The issue in a nutshell
The coalition government’s health reforms didn’t stop with reforming the NHS. The White Paper, Healthy lives, healthy people, published in November 2010, promised ‘a new era for public health, with a higher priority and dedicated resources’. As we reach the end of the government’s five-year term, has this promise been kept?
Public Health England and local government’s new public health functions
As part of the government’s reforms, responsibility for commissioning many public health services moved from the NHS to local authorities and a new executive agency of the Department of Health, Public Health England, was set up to ‘protect and improve the nation's health and wellbeing, and reduce health inequalities’ at a national and local level.
Public Health England opened its doors on 1 April 2013, as local authorities took on their new public health responsibilities. Directors of public health were also given statutory positions on the new health and wellbeing boards.
The transfer of public health functions and staff from the NHS to local authorities has gone, in most cases, remarkably smoothly, with directors of public health confident of better health outcomes in the future and reporting positive experiences of working in local authorities. Many directors are also influencing local authority decisions well beyond the confines of their ring-fenced public health budget. However, progress is variable, and in some areas there remains much work to be done to bridge the cultures of the NHS and local authorities, and clear differences in the understanding, value and use of scientific evidence to determine decision-making and policy.
The Public Accounts Committee – the parliamentary select committee responsible for overseeing government expenditure – has recently judged that Public Health England ‘has made a good start in its efforts to protect and improve public health’, though it needs to do more to challenge central government about how its policies impact the public’s health (something the Health Select Committee was also concerned about). The Public Accounts Committee also called for Public Health England to support local authorities to prioritise cost-effective interventions and ensure that the right allocations go to the areas with greatest need more quickly. Public Health England’s own stakeholder review, for which it deserves praise for publishing warts and all, echoes this sense of a work in progress.
Public health allocations
In the first two years of the parliament, the government’s ring-fenced public health allocations to local authorities (money to be spent solely on improving the public’s health) were relatively generous, with higher real growth in funding than for the NHS. However, the allocation for 2015/16 is the same in cash terms as 2014/15 (additional money going to local authorities in October 2015 is only a transfer, as local authorities take up responsibility for young children’s public health). Beyond the ring fence, local authorities have been cutting their wider functions, such as leisure and park services, many of which impact on the public’s health. An investigation by the British Medical Association suggested that some local authorities were using ring-fenced money to maintain other threatened services.
Public Health Responsibility Deal and wider legislation
At the start of the parliament, the Public Health Responsibility Deal – which aims to work with industry on a voluntary basis to improve the nation's health in five areas: food, alcohol, behavioural change, physical activity and health at work – was perhaps the most visible public health policy. While the Department of Health’s independent evaluation is yet to report in full, a recent publication on the alcohol part of the deal concludes that ‘the most effective evidence-based strategies to reduce alcohol-related harm are not reflected consistently in the Responsibility Deal alcohol pledges’. Early on in the parliament the House of Lords Science and Technology Committee came to a similar view on obesity, saying that ‘the current Public Health Responsibility Deal pledge on obesity is not a proportionate response to the scale of the problem’.
Alongside the deal, the Department of Health also produced strategies on tobacco, obesity and alcohol. Most of the focus has been on standardised tobacco packaging and minimum unit pricing of alcohol. The former was recently passed into law, making the United Kingdom only the third country in the world to do so (following Australia and the Republic of Ireland). On the latter, despite promising to introduce minimum unit pricing, the government has not done so.
Prevention and public health
The NHS five year forward view published by NHS England and other national bodies in October 2014, argues for ‘a radical upgrade of prevention and public health’. However, for much of this parliament, the focus has been on implementing structural NHS reforms, balancing the books and latterly quality of care, with a lack of policy attention to prevention and public health. One sign of this is the fate of Making Every Contact Count, a key policy flowing from the second phase of the NHS Future Forum in 2012, which encourages all NHS staff to support patients to quit smoking, improve diet, and achieve a healthy weight, and level of exercise and alcohol intake. While there has been some good action on this in some areas of the country, a national strategy was still waiting in the wings to be produced ‘by March 2015’ at the back of NHS England’s 2014/15 business plan.
Similarly, there has been little sign that the government has taken into account the impact of its wider NHS reforms and fiscal programme on public health, despite an initial focus to give wellbeing an equal status with maximising economic growth. Indeed, in November 2012 the government abolished the body it created to see its public health reforms through, the cross-government Cabinet sub-committee on public health. This was the committee that, before coming to power, the Conservatives said would ‘send a powerful message that public health is the responsibility of all government departments’.
The King’s Fund verdict
Evaluating public health policy is complex, because so many wider government actions, both local and central, impact on public health. There are also time lags, both in measuring the outcomes of public health policies, and in data release and analysis.
However, there have been some successes: in particular, the process of public health reform has been remarkably smooth, in marked contrast to NHS reform. As part of that process the government has transferred ring-fenced, dedicated resources for public health to local authorities.
Public Health England and local authorities appear to be adapting to their new roles well, but more is expected from Public Health England in its challenge function to the rest of government. Good intentions have not yet been translated into outcomes by local authorities.
Meanwhile the NHS has been slow to act on Making Every Contact Count, and has only belatedly started to refocus on its role in prevention through the Forward View. While the passing of legislation on standardised packaging of tobacco is historic, the government has backed off from its own commitment to minimum unit pricing of alcohol and dismantled the machinery that could have assessed the public health impact of its wider actions.
Our overall verdict is that the government has delivered its commitment to reform public health and provide dedicated resources, but it has not given public health the priority it promised.