Reflections on the UK's approach to the 2009 swine flu pandemic: Conflicts between national government and the local management of the public health response

► The response to H1N1 in Birmingham indicates local-national management conflicts. ► The national containment policy and prophylactic use of antivirals was contested. ► Failure to balance national coordination with subsidiarity and flexibility occurred. ► A public health perspective was lost in the disproportionate response. ► Effective pandemic response requires a flexible multilevel public health apparatus.