Local government public health funding: putting the jigsaw together without the picture on the box

The majority of local government spending on public health comes through a direct annual grant from the Department of Health and Social Care, received every year since 2013/14, when public health functions were transferred from the NHS to local government. Since 2013/14 there has been transparency around this funding, through an annual cycle of allocations being announced by central government, followed by local government plans for spending this money, and finally how much they do actually report as spent, known as ‘out-turn’.  All this has been available either from the Department of Health and Social Care itself or in the Department for Levelling Up, Housing and Communities (and formerly Ministry of Housing, Communities and Local Government) accounts (plans and out-turn).

How has this funding been working in practice in recent years? Figures 1 and 2 show what has been happening since 2016/17 (we have set out trends before this date and some of the complexities of interpreting them elsewhere).

What these figures show is falling allocations over the period in cash terms to 2019/20 and a slight rise from then on. Unsurprisingly, in real terms the fall is steeper, plateauing by 2020/21 and remaining roughly at the same level to 2024/25, delivering the intention of government to ‘…maintain the Public Health Grant’ in real terms over the latest Spending Review period from the recent Levelling Up White Paper. However, this is based on very optimistic GDP deflator forecasts, and with local government expected to deliver more from this budget, it is therefore highly likely that the spending power of the grant will fall significantly, the first sign of that will be when the next estimates of the forecast GDP deflator are published at the end of this month.

The public health grant alone is becoming a less useful guide than it was for understanding what is happening to local government public health spending. For example, there was a gap between allocations and what was spent (out-turn) for 2019/20, when local government spent over £500 million more on public health than it was allocated through the grant. The reason for this is almost certainly spend on Covid-related activity, and this will also be true for 2021/22. Public health teams have received resources from the Contain Outbreak Management Fund. The National Audit Office reported that by December 2020 £978 million had been allocated to local authorities through this fund, but it is not easy to track exactly how all this is accounted for and how much is on public health.

'The public health grant alone is becoming a less useful guide than it was for understanding what is happening to local government public health spending.'

The government has also announced additional resources for specific areas, outside the public health grant, all of which are clearly welcome. In particular, a big increase for local government drugs services, £780 million over three years in response to Dame Carol Black's review; £100 million for weight management services, around £30 million of which is to be distributed through local government public health teams; and an early years ‘Start for Life’ commitment of £170 million over the spending review period. But, that’s not all that’s changing. The demise of Public Health England and the creation of the Office for Health Improvement and Disparities and the United Kingdom Health Security Agency in its place, with some clinical public health services going back into the NHS, means funding flows from these bodies into local government will change too.

The public health grant alone is becoming a less useful guide than it was for understanding what is happening to local government public health spending. For example, there was a gap between allocations and what was spent (out-turn) for 2019/20, when local government spent over £500 million more on public health than it was allocated through the grant. The reason for this is almost certainly spend on Covid-related activity, and this will also be true for 2021/22. Public health teams have received resources from the Contain Outbreak Management Fund. The National Audit Office reported that by December 2020 £978 million had been allocated to local authorities through this fund, but it is not easy to track exactly how all this is accounted for and how much is on public health.

'In practical terms all this makes the job of directors of public health and the services they commission more complex'

In practical terms all this makes the job of directors of public health and the services they commission more complex, as various taps get turned off (including the Contain Outbreak Management Fund in the near future) and turned on (such as drugs and weight management services). It also makes it harder for anyone else to understand what is going on.

In conclusion, the jigsaw puzzle of local government public health funding is getting harder for anyone outside government to piece together. The Department of Health and Social Care needs to bring this all together into a more comprehensive and consolidated  view of what is happening to the resources for public health in local government. It needs to be much clearer, for all to see, how much money gets to local public health teams, and how much is actually being spent – piecing together this jigsaw is rather hard when you’re not sure of the picture on the box.