Public health gains despite slimmer budgets

25 Nov 14
Public health is rising up the NHS agenda, and being promoted by local authorities. But the focus is still too much on individual lifestyle changes.

By David Buck | November 25 2014 

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Public health is rising up the NHS agenda, and being promoted by local authorities. But the focus is still too much on individual lifestyle changes.

Sifting through the tea-leaves: is the NHS about to make more of the running on public health?

I went on a late summer holiday – Sicily since you ask – and when I came back NHS England had produced its Five-Year Forward View (5YFV), with Public Health England supporting the public health agenda with a new five-year strategy of its own. 

We also had the surgeon Lord Darzi’s review of London’s health system, majoring on lifestyle change, and out-turn figures for local authorities’ public health spending. Waiting in the wings, and probably out before Christmas, is the National Audit Office’s assessment of Public Healt England’s spending and accountability.

So, quite a lot of tea-leaves to sift through but there are some common patterns. In particular, the public health focus of the 5YFV, PHE’s strategy and Lord Darzi’s review were all primarily concerned with changing lifestyles and behaviour. 

One of the risks in shifting responsibility for public health to local authorities was always that the NHS would focus on it less, despite the fact that about half of Public Health England’s budget is ported to NHS England for immunisation, screening and other preventive services. And there were increasing signs that this danger was becoming a reality, notably in the long and unexplained delay in any NHS England strategy on Making every contact count. This is the much-vaunted commitment to ensuring that every contact with the NHS is an opportunity to influence someone’s behaviour. That is still only slated for ‘by March 2015’,  at present three years after the then health secretary, Andrew Lansley, committed to it. So, it’s good to see NHS England chief executive Simon Stevens reinvigorating the health service’s role in lifestyles and prevention – both because it is ‘a good thing’ and because it is in its own self-interest. Ramping up prevention holds out the promise of helping to reduce demand on the NHS.

Which brings us to the second theme in these documents, the money. The 5YFV, without presenting any modelling, clearly sees that more prevention will help to check demand on NHS services. So, it’s worth taking a look at how local authorities have been spending their public health budgets. We were reminded of this when new figures from mental health charity Mind hit the headlines last month, revealing that councils were spending less than 1.5% of their public health budgets on mental health. There were similar stories last year, but about spending on obesity. This is the consequence of devolution and local control over decisions, so let’s look a bit more behind the numbers.

Local authority net revenue expenditure

Figure 1 shows planned local authority net revenue expenditure on public health (as defined by the Department of Health) in 2014-15. Overall planned spending was just under £2.85bn. Within this, the majority of the money will go on mandatory functions associated with sexual health and drug services. But figure 2 is in many ways more interesting, as it shows the expected percentage change in expenditure from 2013-14. So we can look at how local authorities have been shifting their spending priorities. Overall, the chart shows that they have planned to spend over 13% more on these functions in 2014-15 than they actually spent in 2013-14 , no mean feat during a time of austerity and cuts. Within this, the winner in terms of growth was the NHS Health Check (though from a very low base). In absolute terms, miscellaneous spending, adult drug misuse and the Health Check again were the winners. Planned spend on physical activity in children was the biggest absolute and percentage loser over the year.

Percentage change in net revenue expenditure

Of course, there will be some definitional issues in the data (for instance, local authorities could claim that parks and recreation services count towards children’s physical activity), but it does seem to show that local authorities are investing more in public health, at a time when that is very difficult, and making some real choices over prioritisation.

This information will be important in informing the NAO’s upcoming report. No doubt the NAO will be crawling through these numbers. But it is likely it will also be looking at accountability too. First, between local authorities and Public Health England, for how cost-effectively the former have been spending the grant. Second, how Public Health England has been discharging its general functions. This will be interesting; Public Health England’s first parliamentary outing – with the Commons health select committee – didn’t go well.

This brings us back to the theme of lifestyles – or rather the missing or at best distant theme from this raft of recent policy documents, the wider determinants of health. Academic evidence tells us that the greatest contributor to our health is not the NHS’s treatment or our lifestyles, but all those things that make up our living conditions. The 5YFV recognises this to a degree in arguing that the NHS needs to work with and be more deeply embedded in local communities.  

Specific local authority functions % change

However, given its immense scale as a commissioner and employer, the NHS needs to be both recognised for and challenged more on its wider economic and social contribution: to relievinbg poverty, to paying the living wage and in other ways, all of which help improve health by impacting on the wider determinants. 

The King’s Fund has made this case in a paper, Tackling poverty: making more of the NHS in England, written for the Joseph Rowntree Foundation. This is where we would have expected much more from Public Health England’s document supporting the 5YFV,  yet it focuses primarily on lifestyle change. This is all the more surprising given Public Health England was the commissioner of  the Due North report, which sets out a powerful case for an equally strong focus on the wider determinants in tackling inequalities in health between the north and the south of England.

So, in answer to the question posed. Yes, it does look like the NHS will be making more of the running on public health, but very much with a focus on lifestyles.  This is welcome, but there is much more that local government and Public Health England can do on the wider determinants of health too.  

David Buck is senior fellow, public health and inequalities, at the King’s Fund.

This feature was first published in the December edition of Public Finance magazine

NB. all graph figures relate to planned expenditure


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