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After the Spending Review: Public Health in a smaller state?

“This Spending Review finishes the job of reforming the public health system, delivering average annual real-terms savings of 3.9% over the next 5 years. Across the country, councils have already begun to develop new ways to deliver public health, showing that it is possible to deliver better health for local people and also better value for the taxpayer, but there is more to be done. Councils can seek to deliver efficiencies in this area, and can learn from best practice. So it is right that as the government eliminates the deficit, all funding is spent in the best way possible. Public Health England will continue to support local authorities in this process.”

(Source: https://www.gov.uk/government/publications/spending-review-and-autumn-statement-2015-documents/spending-review-and-autumn-statement-2015 )

 

So the Spending Review has happened. In some ways we all got what would happen wrong, the Chancellor surprised everyone, while disappointing many and setting us all wondering. Some of the surprises were pleasant, some less so.

There were some good things. Tax credits, and with it the public health benefits of keeping some families out of poverty is something I am grateful for. The extra money for mental health too, is to be welcomed, assuming it turns out to be real money and not previously announced. We’re still in the process of trying to decipher what’s new, what’s previously announced and what the implications are. But it could have been a great deal worse.

I’m not underplaying how difficult this will be, I’m just saying that it is mixed and there are some things to welcome, while the public health cuts still seem to run counter to an expressed policy aim in Government of saving cost to the public purse by stopping people needing public services.

The Local Government Association’s useful document Prevention: A Shared Commitment (1) and Creating a Better Care System (2) strike me as two major opportunities to assist that expressed policy, which the Spending Review has missed. It seems that local authorities facing ever less money will be forced to turn to demand reduction, prevention and early intervention to make budgets balance. That will require good articulation of what will deliver those reductions in demand and need, a point I will return to.

The Public Health Budget

My feeling on the Public Health cuts is that we should acknowledge that it could have been much worse; and we should recognise that, even though it will be tough and challenging and the cuts will have an adverse impact on the health of at least some of the population. That in no way minimises the challenge or the harm.

The Public Health budget for England will be reduced by 3.9% on average until the end of the current Parliament. Duncan Selbie, CEO of Public Health England stated today in a letter to Chief Executives and Directors of Public Health in local government that on top of the 6.2% cut (the £200million) in the current financial year there will be cuts of 2.2% in 2016-17, 2.5% in 2017-18, 2.6% in each of the two years after that and then flat cash in 2020-21. By this time the ring-fence will have gone anyway and public health will be funded from Business Rates.

Public Health in context of Local Government Finance

The LGA estimates that overall council budgets will fall by 24% by 20-21. The Chancellor has allowed councils to protect social care, at the expense of a 2% increase in council tax. This may raise decent amounts in some areas, but in some smaller and northern authorities it may raise little. The move to allowing councils to retain business rates is also nothing like as simple as it seems, and we will need to be alert to the issues for the whole council as well as Public Health in this move.

For some time Social Care and Public Health have been noisy, wicked and troublesome problems in political terms. It’s worthwhile considering this when we think about the Chancellor saying to local councils in England that they can pay for Social Care by a 2% precept on council tax  and Public Health can go into business rates from 2018. Depending on which way you look at it either the Chancellor has given local areas total control or he has put the solution – and the blame – for two noisy aspects of the local government portfolio away from Whitehall. If you can’t raise enough money to prioritise and pay for social care and public health through these new powers (despite the inequalities in how much different areas are capable of raising because of their taxpayer base), well, central government can’t be blamed. It’s those local councils not doing what they should.

Moreover, the debates on the target per-capita of funding and the formula for it may also be a casualty of this new finance shift. If public health funding goes into business rates, the idea of getting to a target for public health funding may go into the local, not the national realm. If councils don’t want to fund their public health functions to target, that’s their choice, the rhetoric might run, and not a matter for central government. The electorate can make its views known at the ballot box. The government’s statement that this “Spending Review finishes the job of reforming the public health system” may well turn out to have many more layers of meaning than just mainstreaming public health financially as well as organizationally into local government.

