What we think
Although people are living longer than ever before, England faces significant public health challenges. Improvements in life expectancy have stalled, health inequalities are widening and our obesity rates are among the worst in western Europe.
Despite repeated promises from the government to strengthen public health and prevention, local authority public health grants have been substantially cut, with expected spending in 2019/20 £850 million lower in real terms than in 2015/16. While the 2019 Spending Round committed to increasing the public health grant in real terms next year, it is not yet clear by how much. At best, this increase will halt further cuts to services but it will not come close to providing the extra £1 billion needed to restore spending to the level of 2015/16.
Funding cuts in recent years have led to reductions in vital services such as health visiting, stop smoking support and sexual health clinics. This puts people at risk of poorer health and is 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.
Greater certainty over funding beyond 2020/21 is needed. This should be accompanied by a much stronger focus on public health and prevention across government that makes full use of all the levers available to policy-makers. This should include 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.
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 and a cross-government strategy on health inequalities.
In 2013, local authorities were given new legal responsibilities for improving and protecting the health of their local population. They also inherited responsibility for ensuring provision of a range of public health services previously provided by the NHS including most sexual health services, smoking cessation, lifestyle advice and substance abuse as well as wider health protection work such as protection from outbreaks of infectious disease and from incidents and environmental hazards such as chemicals and radiation. Local government is a natural home for many of these responsibilities as they overlap with the wider role of local authorities that affect health – such as housing and economic development – allowing for a more joined-up local approach to public health.
Central government, through 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, impacting on services that are vital for keeping people well.
Reductions to public health and other budgets have come at a time when the public’s health is facing major challenges. Improvements in life expectancy have slowed dramatically and health inequalities are widening. Rates of smoking remain high in certain populations and levels of obesity remain a major cause of concern, with almost two-thirds of adults and nearly one-third of children now being overweight or obese. Reductions in public health funding have also coincided with a rising incidence of some sexually transmitted infections and record numbers of drug-related deaths.
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 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.
Preventive and 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 for public health 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.