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Public health spending: where prevention rhetoric meets reality


The government has published its much-trailed Green Paper (now an 'open consultation') on prevention. It contains warm words, some movement on existing issues such as childhood obesity – the prime one banning sales of energy drinks to children under 16 (on which the government has been consulting for some time) and setting out further intent – re-announced steps towards a smoke-free society and re-announcing the creation of a health index to rival GDP in government decision-making.

There are lots of other announcements across a range of areas, each interesting and valuable in and of themselves. But taken as a whole it is not at all clear how they will meet the avowed goal of the Ageing Society Grand Challenge: '5 more years of healthy, independent life by 2035 while reducing the gap between richest and poorest'. The Green Paper neatly skips this by saying this will be picked up in the Spending Review and in a response to (its own) Green Paper by spring 2020.

The inescapable impression, unfortunately, is of a Green Paper rushed out at the end of one administration while waiting for another. In particular, it offers little to local areas and none of the five things that we suggested would help local government, with the partial exception of a positive mention of the Wigan Deal as an example of local government strongly engaging with its communities on health. The decision on the public health grant and whether it will switch to business rate funding has been kicked down the road, yet again.

'The trend of falling spending from the past few years is set to continue, as local government cuts its coat to the shrinking cloth provided by central government funding.'

The lack of anything in this Green Paper for local government is all the more surprising as the government recently confirmed that responsibility for public health should not be placed back into the NHS. This was a welcome vote of confidence in local government's role and effectiveness, and many hoped that the Green Paper itself would signal a step change in resources to help them fulfil that role. It hasn't. But as fortune would have it, the latest local government spending plans for public health were released at the end of June. These don’t make pretty reading.

The trend of falling spending from the past few years is set to continue, as local government cuts its coat to the shrinking cloth provided by central government funding. Figure 1 shows that local government plans to spend £72.5 million less in 2019/20 than it planned to spend in 2018/19 (darker bars). On a like-for-like basis (taking out the impact of the transfer of early years services to local government from the NHS in mid-2016) the fall is £66.3 million in cash terms (lighter bars).

Spending on public health in England, 2013/14 to 2019/20

As ever, this top-level story hides further detail below the surface. Figure 2 digs deeper, showing changes between this year’s planned budget and last year’s, breaking categories down further. It shows that in some areas, notably drug and alcohol services, some functions are seeing increases and some decreases. Spending on prevention on both adult alcohol and drug misuse is planned to rise in proportionate terms (albeit from a low base), but spending on treatment is set to fall.

Change in public health spending, cash terms, 2018/19 to 2019/20

In others, notably children's drug and alcohol misuse services and sexual health services, spending in all categories – prevention, testing and treatment – will fall. On treatment, although the Local Government Association and The Economist have pointed out that local authority commissioned services have done well to see more people from a shrinking pot through introducing innovations such as online testing, this is unsustainable and quality of care is at risk. As the Health Select Committee has said:

'The clear message we received was that persistent funding cuts have already had a negative impact on services. We heard that services are at risk of being cut back to the extent that they are unable to deliver fit-for-purpose, quality provision. At our roundtable in Plymouth we heard that funding cuts are particularly affecting the ability of providers and commissioners to focus on anything beyond the minimum that is required of them – mandated STI testing and treatment services and contraception services. The funding for prevention activities and wider supportive services has reduced considerably, meaning that outreach services for vulnerable groups have been stripped back.'

'Pound for pound, we get four times as much health from public health functions in local government than we do from NHS spending.'

If all this weren’t enough, recent work by the Centre for Health Economics at York has shown that, overall, spending through the public health grant is up to four times as cost-effective as NHS spending. Think that through for a moment: it means that pound for pound, we get four times as much health from public health functions in local government than we do from NHS spending. And yet the NHS budget is protected and prioritised and local government public health budget is cut.

The Health Foundation has estimated an overall fall of almost a quarter in spending power per person between 2014/15 and 2019/20. That is why we and they have jointly crunched the numbers to show that simply to put back the prevention 'buying power' that has been lost requires a further £1 billion per annum (taking into account inflation and population growth). That should be the minimum, given that spending on these public health functions is such a good buy.

So keep all this in mind when you read the prevention Green Paper and test the rhetoric against the reality. Warm words are welcome, as are some of the individual commitments, and if the new health index really does put health on a par with GDP in government decision-making, then it will have been well and truly worth it.  But in the here and now the government has been disinvesting in prevention by starving local government of the resources needed to deliver it.