What we think
Although most people are living longer than ever before, England faces significant public health challenges. Improvements in life expectancy have slowed, health inequalities are widening and our obesity rates are among the worst in western Europe.
Despite repeated promises to strengthen public health and prevention, government funding for local authority public health budgets has been substantially cut in recent years. Even with a recent uplift, the public health grant in 2020/21 was 22 per cent lower per head in real terms compared to 2015/16. Restoring spending per head to this level would require additional investment of £1 billion.
This has led to reductions in vital services such as health visiting, stop smoking support and sexual health clinics, putting people at risk of poorer health and storing up problems for the future. Some key public health indicators are beginning to worsen. For example, some sexually transmitted infections are rising, and the number of deaths due to drug poisoning has reached a record high.
Looking ahead, local public health teams will need to meet the ongoing and long-term effects of Covid-19 and restart services that were paused during the pandemic. At the same time, the government’s decision to dismantle Public Health England and establish a new National Institute for Health Protection risks causing significant uncertainty and disruption at a time when the public health community should be fully focused on responding to the pandemic. As these changes are taken forward, it will be essential for the government to provide clarity about responsibilities for health protection and improvement to avoid further complicating the balance between local and national decision-making.
More broadly, it is time to give the same priority to promoting wellbeing and preventing ill health as to diagnosing and treating illness. This means adopting a new focus on population health, going beyond the NHS and public health system to focus on the wider determinants of health and the role of people and communities. This requires action at national, regional and local level, including ambitious national goals to drive progress, a cross-government strategy on health inequalities and a bolder approach to using tax and regulation, learning from successful interventions such as the measures taken to reduce smoking and from the Soft Drinks Industry Levy and salt reduction.
In 2013, local authorities were given new legal responsibilities for improving and protecting the health of their local population, effectively moving responsibility and accountability for public health to local government, while Public Health England was created to support the public health system and protect the public against major health risks. Local authorities also inherited responsibility for ensuring provision of a range of public health services previously provided by the NHS including most sexual health, smoking cessation and substance abuse services, as well as wider health protection work such as protection from outbreaks of infectious disease.
The Department of Health and Social Care pays the ‘public health grant’ to local authorities so that they can deliver these services. However, this grant has been squeezed substantially in recent years, and despite an increase in 2020/21, is now 22 per cent lower in real terms compared to 2015/16. NHS England and NHS Improvement also receives a budget of around £1.3 billion per year to commission public health services such as immunisation and screening. Public Health England had a budget of £1 billion in 2018/19 to fund their work.
Reductions to public health and other budgets have coincided with some major public health challenges. Improvements in life expectancy have slowed dramatically and health inequalities are widening by some measures. Rates of smoking remain high among some groups and levels of obesity remain a major cause of concern, with almost two-thirds of adults and nearly one-third of children overweight or obese.
Both the NHS Five Year Forward View and the NHS Long-Term Plan made prevention a priority, and it continues to be highlighted as a key priority of the Secretary of State for Health and Social Care. The government’s Green Paper on prevention Advancing our health: prevention in the 2020s set out some welcome initiatives – for example on childhood obesity, mental health in schools and intentions to move towards a smoke-free society – but overall it fell short of the scale and ambition needed to address these challenges. This was followed by the government’s plan on obesity which included some useful changes such as proposed restrictions on junk food advertising aimed at children, but also fell short of what was needed.
In August 2020 the government announced a major re-organisation of the public health system. A new National Institute for Health Protection will be established to focus on tackling the pandemic and, in due course, on preparing for future threats to public health. As part of the planned changes Public Health England will be disbanded and its prevention and health improvement functions will be reallocated to other organisations.
Preventive public health services are essential to help avert the onset of disease, improve people’s quality of life and reduce health inequalities. Evidence shows the return on investment from public health interventions is high and creates value of different kinds – economic, social and personal. Inaction on public health only shifts the burden of poor health to other parts of the system and may lead to costlier interventions and treatment in the long run.
Wider reductions in local authority budgets since 2010/11 have also had an impact on services that support the health and wellbeing of the whole community – such as housing, transport, leisure centres and green spaces. This will make it harder to realise the government’s ambitions to prioritise prevention. Making a reality of these ambitions will require a focus on population health with local authorities, NHS organisations, the voluntary and community sector, communities and others working together to improve health outcomes, promote wellbeing and reduce health inequalities for their local populations.