The public health settlement announced last week signifies a real-terms decrease in allocations for public health in England.
Local authority officers may have got used to the year-on-year austerity meted out by central government. It has taken out over £10bn since 2011. But the public health community will not be happy to be drawn into the race to the bottom.
The sector’s move from the health service to local authorities was intended to protect public health from decades of stifling under the juggernaut of acute care; to put public health where it belonged and to protect and grow it.
The sum of £2.79bn for 2015-16 is the same amount as last year’s public health ringfence. It is particularly galling at a time when clinical commissioning groups in the health service have had funding increases.
It does not enhance this government’s reputation, nor does it aim to prevent more illness and disability. And it does not suggest central government is any closer to thinking and acting in an integrated way on improving health and independence, and reducing disability and disease.
Figures from Local Authority Revenue Expenditure and Financing: 2014-15 Budget, England show public health budgeted expenditure is £2.84bn, so it would appear that councils are planning to fund the £54m balance from other sources.
The scope for local authorities to apply their funds in a discretionary fashion towards major public health issues is limited – £2.18bn goes on prescribed functions and major commissions in sexual health, drugs and school nursing. In all the other budget areas the amounts committed are puny given the scale of the problems.
We are a huge distance away from ‘industrial scale’ services to prevent smoking, alcohol, dietary and inactivity related ill health.
There is not so much a risk as a certainty that public health money will be diverted to other spending areas.
There are about 30 director of public health vacancies nationwide and the senior management vacuum enables councils to use public health funds to prop up budgets elsewhere.
The faculty’s local advisory committees tell us this is happening around the country. Some councils do so for survival; others use finesse to move it to “public health wider determinants budgets” or use funds to reshape existing council services towards more defined health outcomes.
Some directors of public health, striving to be corporate players, are concerned with the reality of protecting services that we have championed as public health services – early years, young people’s job opportunities and welfare rights.
The UK Faculty of Public Health believes the funding allocation for public health is far too small. The amount transferred from the NHS for all public health services was only £4bn when I had made the case that another billion should have been moved. Then health secretary Andrew Lansley professed his commitment to protecting and growing public health and getting the nation healthy.
However, it is clear that aspiration remains empty political rhetoric. It is disingenuous of the government to talk in terms of two-year allocations and to answer every challenge from fat and fitness to food poverty and accident prevention by saying “£5bn is available” to tackle them.
Public health services represent less than 3% of local government funding. The overall cut in public services should be the major public health concern. Local government budgets have been hammered relentlessly over recent years. And that hammering has disproportionately affected the poorer, mainly northern, councils with the highest mortality rates. The councils with the highest death rates had the highest cuts in revenue support grant.
We are seeing rises in suicide rates associated with economic decline. The movement in policy has been to exacerbate public health inequality – less invested in early years, adolescent health and jobs, workplace health and in reducing income inequalities. The only area in which we may see a genuine capacity for councils to improve health is through their commitments and interest in healthy town planning and the housing improvement agenda.
FPH would like to see whole council expenditure shift towards health improvement. Few types of council have seriously risen to the ‘health in all policies’ challenge. Some councils are looking to use the housing revenue account towards healthy repairs and warm homes, to use the roads maintenance budgets to reduce deaths and disability to pedestrians, or develop the health outcomes achieved through leisure services.
However, the idea of health impact statements in all council policy documents is seen as a bureaucratic imposition on hard-pressed officers. The big prize will not only be to commit the ringfenced funds wisely, but to commit to health improvement in all council spend.
John Middleton, vice president, UK Faculty of Public Health
