In this blog, Professor Matthew Ashton, Director of Public Health, discusses how whole system public health can spark real change, uniting partners, communities, and evidence to build fairer, healthier places where everyone can thrive.
Sir Michael Marmot often draws a powerful distinction between hope and despair. Despair is when we can describe a problem but have no clear path to address it. Hope emerges when we can articulate a plan grounded in evidence and effective interventions. I would go one step further; ambition is when we put that plan into action.
Public health’s greatest hits were never just solo tracks. Smoking reduction, vaccination rollouts, and maternal health improvements all combined policy, community engagement, and cultural change, delivered through systems that learned, adapted, and persisted.
If we’re serious about tackling today’s “wicked issues”, health inequalities, obesity, mental health, and the social determinants that shape them, then we need to work as systems, not just services. That is the promise of the Public Health Whole System Approach (PHWSA) framework. It offers a practical blueprint to align mission, data, action, governance, equity, and learning across sectors, so health becomes everybody’s business, every day.
Whole-system approaches acknowledge that health is created where people live, learn, work, play, and love, not only in clinics. The WHO Healthy Cities movement sits at the heart of this idea and has done so since 1986: prioritising health-supportive environments, basic sanitation and hygiene, access to care, and the civic, economic, and policy linkages that sustain them.
Over time, Healthy Cities evolved into a strategic vehicle for health, equity, and sustainable development, explicitly positioning health high on the social and political agenda of cities and embedding multisectoral change. That’s not theory; its practice taken up by networks across Europe and beyond, with cities like Liverpool, Belfast, Cork and Galway embedding health into all policies, building city health profiles, and investing in health impact assessments (HIA).
Liverpool’s experience illustrates the approach: long-term political commitment to “health in all policies,” capacity-building for HIA, and a partnership-led change to reduce inequities in some of England’s most deprived neighbourhoods.
Launching PHWSA with intent
Prevention is political: Systems change requires formal political endorsement—and renewal cycles that outlast electoral rhythms. Plan for recommitment every five years to sustain momentum and shield prevention from policy churn.
Collaboration is non negotiable: Integrated Care Systems (ICSs), local government, and the voluntary sector must share power, resources, and influence. The evidence from The King’s Fund and others is clear: partnerships thrive when we move from “power over” to “power with,” recognising VCSE organisations as essential system partners.
Equity is the North Star: Without a deliberate equity lens, systems change risks widening gaps. Recent work in Wales and across public health implementation science reinforces that equity must be operational—shaping priorities, resource allocation, and evaluation.
A whole-system approach is not a slogan; it’s a structured way of working. Based on the work we have done in Liverpool, and on extensive learning from elsewhere, the PHWSA framework comprises sixteen interlinked elements that move a place from issue definition to learning loops: define the wicked issue and shared mission; make it data informed and evidence led; frame health as a social issue; drive multi level action; distinguish quick wins from deep system change; map and mobilise resources; leverage networks; secure political commitment; co design with communities; set up shared governance and accountability; agree outcomes and metrics; craft a compelling narrative; build capacity; plan for sustainability and resilience; apply an equity lens; and establish feedback loops for continuous learning.
These components are not linear stages; they are conditions for change. When pursued together, they create the infrastructure of prevention, the policies, partnerships, culture, and capabilities that make healthier choices easier and more likely across a population, and they change the song titles from “Eleanor Rigby” or “Help, to “”Here Comes The Sun” or “Getting Better”.
From framework to action: a practical sequence
A: Define the wicked issue and mission
Name the problem clearly (e.g., health inequalities or obesity) and articulate a mission that unites partners and communities. Be explicit about the system boundaries (what’s in scope and what’s not).
B: Use data and insight to set priorities
Combine local profiles and national indicators with lived experience. In cities like Liverpool, directors of public health have used health profiles and horizon scanning (e.g., Liverpool 2040) to identify drivers, project future burdens, and align action.
C: Frame health as a social issue
Connect the dots across housing, education, employment, transport, environment, and food systems—exactly the settings focus championed by WHO.
D: Drive multi -level action
- Local: quick wins that build trust (e.g., active travel charters, healthier food access, HIA on major developments).
