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One day, the past will catch up with you. Benjamin Franklin once said that an ounce of prevention was better than a pound of cure, and never was that more true of cuts to public health. Does it matter?
NHS budgets are under immense pressure, but that is as nothing compared to the 20-40% cuts in local authorities. When the then PM, David Cameron promised “no cuts to the NHS”, we should have realised that he meant no cuts to the national illness service. Cuts were instead made to non-front-line care, such as public health. As a result of the Health and Social Care Act 2012, public health left the NHS in 2013, and around half went to the civil service, in a new agency called Public Health England (PHE) and half went to “top tier” local authorities.
The BMA’s review “Feeling the squeeze: The local impact of cuts to public health budgets in England” makes for sobering reading. The 5% cuts to public health budgets in 2016/17 when compared to 2013 don’t look so bad, on the face of it. Yet, the NHS, which is under huge pressure, saw a £6 billion (4.8%) increase during that time. Local authorities are raiding every source of funding they can to keep adult and children’s social care going. As this research shows, cuts to public health provided and commissioned services are widespread and not related to population need.
Not everyone appreciates this, but included in the public health handover to local authorities was
79,000 preventable deaths still occur annually from smoking in England, but Bromley has decommissioned its stop smoking service entirely. Interestingly, in Bracknell Forest, Berkshire they have moved onto an app driven service which might provide a more supportive environment. Smoking cessation rates ARE falling, but the harm from indolence, alcohol and obesity mean that more needs to be done. Savings should not be swallowed up in internal accounting exercises, but spent on need rather than what is popular.
If the “no NHS cuts” intent was to avoid harming front-line services, cuts to public health have exposed that as a fallacy: cuts in funding apply to GUM clinics, access to LARCs, cuts to GP provision of stop smoking services, and also health visitor and school nurse provision. When the NHS is under such pressure, cost-shifting is taking place from local authorities to hard-pressed trusts and primary care. The argument by local councillors is that better use is being made of scarcer resources, but it is just shifting the costs onto the NHS.
The shame is that public health was the strongest advocate for evidence-based policy and services in the NHS. This research shows that the cuts are taking place at random, without any link to need. Nor is there anyone to hold them to account. In my experience, transparency helps expose difficult decisions to wider scrutiny so why aren’t shifts in funding supported by a Health Impact Assessment, showing the clear population benefit for alterations in service, as well as elucidating the harms and the mitigations against that harm. In my opinion, this HIA should be published in the Director of Public Health (DPH) Annual Report as an addendum. Perhaps a shift of more than 20% should trigger such a process, and be part of the due diligence required by PHE for the Grant? Transparency and accountability are excellent hallmarks of a high quality function. Why not also publish - in the DPH Annual report - routine audits of the effectiveness and cost-benefit of the new model of service perhaps 18-24 months after the new service model beds in? Local Authorities are obliged to print the DPH report, so it provides a great vehicle for transparency...especially if this is something PHE look for.
Evidence of impact and evidence of effectiveness are sorely needed. The cuts in public health have also led to a reduction in specialists in the field, meaning there are fewer people able to carry out these tasks. The problem is that policy made by fiat/diktat/accident is probably wrong, may cause more harm than good, and will be wasteful. We should all be concerned. Perhaps the NHS needs to reinvent public health all over again?
Dr Sohail Bhatti is the public health medicine committee deputy chair for local government
Excellent summary of the reality in many local government areas. Thk you