Against a backdrop of substantial change in the way public health services in England are commissioned, and increasing funding pressures on local government, the QualityWatch programme today publishes its latest report, Focus on: Public Health and Prevention.
Combining quantitative data from 20 indicators across five key areas of public health with a survey and in-depth interviews with senior public health professionals, the report provides a glimpse into the current state of public health services and explores the potential impact on key health outcomes.
As yet, there hasn’t been a marked change in quality indicators. Looking at quality measures across stop smoking services, sexual health, immunisation, childhood obesity and substance misuse, the majority of public health indicators continue to follow past trajectories. Some service areas are continuing to deteriorate and some are continuing to improve. Differences in trends across local authorities were evident. The most deprived areas had worsening trends in rates of sexually transmitted infections – with striking increases in gonorrhoea and syphilis – but did demonstrate significantly better improvement in teenage pregnancy rates compared to the national trend. The complexity of public health makes it difficult to attribute changes to any single factor, whether legislative or financial.
Survey evidence from a sample of senior public health professionals (n=37) presents a mixed picture of opportunities and implementation difficulties from the Health and Social Care Act 2012. The Act was generally welcomed by survey respondents as an opportunity to improve public health services, through strengthened procurement by local government and more opportunities to work across council functions.
“Local government is much better at procurement and contract management than the NHS. Once out of the NHS system it becomes apparent how stifling the top-down NHS approach to this is.” [Survey respondent]
However, some survey respondents also reported that the changed environment has led to organisational problems which may have an impact on quality, including fragmentation of services across local government and the NHS, an increased burden of commissioning for local authorities and providers, and reductions in public health input into NHS commissioning in some areas.
The issue of funding has changed the context for delivery of locally devolved services. Survey evidence from senior public health professionals, and interviews with 11 directors of public health and 11 provider and advocacy organisations in public health, indicates that financial issues will be a key challenge to prevention over the next five years. While public health funding is ring-fenced, overall local government funding has substantially reduced, leading to concerns about the sustainability of local services and the loss of local capacity and workforce needed to deliver services. It was felt by some that this context could make local decision making about prioritisation of services challenging.
”Local relationships [are] currently very good but could be threatened by constant pressure on all parties. The council has shown great interest in public health and willingness to engage across all directorates, but financial pressure is huge and even with [the] ring fence, councils across the region have sought to use public health funds to prop up other services.” [Survey respondent]
So, while quantitative indicators do not show a marked change in outcomes resulting from the changed legislative and financial environment, qualitative evidence points to concerns about increasing difficulties ahead in the form of tougher prioritisation decisions and maintaining effective and equitable access to services with diminishing funds. QualityWatch and other monitoring programmes should carefully track any impact on the quality of services.
The potential to improve the public’s health by addressing the wider determinants of health within local government is well recognised, as is the NHS’s commitment to prioritising prevention. However, system-wide financial pressures may mean these aspirations are difficult to achieve.
As one survey respondent wrote: “The risk is, as money is tight, people do not collaborate and share, but it is in everyone’s interest to get prevention right.”