- Regional: align ICS strategies and pooled resources for prevention. Evidence shows collaboration improves when power is shared and VCSE partners are embedded.
- National: pursue legislative and fiscal levers that shape environments (e.g., HFSS regulation; speed limits to support active travel)—with consistent policy alignment to avoid undermining local progress.
E: Balance quick wins and system change
Visible improvements (campaigns, micro interventions) matter for momentum; but durable gains come from governance, culture shifts, and sustained funding.
F: Build shared governance and accountability
Agree roles, decision-making, reporting, and equity commitments across sectors. ICSs and place-based partnerships need clarity and continuity to navigate reform turbulence.
G: Measure outcomes across health, social, and economic indicators
Track both reach and equity, who benefits, who is left out, and whether gaps are narrowing. Use practical frameworks (e.g. PRISM with an equity lens) to maintain focus on implementation and sustainability
H. Craft the narrative
Plain language stories turn frameworks into movements. WHO’s city leadership guidance emphasises the importance of visible, values-based governance and community participation that keeps health high on the agenda.
I: Invest in capacity
Train leaders and frontline teams in systems thinking, collaboration, data use, and behaviour change. The King’s Fund’s leadership programmes and learning from Healthy Communities Together show how to sustain motivation and shift.
J: Embed sustainability and resilience
COVID 19 showed that shocks are inevitable; whole system prevention must be durable through political, economic, and social turbulence. WHO’s urban health work and Healthy Cities materials stress resilience in governance and environment design.
PHWSA in obesity: Wales as a living laboratory
Wales offers a practical case of whole-system approaches to healthy weight: national methodology, system leads in every health board, nine step guidance, and policy levers that reshape environments (from advertising restrictions to active travel). Local areas, from Powys to Cardiff and Vale, are using system mapping, equity-focused priorities, and cross-agency action plans to make healthy choices more accessible and affordable, particularly for families in the early years.
The lesson: population-level behaviour change emerges when policy, place-making, service design, and communications move together, guided by data and attuned to lived experience.
Politics, partnership, and the equity lens: held together
Governance, collaboration, and equity are non negotiables. A formal political commitment, renewed on a cycle, creates the authorising environment for prevention. Partnerships across sectors shift power and align resources. And an explicit equity lens ensures we reduce disparities rather than reproduce them.
This echoes long-running WHO guidance: healthy cities are defined by processes, not outcomes; participation, prosperity, planet, and place matter as much as people. The system is the intervention.
The power of narrative: making prevention a shared story
Public health’s historic successes were cultural as much as clinical. The stories we tell, about fairness, opportunity, and the environments that shape everyday choices, build movements that outlast programmes. WHO’s city leadership work and the King’s Fund’s insights on collaborative leadership remind us: when people see themselves in the mission, they contribute, persist, and innovate.
A call to action
If prevention and equity are inseparable, then system change is our only path forward. The PHWSA framework provides the scaffolding; Healthy Cities provides a living model; and places like Liverpool show how to turn commitment into practice, learning, and progress.
The time to act is now
Begin by clearly defining the wicked issue you want to tackle, whether it’s health inequalities, obesity, or another systemic challenge, and articulate a shared mission that resonates across sectors and communities. Bring partners together early and often, building trust and clarity of purpose. Secure the political mandate that gives prevention staying power beyond electoral cycles, and map the data alongside lived experience so priorities reflect both evidence and reality.
Make equity your guiding principle, ensuring that every decision actively reduces disparities rather than deepening them. Establish governance structures that clarify roles, responsibilities, and accountability, then move from planning to delivery with multi-level action, quick wins locally, policy alignment regionally, and legislative levers nationally. Measure what matters, tracking progress across health, social, and economic indicators, and use those insights to adapt and improve. Above all, keep telling the story in plain language, through every channel, so that prevention becomes a shared cultural norm and health truly becomes everyone’s business. This is not a one-off project; it’s a movement.
In the end, whole‑system public health is an expression of ambition, the courage not only to understand the problem, and not only to design the plan, but to deliver it together, across sectors and communities, until the system itself changes.
