Who gets how much of the public health budget?

In February, I blogged about the Department of Health’s attempt to assess how much the NHS has historically spent on public health and what that would mean if allocated to the key organisations in the new system. In particular, the Department needs to know this in order to transfer funds to local authorities so they can fulfil their new public health commitments from 2013-14. How much local authorities get will be decided centrally for the first time, in contrast to the current system where primary care trusts take their own decisions.

The Department asked the Advisory Council of Resource Allocation (ACRA) to help it make that decision. Its recommendations have now been released in Healthy Lives, Healthy People: Update on public health funding. The new document does take some steps forward. Importantly, the allocation of funding will be based on need at small neighbourhood level which will ensure that it is more precise. For example, wealthier local authorities with small but concentrated pockets of need should receive the appropriate funding to deal with it.

Back in February, I argued that the trickiest decision for the Department will be whether to stick with the historical pattern of spending, or if that seems really out of line with need, to allocate it on some other basis. ACRA has now recommended, and the Department has accepted, that the measure that should be used – at least initially – is the under 75 standardised mortality ratio.

Figure one therefore shows the Department’s estimates of how much local authorities would get under the current system against ACRA’s recommendations on how that total amount should be allocated.

Click on the graphs below to expand.

Figure one: Allocation of public health resources to local authorities: Flows to on the basis of new system responsibilities in 2010-11 vs ACRA's recommendations


This graph shows a real divergence. Only 56 per cent of local authorities are actually within 25 per cent either way of where ACRA’s formula suggests they should be based on 2010-11 total spend. Clearly, individual primary care trust (PCT) decisions taken across the country, when seen as a whole, have been poor at matching the need for public health interventions.

Figure two plots the extent of under- or over-funding against the deprivation levels of local authorities. It sheds light on whether current spending in the poorer, more deprived communities is more or less out of synch than the better off ones. The vertical axis shows how far each local authority is adrift from ACRA’s recommendation, the horizontal axis shows the index of multiple deprivation, with smaller numbers meaning lower deprivation. In short, it shows that higher levels of under-funding tend to be seen in less deprived local authorities and vice-versa, although the relationship is not strong. 

Figure two: Public health under- or over-funding by local authority according to ACRA's recommendations vs index of  multiple deprivation


Public health under- or over-funding by local authority according to ACRA's recommendations vs index of multiple deprivationFrom the perspective of improving population health, these graphs make a compelling case to move quickly to ACRA’s preferred allocation. Public health funds are not where they should be. What then does the Department have to say about this? On page 9 it states, '...the current restrictions on growth in public health spending will mean that, initially, progress towards the preferred distribution is likely to be slow.’ This is bad news for the public health of England. Faster progress, getting under-funded areas closer to the preferred allocation, ideally funded through growth in the public health budget, would be a strong demonstration of the government’s commitment to reduce health inequalities.

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#1263 David Buck
The King's Fund

The original version of my blog above had an error in it, for which many apologies. In Figure 2 above, the direction of the relationship between under- or over-funding was presented as being more likely to be more under-funded the more deprived the authority. In fact, the relationship is reversed, which has now been reflected in the Figure and in the surrounding text.

#1264 mike stone

I'm only reading this because I have some spare booked computer time, and I'm not sure what 'the under 75 standardised mortality ratio' is. But I'm assuming it is a way of counting who seems to be dying younger than 'would be expected, in some sort of 'equitable' world' ?

Don't you also need to make some assumptions, about whether preventing someone from dying at 72, or pushing someone to die at 78 (assuming the non-intervention death age would be 75), each cost the same amount the money ? It isn't clear to me, that such a simplistic assumption is necessarily true - is that accounted for, or is that 'set aside for now - we haven't got there yet' ?

#1265 Warren Escadale
Policy & Research Manager


Thanks for this and your February blog. Really helpful and insightful.

I'm confused though. Is the assertion of over-funding in areas of deprivation based on the accuracy of ACRA's proposed formula?

Would we not expect that better investment in public health would reduce deprivation (obviously it would need to be part of a broader strategy) and therefore inequality?

Does not, therefore, the line in figure 2 show the variance between ACRA's formula and the many decisions made at a local level about what is necessary (within negotiated constraints) for delivering an adequate local public health programme? ie that ACRA's proposals need to tilt the line horizontal? ("The Buck Tilt").

How can it be the case that we are over-funding public health and prevention activity in areas of deprivation?

I'd be interested in your thoughts - as always.


#1266 David Buck
The King's Fund

Thanks Mike and Warren for your questions.

Taking Mike's first. Yes the SMR under 75 is a proxy measure for preventable death, but also correlates well with other measures that are important such as morbidity. So it gives some sense of which area's populations may be in higher need than others for effective public health intervention. It's a good question about the relative costs of prevention in different cases. The Department will take this into account to some degree, through estimates of different input costs in different areas, for instance of staff. It's not clear to what extent it will, or can, control for individual factors as you raise. This of course also raises the interaction with the broader NHS treatment budget and how that is allocated, age is the largest determinant of that, so the NHS will receive more in areas with older patients.

Turning to Warren's point. I don't think ACRA needs to necessarily aim to tilt the line, but it does need to get those that are clearly under-funded up to the line. The irony, and issue, about this as i touched on in my February blog, and as you refer to, is that "under" funding derives from past individual PCT decisions taken with no reference to any national standard, such as SMR that will now be introduced. Now that there will be a fixed pot for public health spending (although LAs can supplement it) from government it would seem very unfair to those who have "over" spent in the past to see their budgets effectively cut. It is extremely unlikely the Department would therefore do this, but is also why with very little growth in the public health pot likely it will be next to impossible to make any headway in bring under-funded areas up to the line. This is a political call for the Secretary of State, how much does he value public health vs funds for treatment?

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