Hard Times for Public Health

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Beck Taylor

Beck Taylor is a public health physician and clinical research fellow.  She conducts research in maternity and child health in the Institute of Applied Health Research at the University of Birmingham, funded by the West Midlands Collaborations for Leadership in Applied Health Research and Care

Recent years have seen dramatic changes to the structure of our public health system in England, triggered by the 2012 Health and Social Care Act. Last month’s Health Select Committee report scrutinises how the changes are working in practice.

In 2013 we saw the return of the majority of public health responsibilities to local authorities, following a 40 year period where public health resided firmly within the NHS.  The Health Committee supports the widely welcomed move of public health to local authorities, noting that they are better placed to influence wider determinants of health.  

The primary threat to public health highlighted by the Committee was the need to step up preventive efforts with less money now available, and the ‘false economy’ of failing to invest, echoing the serious concerns expressed elsewhere, including by representatives of the King’s Fund, Nuffield Trust, Local Government Association, Faculty of Public Health, and Health Foundation.  It has been suggested that the low level of investment signals that the Government views prevention as ‘nice to do’ rather than an essential service.  Only 4% of local authority spending is allocated to public health and the report details the 6.7% (£200m) cut in public health funding that took place in England 2015, with further reductions planned, representing a real terms reduction in overall public health funding from £3.47bn to £3bn by 2021.  The Committee warned that these cuts and the pending removal of the ring fencing of public health budgets needs careful management to avoid exacerbating heath inequalities.  Ben Barr and David Taylor Robinson’s analysis provides insight into how the approach taken to the cuts can impact on inequalities, and it provides insight into how this might be minimised.

The Committee found evidence to suggest that early budget tightening stimulated innovation and promoted efficiency, but that organisations were now reaching their limit.  The report highlights the contradiction between a government which puts prevention at the heart of its policies while failing to adequately resource it.  With a rising tide of morbidity and an ageing population, every year that passes without sufficient investment in prevention, adds to the future human and financial cost. 

The Select Committee identified further limitations in the system, including significant variation in quality, accountability and benchmarking of performance between local authorities.  They highlight tension between politics and evidence in local government, presenting a challenge in terms of addressing health inequalities, particularly in populations who may be perceived as ‘undeserving’.  Pre-2013 Directors of Public Health made decisions based as far as possible on need, but political influence now plays a more significant part.  

Data sharing was also found to be a significant barrier in the post-2013 public health system.  Data regarding health and healthcare was easily accessible to public health teams when they were based in NHS organisations.  In the post-2013 era, teams in local authorities do not have automatic access to NHS information, and difficulties in gaining permissions and access were reported to the Committee.  Data enable the diagnosis, treatment and monitoring of health at a population level, and the Committee recommended that this issue is addressed urgently.  They also identified workforce issues, in particular a need for regulation for the diverse range of professionals working in public health. It was also recommended that public health be given more power to influence local planning and licensing decisions that impact on population health, for example to avoid a geographical concentration of outlets serving alcohol, or fast food outlets near to school premises.

New national public health structures were found to be facing a wider range of challenges post-2013.  The Committee recommended clarification of roles and responsibilities across the Department of Health, Public Health England, and NHS England, to address confusion, duplication and gaps in leadership, highlighting the recent challenges in delivering post-exposure prophylaxis services for HIV as an example.  They also highlighted how national organisations had made slower progress on embedding public health in all policies compared to their local government counterparts, and recommended the appointment of a Cabinet Office Minister for Public Health to expedite change.

The report welcomed the ‘sugar tax’, but unfortunately the Childhood Obesity Strategy, roundly condemned as weak, suggests that the further ‘brave and bold’ action advocated by the Select Committee is unlikely.  The Committee also suggested that the NHS is failing to pull its weight in terms of prevention, missing a huge opportunity to improve the health of NHS patients and staff.

The Committee’s damning report confirms what most working in public health today already know: we have failed to deliver Wanless’ ‘fully engaged’ scenario, where a healthier population places less demand on services, and prevention is significantly underfunded.  This poses a serious threat to the wellbeing and prosperity of our communities, and sustainability of services. 

The new public health system is still emerging, and extensive work and commitment are required to ensure that it can be fit for purpose.  It will take political will and courage to rise to this challenge, and that appears to be far from guaranteed.  Time will tell if Health Select Committee scrutiny and action can influence the direction of travel, or whether public health will find itself on a path of weakening influence and impact.