Cut to spend: the wrong approach to Public Health funding

There are those who think Public Health is nanny state, telling people to “behave themselves” or who feel that public health is purely about education. They may not see some of the things which Public Health does, thinking it’s all about campaigns on diet or alcohol. This is partly our job to let people see what we do.

Let’s be clear, the evidence that well chosen and well prioritised public health services save money for the state while preventing worse outcomes for the person is strong, clear and consistent (3,4). Investing in well chosen public health is an investment to save. Cutting those is a cut which will serve only to cost the taxpayer more later. Yes, there are some things in public health where one may wonder “why are they doing that?” but from smoking cessation through weight management to sexual health and drug and alcohol addiction treatment the evidence of effectiveness and evidence of return on investment is solid. (3,4)

So what would happen if we cut public health services?

  • If we cut health visitors:
    • Essential checks on children and young people’s development would not happen, missing developmental problems which disable or limit children in later life
    • Lack of vaccination cover may mean children develop avoidable illness, with complications of measles, mumps or rubella resulting in potentially serious disability
  • If we cut school nurses:
    • we may miss the early detection of hearing and sight problems in children at school, with significant impact on their development and health
    • Children who would get early help for self-harm or mental health issues may get worse before they get better
  • If we cut sexual health or contraception
    • People may not access contraception and as a consequence unwanted pregnancies and abortions, with cost to the state (benefits, nhs treatment etc) will go up (5)
    • People with sexually transmitted infections may not seek treatment with serious consequences for untreated infections, and outbreaks
    • The rise of antibiotic resistant sexual infections will continue, meaning some infections will become ever more costly to treat. The recent outbreak in Northern England by some estimates cost up to fifteen times the cost of first line treatment when you add all the costs together. How do we stop syphilis and other STIs becoming killers once more? What if Lymphogranuloma venereum – a vicious and serious form of chlamydia – becomes antibiotic resistant?
  • If we cut weight management
    • Diabetes cases and cases of avoidable joint and musculoskeletal problems, needing more expensive health and social care as a result, will continue to rise
    • Diabetes will continue to rise
  • If we cut physical activity
    • Older people who would otherwise use physical activity services will be more at risk of deteriorating muscle condition, and more prone to fall. A single fall can cost over £42,000 in health and social care cost
    • The benefits of physical activity for long term conditions and mental health may be lost, with increased cost from medications and other treatments
  • If we cut health checks
    • Undiagnosed diabetes , heart disease and risk factors for stroke in some people with high risk will mean avoidable emergency hospital admissions and even death
  • If we cut drug and alcohol services
    • The significant success of methadone programmes in reducing acquisitive crime could be lost, with increased crime and more drug related deaths
    • Those drug and alcohol services which are working well in getting people into recovery, off benefits and into work may stall. Meaning people remain dependent on benefits and services when they could be working and contributing to the economy
    • We will see increasing and very costly numbers of people with Hepatitis C
  • If we cut smoking cessation services
    • People with mental health problems, who make up 64% of all tobacco consumption in England, will continue to smoke and die earlier than the rest of the population, and will continue, on average,to need up to a third more medication because of smoking, costing us more money on drugs and care
    • We avoid the benefit of moving people who have been very resistant to giving up smoking to things like e-cigarettes. This means far from seizing the opportunities presented by ecigarettes we end up cutting smoking cessation services AND people who keep smoking tobacco will still cost us large sums in health treatment. How to snatch defeat from the jaws of victory.
    • Routine and manual workers and some other populations will continue to die earlier

I also fear for what this will do to antibiotic resistant disease. We are seeing more infections resist even our strongest and most costly antibiotics of last resort.  There are no new drugs coming down the pipeline for this anytime soon. It is serious.  We are already reaping the cost of rising antibiotic resistant TB – a condition that cost £750 in drugs to treat can now cost up to and over £7,400 to treat, and in a few cases it hasn’t been treatable. People have died.  Antibiotic resistance is real.   I really am not being melodramatic. There is a real prospect this may happen.

