The background to this book was a research study that took place in 2021 and 2022. It sought to understand the circumstances surrounding the abolition of the main institution responsible for public health in England – Public Health England (PHE) – and its replacement by the UK Health Security Agency and the Office for Health Improvement and Disparities. As well as collecting data from published reports, national and parliamentary committee meetings and interviews, we also collected information on the structure of public health governmental organisations in the UK. The main study findings can be found here: https://arc-sl.nihr.ac.uk/sites/default/files/uploads/files/public-health-report-sept-2022-final.pdf (Littlejohns et al, 2022c).

The relevant issues that emerged as we described how PHE was closed can be found in a paper we published in Health Economics Policy and Law (Weale et al, 2023).

While the reasons were complex, they could be summarised by two competing interpretations: an ‘official’ explanation, which highlights the failure of PHE to scale up its testing capacity in the early weeks of the COVID-19 pandemic as the fundamental reason for closing it down; and a ‘sceptical’ interpretation, which ascribes the decision to blame-avoidance behaviour on the part of leading government figures. We reviewed crucial claims in these two competing explanations, exploring the arguments for and against each proposition. We concluded that neither was adequate and that the inability to address the problem of testing (which triggered the decision to close PHE) lies deeper, in the absence of the norms of responsible government in UK politics and the state. However, our findings did provide some guidance to the two new organisations established to replace PHE to maximise their impact on public health.

We then continued our thinking of what was required and presented a flavour of it in a Lancet Public Health Viewpoint article by Hunter, Littlejohns and Weale on ‘Reforming the public health system in England’ (Hunter et al, 2022).

We came to the conclusion that a completely new way of thinking about public health was required, and that would only be achieved by establishing a new social contract with the British people.

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).

Introduction

As we saw in the previous two chapters, the UK now has a new public health settlement. As far as England is concerned, in place of Public Health England (PHE), there are now two bodies, the UK Health Security Agency (UKHSA), with primary responsibility for health protection, and the Office for Health Improvement and Disparities (OHID), with primary responsibility for health promotion. (UKHSA also has responsibility for non-devolved health matters for the whole of the UK.) In addition, the administrative structure of the NHS has been altered with the establishment of integrated care systems (ICSs) intended to bring together local authorities, the NHS and other agencies with the intention of taking a population-based perspective. The one part of the original 2013 Lansley reforms that survived these changes concerns the public health responsibilities of local authorities.

The English reforms have been high-profile changes. Developments in Scotland, Wales and Northern Ireland, while significant, have largely involved a concentration of public health responsibilities over time as part of planned changes to administrative arrangements. In each case, however, the direction of change is the opposite of what has occurred in England. Instead of a separation of health protection and health promotion, the devolved governments have created integrated bodies. These bodies still have to liaise with local government, but they do so from a position in which public health can be seen as a set of overall responsibilities.

This chapter focuses on the policy and process issues to which these new structures give rise. The Hancock reforms, like many machinery of government changes, underline the point that, in some circumstances, organisational arrangements become the prime object of policy. Reorganisation provides a way of deflecting blame and also a way of seeming to make a new start quickly and visibly. Moreover, machinery of government changes are attractive to high-level political representatives, since they signal interest in an area of policy without the need to go into detail about any one aspect of policy. Thus, the political attraction of reorganisation is that it makes the politician play the role of God in eighteenth-century Christian theology, whose responsibility was to create the system that would then look after itself, according to its own laws. However, successful policy must go beyond the establishment of new organisations.

Introduction

In the previous chapter we saw how Public Health England (PHE) was the product of the Lansley broader reforms of the NHS, reforms that also included the return of public health functions to local government. A notable feature of the transformation of the UK since 1998 has been the extension and devolution of powers from Westminster and Whitehall to Scotland, Wales and Northern Ireland. Devolution means that in areas of policy that are not reserved to the UK government, which in health policy are very few, the governments of the home nations have the freedom to determine their own policies, priorities and structures. This has been notably true in the provision of health care services, where the Welsh, Scottish and Northern Ireland governments have opted for greater stability in place of successive structural reforms, and have not made competition and performance management a central guiding principle as the UK government has done to an increasing degree since the Thatcher reforms. However, the distinctiveness has also shown up in public health policies and structures.

Looking at public health in the devolved governments is important for a number of reasons, quite apart from the simple need to avoid Anglo-centrism. In the first place, the organisation of public health in the devolved governments provides interesting points of similarity and difference to those in England. If the replacement of PHE took place without any forethought, the same is not true in the other home nations where, in keeping with health care services, there has been great stability of organisation, alongside policy developments. So patterns of structural organisation provide interesting evidence of the various ways in which public health functions can be organised. As we shall see in this chapter, there is no one uniform set of functions that are the responsibility of the public health bodies. Functions that are the responsibility of a public health agency in one of the home nations may be the responsibility of, say, the environment agency of another home nation.

