University of Liverpool, Public Health and Policy, Psychology, Health and Society, 2nd Floor Block B Waterhouse Buildings, Liverpool L69 3GL, UK.
BMC Public Health. 2011 Oct 20;11:821. doi: 10.1186/1471-2458-11-821.
The public health system in England is currently facing dramatic change. Renewed attention has recently been paid to the best approaches for tackling the health inequalities which remain entrenched within British society and across the globe. In order to consider the opportunities and challenges facing the new public health system in England, we explored the current experiences of those involved in decision making to reduce health inequalities, taking cardiovascular disease (CVD) as a case study.
We conducted an in-depth qualitative study employing 40 semi-structured interviews and three focus group discussions. Participants were public health policy makers and planners in CVD in the UK, including: Primary Care Trust and Local Authority staff (in various roles); General Practice commissioners; public health academics; consultant cardiologists; national guideline managers; members of guideline development groups, civil servants; and CVD third sector staff.
The short term target- and outcome-led culture of the NHS and the drive to achieve "more for less", combined with the need to address public demand for acute services often lead to investment in "downstream" public health intervention, rather than the "upstream" approaches that are most effective at reducing inequalities. Despite most public health decision makers wishing to redress this imbalance, they felt constrained due to difficulties in partnership working and the over-riding influence of other stakeholders in decision making processes. The proposed public health reforms in England present an opportunity for public health to move away from the medical paradigm of the NHS. However, they also reveal a reluctance of central government to contribute to shifting social norms.
It is vital that the effectiveness and cost effectiveness of all new and existing policies and services affecting public health are measured in terms of their impact on the social determinants of health and health inequalities. Researchers have a vital role to play in providing the complex evidence required to compare different models of prevention and service delivery. Those working in public health must develop leadership to raise the profile of health inequalities as an issue that merits attention, resources and workforce capacity; and advocate for central government to play a key role in shifting social norms.
英国的公共卫生系统目前正面临着巨大的变革。最近，人们重新关注了应对英国乃至全球社会中根深蒂固的健康不平等问题的最佳方法。为了探讨英国新公共卫生系统所面临的机遇和挑战，我们以心血管疾病（CVD）为例，研究了参与减少健康不平等决策的人员的当前经验。
我们进行了一项深入的定性研究，采用了 40 次半结构化访谈和 3 次焦点小组讨论。参与者是英国 CVD 公共卫生政策制定者和规划者，包括：初级保健信托和地方当局工作人员（各种角色）；全科医生委员会；公共卫生学者；顾问心脏病专家；国家指南管理者；指南制定小组的成员、公务员；以及 CVD 第三部门工作人员。
NHS 的短期目标和结果导向文化以及实现“少花钱多办事”的动力，加上满足公众对急性服务的需求，往往导致对“下游”公共卫生干预措施的投资，而不是最有效地减少不平等的“上游”方法。尽管大多数公共卫生决策者希望纠正这种不平衡，但由于合作伙伴关系的困难和其他利益相关者在决策过程中的主导影响，他们感到受到限制。英格兰拟议的公共卫生改革为公共卫生摆脱 NHS 的医疗模式提供了机会。然而，这也揭示了中央政府不愿意为改变社会规范做出贡献。
至关重要的是，所有影响公共卫生的新政策和现有政策和服务的有效性和成本效益都需要根据其对健康和健康不平等的社会决定因素的影响来衡量。研究人员在提供比较不同预防和服务提供模式所需的复杂证据方面发挥着至关重要的作用。公共卫生工作者必须发展领导力，提高健康不平等问题的知名度，使其成为值得关注、资源和劳动力能力的问题；并倡导中央政府在改变社会规范方面发挥关键作用。