Some of you may disagree with me, and some of you I know think Public Health should be much smaller than it is, because you tell me on social media. But there is a moral case to try to keep people healthy as well as an economic case. The cuts mean that there are some areas of the business public health teams are currently in that we may need to get out of. How do we do that without harming people, and without adding to the burden of health faced by those already most burdened by ill-health and its determinants?  I’m not against saving money, but we should not seek to save money in ways which will end up costing more. That’s not just bad economic sense, it’s immoral.

And I still think as I blogged some months ago there are many other areas which this spending review seems not to have touched where savings would be easier to make than these (6),  would be bigger in amount in the short and the long term, would be sustainable and would not just create cost elsewhere in the system through false economy.

The challenges for public health

But now is not the time for despondency. Those of us working in Public Health – elected or appointed – face the challenge of trying to sustain what we can of the public health system (the hard end of public health) with retaining that portfolio of services which promotes and protects the health of the public most equitably while doing least harm. This is a test of our mettle like never before.

But there is another, and deeper, challenge. It seems to me that we are at the beginning of another journey which is at least an implicit political choice by government – we are moving to a much smaller state after nearly twenty years of comparative expansion in the public sector.

This second, and bigger, challenge for public health will be how we help public services become more preventive, shifting people to not needing services as much as possible, so when people do need services we can intervene and support. This will test and stretch the public sector to its limits. It is something we in public health must rise to.

There is, too, a third challenge, the enduring fiscal challenge which is the NHS. But more about that below.

The size and shape of the state – a deeper signal amidst the noise?

The signal the Spending Review sends is not just one about repaying the deficit. There seems to be a conscious choice to reduce the size of the State, as the diagram below shows. In a state where most people learn to be independent and can look after themselves, that’s not necessarily a bad thing, because the state can focus on enabling people, and on helping those who really need it, and there will always be those who need it.

 

spend as portion of GDP

 

(Source: http://www.ukpublicspending.co.uk/spending_chart_1970_2016UKp_15c1li011lcn_F0t_UK_Public_Spending_As_Percent_Of_GDP)

 

Public Health focused services could have a natural role to play in a society which is like this, supporting people get the best and healthiest start in life and ensuring the most vulnerable and those who bear the worst burden of ill-health get best opportunity for best health achievable for them. We face a challenge to articulate the preventive and protective role of public health in a smaller state. Our time starts now. And we are not there yet.

A third challenge: whither healthcare in a shrinking state?

But if the size of the state is shrinking overall, what about the NHS? The Spending Review not only protects NHS spending but increases it. In England the state is putting £8 billion more in, and as a portion of GDP spending on health care is increasing in the UK and in England. Our spend on healthcare by proportion of GDP is nowhere near that of the USA (18% and rising.) But it isn’t insignificant, by any means.

 

healthcare percent gdp

 

(Source: http://www.ukpublicspending.co.uk/spending_chart_1994_2014UKp_15c1li111lcn_10t )

Are we really getting value for this? More spend doesn’t equal more quality. The US was recently ranked last of eleven countries for health outcomes despite its spend. The big lesson here is if we fail to reduce inequalities in access and outcomes it won’t matter how much money we put in people will die avoidably. (7) The UK in 2015 was ranked 28th out of 30 countries for our health system by the OECD (8). We have a lot of room for improvement in what we do, and pouring more money in is not in and of itself the answer.

Moreover, if the rest of the state is shrinking overall, that means health care will eat up an increasing share of public spending, which has to be diverted from other areas to feed the demand.

The UK NHS does amazing things, but simply pumping more and more money into the NHS system to inexorably increase the proportion of GDP it consumes, without concomitant rise in health outcomes, is not sustainable when a political choice seems to have been made by the Chancellor to shrink the state overall. Why would you not focus on sorting out the system?  Simon Stevens says he wants to do just that.

