It is well established that a person’s health is not simply the product of the NHS but is shaped by many wider determinants such as housing and employment. The government has made it clear that they want to protect health, and have elected to do so by protecting NHS spending. This has been at the expense of non-health service spending, particularly on welfare, with significant cuts made following the 2008 global economic crisis and five more years of austerity to come.
This approach raises the following questions: is protecting health services really the same as protecting people’s health? And, could cutting non-health service spending damage health more than cutting the NHS budget? With the government’s spending review fast approaching, these questions require answers so that policy makers avoid making spending decisions that could worsen health and widen health inequalities.
So, what is the evidence for the impact on people’s health of cutting non-health service spending? We have scanned a combination of academic papers and research from charities and local governments, from the UK and abroad, to try to better understand what evidence is available and what it tells us.
We found that the evidence is sparse. In the UK, cuts to spending on housing and welfare from the late 1970s to 1990 were associated with an increase in the number of deaths related to alcohol, drug use, suicide and violence, despite an overall fall in the number of deaths from all causes; health inequalities also increased.
More recently several UK charities and local governments have reported a decline in the health of their local communities due to the spending cuts over the last parliament, particularly regarding mental health and wellbeing; this however is largely anecdotal.
International evidence is more substantial but also lacks breadth. For instance, cuts to benefits provision and an increase in the cost of renting state housing in New Zealand was associated with a decrease in the number of deaths but an increase in health inequalities.
Evidence from some Scandinavian countries appears to paint a different picture. During the recession in the 1990s, the Norwegian and Finnish welfare systems suffered spending cuts. However negative impacts on health and health inequalities were fairly limited, and there may even have been some improvements. One suggestion for the Scandinavian experience compared with the UK is that the existing Scandinavian welfare systems were strong and therefore better able to withstand cuts.
So, what can we learn from this?
· Evidence for the impact on people’s health of cutting non-health service spending is limited and of variable quality.
· Evidence from the UK is particularly poor with a lack of academic literature and weak study designs. However, what there is suggests that non-health service spending cuts may be associated with negative impacts on health and health inequalities. The evidence from New Zealand also shows an adverse effect on health inequalities.
· Evidence from Scandinavia suggests that spending cuts can have a limited impact on health and health inequalities that may be associated with its strong pre-existing welfare system.
· The relationship between non-health service spending cuts, health and health inequalities is not clear-cut and it is likely that the impact is context dependent (i.e. the country, the welfare system and the extent of the cuts).
High-quality evidence from the UK is urgently needed to fully understand how cutting non-health service budgets impacts on health and health inequalities, to guide the government in making its spending decisions. For example, cutting funding for the provision of safe play areas for children could be more damaging for the development of obesity and long-term health problems than cutting some health services.
Long-term research on the impact of the cuts made over the last parliament, and those to come, should be carried out to build an evidence base, as future governments will almost certainly face similarly difficult spending decisions. This should be coupled with an ongoing process of data collection and analysis of factors such as health service use, physical and mental health outcomes, and wellbeing, to monitor the health impact of spending decisions, and evaluate policy. Feedback from frontline staff in the NHS, local government, and the voluntary and community sectors is an essential part of this data collection process.
There is considerable potential for further research, particularly in the current financial climate. It is essential that this work is carried forward to ensure that the decisions made on public spending are not to the detriment of the population’s health.
