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Introduction
One of the greatest challenges facing societies in the 21st century is the changing burden of disease, with a shift from communicable to non-communicable diseases affecting countries at all levels of development.1 Chronic diseases pose a particular challenge to public health systems because of their multifactorial nature and frequently strong links to lifestyle-related factors such as smoking, diet, alcohol use, and physical activity. Persisting health inequalities are of particular concern, with people disadvantaged because of education, income, or social position less likely to participate in healthy behaviours.2 In the UK, the annual report (volume one) of the Chief Medical Officer (CMO), published in 2012,3 highlighted the co-occurrence of health risk factors, with people living in deprived areas tending to have higher rates of multiple risk factors than those living in more affluent areas. Deprivation is also associated with a larger burden of chronic disease and, in particular, multimorbidity, including mental health disorders.4 This pattern of health inequality is noted internationally.5
Against this background, the approach to improving the public's health needs to be revisited. We reassessed the framework proposed by Hanlon and colleagues,6,7 who have argued that it is time for a new wave in public health, and have called for others to join the debate about the form that this next wave might take. They have traced the evolution of public health improvement in the UK from the industrial revolution to the present. To illustrate this evolution, they used the metaphor of a series of waves, reflecting major shifts in thinking about the nature of society and health (panel ).
In the UK context, debate about the form of the next wave is particularly timely in view of the changing public health system, with the formation of Public Health England and the movement of many public health functions to local government. Public Health England is an executive agency of the Department of Health that is tasked with the protection and improvement of the nation's health and with addressing inequalities.
In this paper, we aim to contribute to the debate encouraged by Hanlon and colleagues.7 We begin by briefly outlining our interpretation of the evolution of public health practice in the UK, drawing on what...