northern Ireland) Country Review; 2013.
5. Directors of Public Health in Local Government i) Roles, Responsibilities and Context. Department of Health; 2013.
6. The New Public Health Role of Local Authorities. Public Health in Local Government. Department of Health; 2012.
7. Briggs P, Gray S, Patnick J, Blanks R. 2002. Organising a Breast Screening Programme. NHSBSP Publication No 52. Hoddesdon.
8. Maruthappu M. Delivering Triple Prevention: A Health System Responsibility. 2016 Lancet Diabetes Endocrinol. 4 (4): 299-301. doi: 10.1016/S2213-8587(16)00073-5.
9. UK Health Accounts: 2016 – Office for National Statistics. 2018. Available from: https://www.ons.gov.uk/releases/ukhealthaccounts2016 [Accessed 7^th September 2015].
10. Boyle S. 2011. United Kingdom (England) Health System Review. Health Systems in Transition, 13 (1).