Variation in the home nations in the organisation of public health also potentially poses another challenge to effective public health. If public health requires intersectoral collaboration across government, the conduct of policy in the UK requires collaboration across the governments of the home nations.

Chapter 1 laid out the challenges of public health together with the intrinsic dilemmas and conflicts involved in making health truly public. The source of those dilemmas is to be found in the fact that public health identifies many sources of ill health in the determinants that are formed in complex social and economic systems. Ill health is the effect of multiple causes. In terms of governmental organisation, this means that a public health body must interact with a wide range of agencies and sectors across government. However, it also means that any such interaction needs to be based on a strong and well-resourced core of public health bodies, at different levels of government, which can identify health problems and formulate effective policies, even when those policies need the cooperation of other departments of state.

In this chapter we look at the history of those core organisations in England between 2013 when Public Health England (PHE) was established by the 2012 Health and Social Care Act, and 2020 when the announcement was made that it was to be abolished. Our aim is to show how the dilemmas and challenges identified in the previous chapter played out during this period. Figure 2.1 summarises the key points in the timeline.

Public Health England

As part of the Lansley reforms affecting the whole health system and not only the NHS, public health was reformed both nationally and locally as set out in a White Paper, ‘Healthy Lives, Healthy People’ (Department of Health, 2010), and subsequently in the Health and Social Care Act 2012. PHE was established as an executive agency to provide national leadership for public health, while locally the lead responsibility for public health returned to local government, where it had been located prior to the 1974 NHS reorganisation. Although separate from the Department of Health (now the Department of Health and Social Care, DHSC) and organised into regional outposts, from the outset PHE lacked the independence accorded to some other national bodies, notably the National Institute for Health and Care Excellence (NICE). As a civil service agency rather than an arm’s-length body, it remained part of the central DHSC.

We have argued that there is a fundamental puzzle at the heart of the public health crisis that now faces the UK. Although the problems are large, there are many policy measures capable of addressing them that are highly cost-effective and for which there is robust evidence. The importance of these measures has been recognised for decades by informed commentators on health services, the latest example of which has been the creation of integrated care systems (ICSs) and the proposals from the Hewitt Review for government to give a lead in prioritising preventive measures. Unless government implements these measures, the burdens on the NHS will increase, forcing an increasing rationing of medical care among the sick. To be sure, the administrative and governance barriers to action can be formidable. The measures require interorganisational collaboration, never easy for any organisation let alone governments, and an ability at the heart of government to think long-term. The measures also require being explicit about the trade-offs, including the trade-off between more private consumer spending and greater public health protection, that are involved in making health truly public. They require addressing the commercial determinants of health, strengthening and supporting those commercial activities that promote health and regulating and disincentivising those commercial activities that harm health. In short, the challenges of public health require a relentless focus on implementation and policy learning, with firm political leadership to ensure that measures are put into practice and the organisational barriers to public policy coordination overcome.

In this context, the focus on finding one right organisational structure displayed in the abolition of Public Health England (PHE) is inadequate. The view, expressed by Matt Hancock as Secretary of State, that the creation of the UK Health Security Agency (UKHSA) in place of PHE would be sufficient to avoid a repeat of the failures to upscale testing and tracing on the part of PHE was an example of naive ‘if only’ thinking, resting on the assumption that if only PHE had been like the Robert Koch Institute all would be well. Yet distinguished witnesses to the Covid-19 Inquiry, like Sir Chris Whitty and Sir Patrick Vallance, suggested the failures of PHE were the results of successive public underfunding, such that the UK was left without adequate stocks of personal protective equipment or the facilities to manufacture vaccines.

This chapter begins by engaging with debates about class and identity, paying particular attention to the concept of habitus. This permits me to then consider how middle-class identities are positioned as synonymous with authorized ideas of individuality. I then mobilize these conceptual tools in order to evaluate sociology of consumption literature and more specifically the consumption of food. Here, I engage with the cultural omnivore thesis to locate food consumption within increasingly fragmented dynamics of taste. The final section of the chapter engages with literature which accounts for the material and symbolic ways in which food comes to be incorporated into the home. The chapter concludes by focusing on the relationship between time, domestic practice and gender. This provides the foundations from which to consider how eating and feeding others in the domestic sphere relates to classed and gendered performances of authorized identities.

