The Treasury’s announcement of a £200m cut to “non-NHS” funding has raised alarm bells amongst professional organisations from the Faculty of Public Health and Association of Directors of Public Health to the Royal College of Midwives – and rightly so.
Here we go again – the need to identify financial savings has resulted in cuts with short-term benefits to the public purse but which will have a significant impact on health and therefore increase costs in the long-term.
The announcement is at complete odds with NHS England Chief Executive Simon Stevens' vision of “a radical upgrade in prevention and public health” and for the NHS and partners to get serious about prevention, as he outlined in the Five Year Forward View. This is a vision he reiterated last week at his speech to the NHS Confederation Conference, and one which is beginning to take shape – with the launch of the “first ever national evidence based diabetes prevention programme at-scale” in March, bringing together NHS England, Public Health England and Diabetes UK to prevent Type 2 diabetes.
The “£200m in non-NHS cuts” announcement raises questions about the signals the Government as a whole is sending about getting serious about prevention.
A cut to prevention and public health in Local Authorities does not save money, nor will it be achieved without an impact on the NHS.
Why is prevention important?
Because prevention and effective management of long-term conditions is likely to be more cost effective than treating the illness as it occurs. The Department of Health estimates that 70 per cent of the NHS budget is spent on long-term conditions, yet it is estimated that only four per cent of the total healthcare budget is spent on prevention.
Many preventative interventions are cost effective, including those addressing smoking, excessive alcohol consumption, physical inactivity, sexually transmitted infections and substance misuse. NICE concludes that “public health interventions are a good use of public money".
Is it really "non-NHS" funding?
Following the Health and Social Care Act 2012, the responsibility for commissioning local public health services was transferred from the NHS (primary care trusts) to Local Authorities.
Each year the Department of Health , via Public Health England, provides a public health grant to each Local Authority in England to support delivery of public health functions. The funds are used to commission a variety of services, some mandatory (including sexual health services, NHS Health Checks, national child measurement programmes) and others to address local priorities, such as stop smoking services; weight management programmes; and substance and alcohol misuse services.
Many of these functions benefit the NHS in the long-term, for example supporting pregnant women to stop smoking through stop smoking services will reduce complications at birth and improve the health of both mother and child in the longer term.
If we want the NHS to be sustainable we need to consider supporting other funding streams which support people to live healthy lives through other means. The cuts to public spending spanning welfare, housing and social care will all ultimately make it even harder for the NHS to do its job.
What to cut?
The £200m cuts equate to seven per cent of the 2015/16 public health grant (the total is £2.79bn) and according to the HSJ must be found within this financial year. Locally there will need to be decisions on what to cut, which will be difficult if contracts for certain services are agreed for this financial year. In a Director of Public Health position would you rather cut alcohol misuse services or a new initiative to support teenage mothers in your area? It’s a decision no-one wants to, or should have to, make.
Today there is a 20 year gap in healthy life expectancy between those living in the most affluent areas compared to those in the least advantaged areas. The cuts come at a time when should be investing more in prevention not less.
The only threat to the local public health budget?
The announcement makes me wonder if the prevention budget in local authorities is slowly eroding away. The public health grant is ring-fenced until 2016, to be spent on addressing local health needs and the Director of Public Health and Chief Executive of the local authority must provide assurance to the Secretary of State for Health that the money has been spent appropriately to improve health and wellbeing.
However, with a 37 per cent fall in local government funding from 2010/11 to 2015/16, there are concerns that there is pressure on the public health budget to fill gaps elsewhere. Removal of the ring fence may confound this further.
Long-term vision versus short-term challenges
Once again, addressing the short-term challenges has won over addressing the longer term needs of the population health. This announcement is in danger of reinforcing the view that that public health functions including prevention remain nice-to-have but non-essential. Interventions to address smoking, excessive alcohol consumption, physical inactivity, sexually transmitted infections and substance misuse cannot be seen as an added extra for health budgets.
Why is the message on focusing on prevention not getting through?
Davies A (2015) ‘£200m cuts to public health: the situation is getting serious’. Nuffield Trust comment, 16 June 2015. https://www.nuffieldtrust.org.uk/news-item/200m-cuts-to-public-health-the-situation-is-getting-serious