I fully support the ambition of Simon Stevens for prevention in the Five Year Forward View. But this requires a systematic application of public health skills across the system, and not just pumping more money into the NHS. Equally, the answer is not to run new prevention programmes in an entirely NHS driven silo because someone has decided intervention fidelity conquers all other considerations while local existing prevention infrastructure like physical activity infrastructure is left to wither. That will waste money needlessly.

It strikes me that there are three opportunities here for public health:

  1. The opportunity is to really get stuck into the opportunities for prevention across the system of local services, especially where we might be able to prevent the fast impending tsunami of cost from long term conditions and avoidable disability coming at social care and the NHS. No amount of money pumped into the NHS will ever be enough unless we do it differently and preventively. It’s time to turn policy talk into service reality.
  2. That, unfortunately, requires us to work in an area where the evidence for secondary and tertiary prevention is at best lacking, and yet little of our public health science infrastructure seems interested in working on it. But it is an area of pressing need. How do we as public health specialists – in academia as well as in commissioning and provider organisations – articulate to the NHS, social care, housing and other local government functions what are promising routes to save costs, avoid disability and prevent early death in these areas? This could lead to a new impetus in public health science. Because we desparately need it. That means the NIHR School for Public Health Research really needs to rethink its priorities in this new context.
  3. We have an opportunity for a renaissance of service quality public health, and not just what we called healthcare public health. Service quality in social care, childrens services and other areas could benefit from the development and application of public health skills to these challenges. How do we keep people out of hospital? How do we improve primary care to reduce the risk of them needing more healthcare? How do we work as a system across public, commercial and voluntary sectors to keep people healthy, minimise the burden of disease and reduce cost to the state? For example, what could public health do to design a system which reduces the cost to police, probation, housing, benefits, health and social care from adults with very complex issues? This should be the kind of place where public health could excel. IPPR produced a report on this earlier this year (9). Hertfordshire launched a programme several months earlier, even before IPPR produced its report (10), and I am excited to be the Sponsor of this. This is where we should be.

The next five years

To lead in Public Health for the next five years is not just about revisioning the footprint of public health services, though that is vital. The opportunity is to renew Public Health from first principles and rise to the challenges above, helping the system respond. We must monitor and make transparent both where we are successful, and where these cuts harm.

I was tense on Tuesday, worried on Wednesday, and troubled on Thursday. It’s Friday…I’m firmly resolved we need to do it differently . Time to get started….who’s with me?

 

References

  1. http://www.local.gov.uk/documents/10180/6869714/Prevention+-+A+Shared+Commitment+(1).pdf/06530655-1a4e-495b-b512-c3cbef5654a6
  2. http://www.local.gov.uk/documents/10180/6869714/Creating+a+better+care+system+June+2015/0692d75a-5c26-4b85-a2b5-9e7dd59b455e
  3. http://jpubhealth.oxfordjournals.org/content/early/2011/09/20/pubmed.fdr075.abstract
  4. http://www.local.gov.uk/documents/10180/11493/Money+well+spent+-+Assessing+the+cost+effectiveness+and+return+on+investment+of+public+service+interventions/25c68e94-ff2c-4938-a41c-32853b4d4a9d
  5. http://www.fpa.org.uk/influencing-sexual-health-policy/unprotected-nation-2015
  6. https://jimmcmanus.wordpress.com/2015/06/11/a-bit-of-thinking-on-saving-the-country-200m-and-much-more/
  7. http://www.commonwealthfund.org/publications/press-releases/2014/jun/us-health-system-ranks-last
  8. http://www.oecd.org/els/health-systems/health-data.htm
  9. http://www.ippr.org/publications/breaking-boundaries-towards-a-troubled-lives-programme
  10. http://resolving-chaos.org/Hertfordshire
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