There is now general agreement that the UK is facing a public health crisis. Improvements in life expectancy have stalled, health inequalities are continuing to widen, obesity and alcohol misuse are placing an increasing strain on health services, and urban air pollution is now widely recognised as a serious health hazard. However, consensus on possible solutions is absent. COVID-19 revealed the weaknesses of the UK’s public health system – once thought to be among the best in the world. While we are still waiting for the official Covid-19 Inquiry to report its findings, an increasing number of studies are demonstrating where the problems lie – not only in infectious disease control but more generally in public health. Our own research study took place in 2021 and 2022, and sought to understand the circumstances surrounding the abolition of the main institution responsible for public health in England – Public Health England – and its replacement by the UK Health Security Agency and the Office for Health Improvement and Disparities. The publications that emerged from that original study are detailed in an appendix.

Our findings convinced us that what is urgently needed is much broader than simply targeted interventions. A fundamental public policy debate is necessary to stimulate interest in the vital importance of public health and a new approach initiated. We have come to the conclusion that a completely new way of thinking about public health is required, and that would only be achieved by establishing by a new social contract for the UK population. We are not alone in thinking that fundamental change is required. The Institute for Public Policy Research (IPPR, 2023) recently published its first interim report on health in the UK, advocating a new Health and Prosperity Act supported by a Committee on Health and Prosperity – modelled on the Climate Change Committee and designed to independently advise on the above mission (and hold all governments accountable to it).

Our book does not try to revisit all the theories and initiatives to improve public health but explores some of the fundamental barriers and why interventions (even those based on good evidence) are not adequately implemented. We address several key political and governance issues around the social contract idea. We build on the thinking outlined in the history of public health by David Hunter et al, The Public Health System in England (Policy Press, 2010).