Class and identity matters

In the 1990s, sociology underwent a retreat from class. Materialist approaches to class analysis which focused on the division of labour were increasingly posited as redundant, and the fragmentation associated with post-industrialization meant that traditional understandings of class composition were being transformed. With the apparent decomposition of collective categories came theoretical ideas about reflexive individualism and the argument that structural moorings, such as class, were no longer a relevant category of analysis for investigations of inequality. As Beck argued ‘the notion of a class society remains useful only as an image of the past’ (1992: 91). Instead, inequality was increasingly understood as an individualized project: ‘the inequality of dealing with insecurity and reflexivity’ (1992: 98; italics original).

In recent years there has been a move to reinstate the importance of class in British sociology by incorporating the interplay between economic, cultural and social resources. For instance, the Great British Class Survey’s attempt to drive forward a multidimensional way of thinking about class was met with overwhelming popularity when seven million people clicked on the BBC’s ‘Class Calculator’ within a week of its launch (Savage et al 2015). Clearly, class positioning is a keen point of intrigue to fractions of the British public, but it is also a contentious topic.

The interpretations which form the basis of this book are based on rigorous analysis of visual and verbal data co-produced in domestic settings. Of course, had someone else with contrasting experiences and perspectives interpreted the data, a different story could have emerged. But social research cannot claim to uncover a single objective and universal truth; there is always more than one version of the story.

The story this book tells is about the intimate ways that class is connected, through food, to identity and the home. I have recounted data which starts from participants’ childhoods and traced their journeys into the established households in which our research conversations took place. From this vantage point, I learnt about the ways in which respondents incorporate food and ideas about food into their homes to arrive at the point of eating. I have looked towards everyday practices of domestic food provisioning with the aim of understanding how in middle-class settings some foods and modes of eating are valued and normalized, while others are implicitly and explicitly rejected and othered. This sample of 27 self-selected participants residing in the North East of England is by no means representative of the British ‘middle classes’. However, I contend that these small-scale domestic interactions have implications for a broader understanding of the relational ways that class both provides access to particular ways of eating and reproduces eaters who participate in very specific ways of valuing ‘good’ food. In this final chapter, I gather together the themes which have emerged in this book to offer a concluding discussion about the broader implications of taste, middle-class identities, and domestic food provisioning in contemporary Britain.

Reflexive identities

Ingrid: I apologize that The Archers has just come on (laughs). It sounds so middle class (laughs).

KG: I remember now you said you listened to the Archers while you had your tea (laughs)

Participants were recruited for this research based on my assumptions that they were located in middle-class social positions. Interview talk highlighted the contested ways that participants related to their class position. Reflecting research which highlights the ambiguity of class belongingness (Savage 2000; Friedman et al 2021), overall participants struggled against social categorization, specifically as being seen as middle class in any straightforward way.

The previous chapter explored how tastes (and distastes) in food can be ways of situating the self in relation to another. This chapter looks at the enactment of food choices to examine how classed identity is articulated through doing. Participant biographies drew on notions of abundance and diversity in relation to food availability suggesting that the processes of food choices warrant further analysis. In light of this, I now examine the relationship between choice and the classed positioning of ‘good’ food within the contemporary food terrain. By focusing on practice, I relate the doing of choice to a complex and manifold set of routines, habits, preferences, and systems. I argue that the detailed ways in which participants choose from options to feed themselves and their households can act as a signpost to how they construct their sense of self, both individually and the household as a collective. Therefore, I explore the work done at a household level to manage choice, and the knowledge and skills which inform everyday investments. I scrutinize how these processes reproduce contextualized norms of middle-classness. This forms the basis for the following chapter, which picks up on this relationship in order to analyse participant enactment of familial relationships via food in the home.

To start the chapter, I turn my attention to the ways in which participant understandings of ‘good’ food are grounded in an attempt to ‘decommodify food’ (Wilk 2006: 20; italics original). That is, through the process of cooking and preparing food, participants infuse food with personal, cultural, and social value. The value of food, however, stretches well beyond the immediate domestic work of cooking and preparing food, because it embodies a complex symbolic and material work of controlling and selecting the food which crosses the domestic threshold. I therefore draw on participant experiences of the marketplace to explore these processes of domesticating food. I note that participants’ enactment and resistance of certain processes potentially constructs them as critical and discerning consumers. This is fraught with conflict however as the narratives of the most harried participants of the sample suggest.

The kitchen

To start, I want to first pay attention to how the kitchen functions as a central domestic space for the making and doing of ‘good’ food. Most first interviews and all second interviews occurred in kitchens.

Food is a biological necessity; we need to eat to live. But living through food extends beyond sustaining our bodies with the nutrients it provides. The materiality of food also sustains a range of social and cultural arrangements, including relations of power. What we eat, or not, carries social messages about social categories such as nationality, gender, ethnicity, and class and as such is central to our identity. While some things are naturally inedible, some things are culturally and socially disgusting.

