The opinions which follow are entirely personal and do not claim to reflect those of or have endorsement by any organisation.
Folk will doubtless have read of the proposals by the Chancellor to cut £200m from the local authority public health budgets in year. We still await detail of what is proposed.
David Buck, from the King’s Fund, gives an excellent breakdown in today’s LGC (Local Government Chronicle) of why this is much more serious than initially suggested. David says that
“many unanswered questions remain, including how this relates to the transfer of children’s services from the NHS to local government planned for October. This will be worth more than £800m each year.”
David recounts that the proposal comes on top of a standstill in public health funding. Secondly, he says it seems to contradict the commitment to Prevention echoed in the NHS Five Year Forward View, and then, thirdly, reminds us that many of the services commissioned by Public Health are commissioned from the NHS. Despite the recent commitment to protect the funding of the NHS. This will impact on the NHS, and directly. But David’s most telling point is to warn of wider consequences:
“Locally, it could easily create perverse incentives that lead away from integration. Why would clinical commissioning groups enter into pooled budgeting arrangements with local authorities, when they know their funding is safe and sacrosanct but local authorities’ money is not?”
David’s piece is here, and is well worth a read. Equally, Keith Cooper’s editorial comment in the same issue is extremely good at highlighting how this proposal will have a wider impact than just local government.
Apart from being really quite incisive sets of comments, it’s heartening how the local government press has taken enthusiastically to the potential which public health has as part of the local government family.
We are, I think, just beginning to articulate the possibilities that prevention could deliver for better lives, better health and a more sustainable public purse. It’s entirely right that the Government of the day usually has expected and should expect its public officials to deliver the “Four Es” – Economy, Effectivness, Efficiency and Equity – from public spending, especially in an era of austerity. I just think that there are much more effective and far-reaching ways of doing it than applying a poorly thought through £200m clawback.
This was highlighted yesterday and this morning with the launch of the ‘Smoking Still Kills’ strategy where the argument for preventative services is expounded; and the success to date of reducing costly and painful death and disease from tobacco is evident. Giving preventive activity time to embed really can yield differences. Locally our new approach to drug recovery is reducing the spend on residential rehabilitation and the cost to social care. There is money to be saved here, but we need to do some lateral thinking. Prevention can be made to work, but only if we see it as a system, and work as a system.
There is no way the current £200 million proposal can happen without impacting on the NHS
At an estimated 7.4% of in year public health spend, it is highly unlikely that Local Authorities will be able to achieve efficiencies across all areas of current public health spend without affecting the statutory Public Health services (e.g. sexual health, health checks ) or other NHS services which constitute a considerable proportion of the public health grant and service investment (e.g school nurses, health visitors). David Buck points out that not cutting NHS servics is a Government Manifesto commitment.
Page 38 of the Government’s Manifesto reads
“We will support you and your family to stay healthy. We are helping people to stay healthy by ending the open display of tobacco in shops, introducing plain–packaged cigarettes and funding local authority public health budgets. We will take action to reduce childhood obesity and continue to promote clear food information. We will support people struggling with addictions and undertake a review into how best to support those suffering from long-term yet treatable conditions, such as drug or alcohol addiction, or obesity, back in to work.”
As a public health professional this is inspiring. In fact, we have two social enterprises in Hertfordshire who spend all of their time getting people into work after battling drug and alcohol dependency. And they do a good job. I was hoping to expand this ethos more widely to mental health and other long term conditions but without being able to use public health money for investment, it’s unlikely the money will come from anywhere else. The current proposal to cut £200m is not the way to help the local health economy’s existing plan for delivering those commitments, or prevention savings more widely.
Alternative Efficiency Proposals in the short term
Some colleagues and friends have been in discussion with me. And I have shamelessly purloined some of their ideas here. (You know who you are, and thank you.) If £200m really has to be saved from NHS spend this year, (and remember much public health spend is actually spend on the NHS) then I think a more constructive approach would be to:
- Give Hospital Trusts a £200m target to reduce avoidable costs from procurement and agency staff commissioning. The ‘Carter Report’ widely trailed in the news today suggests that Hospitals may not be gaining the £400m in procurement and agency savings alone they could reap in these areas[i].
- Give NHS Trusts a £200m target to reduce ‘interventions of limited clinical value’ in NHS provision. The Academy of Royal Collages Report (November 2014) suggests that 20% of all health care activity is effectively over-treatment as it ‘brings no benefit to the patient’[ii] .This could be done without harming health outcomes.
- Introduce a Sugar Duty at 20 pence per litre in England[iii]. The impact nationally over twenty years would be to:
- reduce the cases of diabetes by just under 50,000
- prevent almost 9000 cases of cancer
- reduce strokes and cases of coronary heart disease by over 33,000
- save the NHS at least £15million a year in healthcare costs for treating those diseases.
- improve the quality of life for tens of thousands of residents.
4. Introduce the levy on the tobacco industry called for in Smoking still kills. This could pay for the cost to local government of social care, cleaning, litter, smoking cessation, tobacco control and other measures; and the cost to the NHS of treating diseases attributable to smoking like COPD, cancer and even Diabetes as identified by the recent report of the US Surgeon General.
All of the first 3 measures above are evidenced based (references in footnote below), would reduce costs, would bring clinical benefit to patients, would improve health outcomes for citizens and would improve NHS productivity without reducing its capacity to prevent future demand. The fourth measure is argued for in Smoking still kills.
Additional Efficiency Proposals in the medium term
Obviously we would and could make further savings by doing things differently. Preventing diseases from escalating or worsening and treating as quickly and cheaply as possible continue to be options which we can explore further. Here are just five of my list of candidates for saving money while improving health:
- Make greater use of pharmacy for minor ailments and long term conditions
- Drive down the cost of consultations and polypharmacy in multimorbidity by delivering models of care which address multimorbidity per se, rather than accumulating niche guidelines, treatments and consultations for multiple individual conditions. And please don’t say we’re doing that. The last 29 conversations I had on this with clinicians had one consensus point: we can do a lot better.
- Invest in self management – there are promising models here.
- Identify early high risk of escalating disease and disability and keep people at optimal levels of functioning through good pathways and practice.
- Learn from the five best countries in the world about keeping people with long term conditions economically active (eg in the workforce).
There are, with some thought, good implementation science and hard work, many places from which we could save sustainable sums that will be multiples of £200 million. And we could improve health into the bargain. It wont be overnight. The way to do it is focus the public health, local government and NHS workforce on prevention and quality, not chasing short-term cuts. You don’t even need to invest here; just don’t cut to transform and save.
[i] Academy of Royal Collages (2014) Protecting resources, Promoting value: A doctors guide to cutting waste in clinical care http://www.aomrc.org.uk/publications/reports-a-guidance?view=docman
[iii] The Children’s Food Campaign has published a tool that allows people to view the impact a sugary drinks duty could have in their local area. The figures, available on www.childrenshealthfund.org.uk show that the introduction of a duty on sugary drinks could reduce rates of diet-related diseases by tens of thousands, as well as save the NHS and public health budgets in England £300 million over twenty years.