Prevention is better than cure – except when it comes to paying for it

This content relates to the following topics:

We welcome Matt Hancock’s signal and intent that prevention will be one of three priorities distinguishing his time as Secretary of State for Health and Social Care. The policy paper, Prevention is better than cure recognises the complex factors that drive population health and announces a Green Paper to come next year. It also sets out a long list of existing government actions and commitments but stops short of committing to anything new in the short term. 

Several commentators pointed out the disjuncture between the narrative of the document and what has been happening on the ground. Public health is currently in the fourth year of a five-year funding squeeze that, on current estimates, will see spending per person fall by nearly a quarter between 2015/16 and 2019/20. We have been tracking how local government public health budgets have been changing since 2013/14 when local government, rightly in our view, regained responsibility and the funding for important elements of public health. We now have the latest tranche of data, this time on the final out-turn expenditure for 2017/18.

Figure 1 shows the distribution of local authority net revenue expenditure on public health functions in 2017/18. The largest category was spending on prescribed services for children aged 0–5 years (for example health visiting) at £759 million, a responsibility that local government took on from the NHS in mid-2015/16. The lowest spend was on wider tobacco control, at £9.7 million. The overall spend by local government was £3.36 billion. 

Figure 1: Local authority net out-turn public health expenditure, 2017/18

Local authority net out-turn expenditure 2017-18 (£ millions)

Source: The King’s Fund analysis of local authority revenue expenditure and financing data, available at: https://www.gov.uk/government/collections/local-authority-revenue-expenditure-and-financing#2017-to-2018

Figure 2 shows percentage changes in expenditure between 2017/18 and 2016/17. The biggest percentage cut was in health protection expenditure, followed by big cuts in elements of spending on interventions concerning drug and alcohol misuse and sexual health services, although prevention of substance misuse in adults did see a rise. Taken as a whole, both substance abuse services and sexual health services have seen year-on-years cuts in expenditure. 

On sexual health services, the health select committee is currently investigating how services are coping. We have submitted our evidence to this inquiry, arguing that local authorities have made significant efficiencies but that cuts now need to be reversed, especially with the incidence increasing of some sexually transmitted infections. Overall, local government spent 3.3 per cent less on public health services in 2017/18 than it did in 2016/17. Despite these figures, to its credit, local government is still spending almost £150 million more than the grant received from central government for these services, at a time of intense stress to overall local government finances and services. 

Figure 2: Percentage change in local authority net out-turn expenditure, 2016/17 to 2017/18

Percentage change in local authority net out-turn expenditure 2016-17 to 2017-18

Source: The King’s Fund analysis of local authority revenue expenditure and financing data, available at: https://www.gov.uk/government/collections/local-authority-revenue-expenditure-and-financing#2017-to-2018

This expenditure of course pre-dates Matt Hancock’s role as Secretary of State for Health and Social Care, as well as the additional funding announced as part of the NHS70 celebrations, and the most recent budget. The first did not apply to local government public health spending (alongside other spending such as for NHS training), and the second was similarly silent. 

One way to interpret Matt Hancock’s document, and its timing, is as a shot across the bows of the NHS long-term plan, signalling that the Secretary of State wants to see a strong commitment to prevention in future NHS spending. If that is the case, we would welcome that. But that’s only one part of the picture. In a recent interview with the Health Service Journal, the Secretary of State indicated that next year’s planned cut in public health spending will not be reversed, as ‘budgets are already set’. This is no longer just disappointing but is out of kilter with his message that prevention is better than cure.

In that light, Duncan Selbie’s interview in the Health Service Journal is important:

‘It’s inconceivable to me that you’d have a prevention vision from the secretary of state that puts the public’s health – if you like health in its broadest understanding, how we help people to stay well, how we use the NHS in a more sustainable way – it is inconceivable that you would then be reducing expenditure on prevention. But those are matters for the spending review and the Treasury.’

It seems, to date at least, that prevention is better than cure, except when it comes to paying for it. This is simply not good enough. We will present ‘A vision for population health’ at our annual conference, giving more detail on our views on funding, national leadership for population health and ‘who needs to do what’ to make it a reality. We look forward to welcoming the Secretary of State and others to the conference.