This book is about food and class, the middle classes to be more specific. Consider these two narrative descriptions. They come from two of the 27 middle-class participants who contributed to this study. I had asked them if they could talk me through the contents of their refrigerators. At face value, they appear to be just that: lists of foods in a fridge. However, closer scrutiny of these descriptions lays bare a whole range of wider social and cultural processes and meanings. Starting with Fiona, we learn that she buys black pudding for her partner, despite her distaste for it, and that she is open to trying new foods. We learn that while her fridge contains several global foods, which she confidently lists, she questions the presence of pre-packaged sweet chilli stir-fry sauce. She concludes the narrative by jokingly pointing towards a bottle of champagne. With Jane, we learn that she differentiates between cow’s milk, which ‘doesn’t feel right’, and cheese, which she happily eats despite the obvious contradiction. We learn that she enjoys baking and spends time on it – the feeding of the sourdough starter is a continual process. What is particularly interesting is that the descriptions Fiona and Jane employ, position the foods listed as ordinary. They are ‘just the usuals’, as Jane suggests. Throughout this research, I was shown a range of household foods, some of which were expensive and specialist and required specific culinary knowledge and commitment. But despite these foods being anything but ordinary, their positioning as unremarkable highlights the salient ways that food practices can be normalized. I want to explore how class is implicated in this process.

This chapter speaks to debates around notions of individualism, reflexivity and choice. It has two main foci. First, I show how the centrality of individuality in participant narratives reproduces (classed) ideas that individual and reflexive food consumption is central to the makings of identity. A theme of not belonging to collective categories such as class, emerges across the sample, but the repeated pattern of distancing from group belongingness I see as indicative of some form of collective recognition which operates around the notion of being individual. From this, I suggest that participants’ propensity to narrate a position of individuality can be situated within a broader discursive framework of consumerism within which notions of individual choice dominate. Second, I place theoretical emphasis on practices and dispositions as a manifestation of a continual ‘point of suture’ (Hall 1996: 6) between the self and (classed) social position. I consider participant biographical data through a sociohistorical lens, noting that going to university, travelling and establishing households emerged as key moments in coming-of-age food stories. Drawing on participant narratives of mobility, I note that personal transition points involving the acquisition of capital often go hand-in-hand with encountering, and honing, understandings of ‘good’ taste. Regardless of chronological age, what emerges from these stories is that the expansion of tastes is understood as a consequence of globalization and relatedly, the increase of diversity, abundance and choice in the field of food consumption. Considering participants’ experience of taste expansion in a broader social context, I question the extent to which a consumerist ideology, which stipulates the centrality of individual choice, impacts on their orientations towards consuming diversity.

Unique identities

Before exploring how food features in life histories, I want to first unpick how participants ‘see’ themselves as classed (or not). I have noted previously that class is a contentious concept. This is not limited to the conceptual realms of sociological debate. Participant narratives about class highlight the conceptual slippiness and fuzziness of class, despite it being employed (or variations of the term) in everyday contexts as what follows will show. I asked about class at the end of the first interview and many participants offered lengthy responses.

Bourdieu argued that taste in food ‘reveals the deepest dispositions of the habitus’ (1984: 190). Taking this as a starting point, this chapter explores how taste is not merely a matter of individual preference and choice, but a reflexive accumulation of generative learning. That is, orientations to food are continually learnt. I look to the past, present and future to explore how the sample mobilized learnt attitudes via familial social relationships alongside a disposition to gather and accrue capital as a means to do ‘good’ food.

The participants I worked with clearly appeared to prioritize the strategic importance of setting up intergenerationally produced foodrelated dispositions. I consider how the parents in the sample construct narratives around the importance of instilling ‘good’ food habits in their children. This social training centres on delivering children a healthy and diverse spectrum of foods. Yet, there are tensions in participant framings of ensuring their children are open to all foods and encouraging a disposition to make discerning choices clearly emerges as valued. In an era where childhood obesity is often moralized as a literal embodiment of bad parenting, the ways in which participants prioritize the production of ‘healthy’ children can be read as a reflection of their identity as parents. To elaborate on this further, I look towards the household meal, since it figures in so many narratives as an occasion where participants seek to ‘do’ family. I demonstrate how the socially constructed ideal of the family meal appears as a backdrop against which participants navigate between controlling, managing, and encouraging diverse tastes via the sociality of eating. Building on literature which frames the household meal as an occasion for the production, and display, of family, I show how participants negotiate everyday temporal constraints to stage household meals in order to reproduce notions of good taste via the exchange of food in a very particular domestic setting.

Embodied knowledge

I want to start this chapter with a glance towards public health messaging to consider how participants make sense of and engage with health as embodied individuals and how knowledge is situated in relation wider discursive frameworks about the performance of valued identities through food.