Cuts to public health spending: the falsest of false economies

Public health

Back in June, with no prior warning, the Treasury announced that the 2015/16 public health grant to local authorities would be reduced by £200 million. Last week, the Department of Health finally released the consultation on these ‘in-year savings’ (for the rest of us that means cuts).

Given the delay in doing so following the announcement, you’d be forgiven for thinking that it is an extensive, highly technical document setting out complex options. But it’s not – it’s 20 pages, including annexes. So why the delay? Why is the consultation open for just four weeks? And why does it take place in August, when many people are likely to be on leave? Presumably because it is already desperately late to be cutting in-year budgets – suggesting the cut caught the Department of Health by surprise. Not so long ago, the Department was trying to give local authorities planning certainty by issuing multi-year budgets – the contrast between this and an in-year cut could hardly be more stark.

We have set out our view elsewhere on the wisdom of cutting public health budgets, arguing that it will undermine commitments to prevention and discourage integration. And the consultation does answer some of the questions we posed there, including whether funding for public health services for children aged 0–5 – which is only being transferred from the NHS to local authorities from 1 October – can also be cut now that it is no longer protected by the NHS ring fence. The answer is yes, as long as statutory responsibilities are met. This may be sensible, giving local authorities maximum room for manoeuvre, but it sits uncomfortably with the government’s claim that these are ‘non-NHS’ cuts.

But to the meat of the consultation itself. The Department of Health favours the simplest option – translating the £200 million reduction in funding into a flat 6.2 per cent cut to all local authority public health budgets. The reason for this is primarily for simplicity, supported to some extent by personal soundings from those in local authorities who are already planning on this basis. But other options shouldn’t be dismissed: taking a larger cut from local authorities who remain above the target funding allocations defined by the Department of Health; or taking more from local authorities who carried forward unspent reserves from last year. More details are in the consultation.

In an eerily prescient move, Ben Barr and David Taylor Robinson looked at the potential implications of some of the options available. One option, not put forward by the consultation paper, would be to take less from local authorities with higher levels of need. On Barr and Robinson’s definition of inequality – the relative impact of the cuts on local authorities with different levels of deprivation – the Department of Health’s favoured option of a flat cut and the option of cutting on the basis of target allocations are both less equitable than cutting on the basis of need. Other options are also possible, including taking less from authorities spending more on demand-led services, such as sexual health, since they have far less discretion over what they do with their funding as it is. So, the devil really is in the detail.

Beyond the consultation, the next challenge will be the Spending Review. Remember, the ‘in-year’ cut is already on top of a cash standstill budget for public health in 2015/16. Yet, there is now growing evidence of the benefits and return on investment of local authorities’ public health spending, in areas such as the promotion of walking and cycling, and investment in housing. Many of the financial benefits flow to the NHS. Public Health England, urged on by the Public Accounts Committee, is prioritising the further development of return on investment information. This will be useful to local government no doubt, but central government and the Treasury need to receive feedback on, and be held to account for, their decisions in this area too.

We will be making it clear in our Spending Review submission that further cuts to public health spending and activity will be the falsest of false economies, not least for the NHS. System leaders Simon Stevens, Jeremy Hunt and Duncan Selbie have all emphasised the importance of prevention and public health – which are at the heart of the NHS five year forward view. The Spending Review will be a litmus test of whether this is taken seriously by government.

Comments

Public health is stuck in an ancient mindset that 'nothing can be done unless it's in a whacking great public sector programme costing £m and £m'.
The millennials just want the information; stick it up on the net in accessible places and forms. Let them decide, use it and spread it. Cost; near-zero.

I concur with many comments but one thing seems to be forgotten - if you reduce funding in anything, leaders and managers then have to think differently and produce better results based on what they have.
Endless flows of money, as in the past does not help to gel the mind and produce better results. Just look at some of the most basic needs of patients that continually go uncared for and frequently brought into the spotlight. Also the total inability to come up with an integrated care plan - after how many years, meetings, conferences and think tanks!
Public sympathy is still there but it is on the decrease. We would all like more but have to make do and get on with what we have and are paid to do - and paid very well in very many of the management positions

I've read this blog in a break from digesting the Government's consultation for developing a new sports strategy... where there is significant reference to the health benefits of sport, exercise and physical activity. There is even a section headed by Jane Ellison, minister for Public Health. This document states that CCGs and HWBs will become more important in commissioning physical activity solutions in the future and suggests - no surprise - that funding should come from Public Health Budgets.

They seem to conveniently forget that not only are they cutting these, but have already made massive inroads into all the other local authority funds that support the social determinants of health - culture, leisure facilities, youth services and are vital tools in an effective approach to meet the NHS call to prioritise prevention measures.

Please do respond to the Sports Strategy consultation: https://www.gov.uk/government/news/government-kicks-off-consultation-to-help-strengthen-sport-across-the-country
...to ensure that a public health view is reflected in the feedback they receive.

I think these cuts demonstrate the completely broken nature of decision making in government.

The rationale is based purely on a top-down target to reduce government spending right now with no consideration at all about whether government spending or outcomes will be better next year. This will be exacerbated locally in many regions as local authorities will salami slice all projects instead of simply eliminating the least useful ones.

Sometimes governments do have to spend less in total. Many public sector projects don't do much good (actually, this is also true in big private firms). But the best way to spend less tomorrow is to be discriminating about how and where the money is spent. Sometimes the best way to save tomorrow is to spend intelligently today. This might involve radical cuts to politically favoured but actually useless projects in one area so more can be spent on important and effective projects elsewhere. What we actually get is blanket cuts in politically disfavoured areas even if the implications are bad for everyone tomorrow.

I'm fairly sure there are many useless ways to spend money in public health. But I'm also sure that these cuts won't help in any way to make the budget holders spend their money more effectively or help the government hold down future spending.

Plymouth was seriously underfunded when given responsibility for Public Health when compared to similar authorities across the country.

The timing of this reminds me of the publication of the 1970 Balck Report - nothing changes.

Where has the public engagement in this potential significant change to services. It wouldn't meet the expectation required of the NHS in developing and commissioning new services? This needs a significant public debate.

I would advocate for these "savings" to take account of LAs with the greatest health burden or need. Services offered in conurbations like London often serve clients that do not contribute to local taxes ,and yet are (rightly) entitled to access; this applies to sexual health and smoking cessation amongst others.
My concern for smoking is that we know that it is the biggest driver of health inequality, but is now particularly vulnerable as it is not statutory provision for local authorities.
Invest to Save has been a public health mantra for some time. We will see how many LAs are able to continue to stand by this with other statutory provision under pressure.

This will impact recent good work around alcohol prevention and treatment - also proven 'invest to save' measures. Alcohol, always the poor sister, with no specific budgets or targets, will be especially at risk, depsite its massive £21 billion national cost. Sigh.

Thank you for this article.
Sexual Health is now commissioned by local government and all discussions with providers are framed by the plan to spend 20% less on services across the capital. As the public health indices continue to worsen (see link below) there appears to be no appetite to focus on outcomes, quality or bolstering prevention spending. The focus is to balance the books and the only clear short-term mechanism to realize that is to start to reduce access which runs counter to our public health role. Unfortunately in the current climate the demonstrable return on investment for our services hold no currency. The poor outcomes that will arise from the planned changes in funding (increase in HIV, STI complications and abortions) fall under a separate budgets and therefore there is no feedback loop in place for those who have to implement the unpalatable changes.

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/437433/hpr2215_STI_NCSP_v6.pdf