This April marked five years since public health transitioned from the NHS to local authorities in England. A recent Association of Directors of Public Health survey found 67% of respondents strongly or somewhat agreed that the move had weakened the relationship between public health and the NHS.
However, a recognised feature of the transfer has been improved quality of commissioning. That many services are now delivered more cost-effectively than in the NHS partly undermines judgments based purely upon spend—reduced funding is not necessarily a service cut. For example, my own council (Newcastle upon Tyne) spends around half as much on Stop Smoking Services as at transfer, but had an increased rate of supported quitters in 2016-17.
A driving force, perversely, has been centrally-imposed, counter-intuitive, and ultimately counterproductive cuts to the public health grant. Tighter specification of process and outcomes, and more disciplined procurement have buffered us, but there is a limit to better commissioning. Many would argue it was passed some time ago.
Moreover, for services with a long-term, cumulative effect, the calculus of commissioning, with its excessive emphasis on short-term, institutionally-specific returns, makes little sense. Standard NHS health-economics fails in this context. Nobody buys cheap QALYs in prevention because benefits are long-term and accrue somewhere else.
Councils are not immune to these pressures, but have the enormous additional burden of austerity. It seems more forgivable to question the value of obesity services when the alternative is closing Children’s Centres.
Ironically, the departure of public health has driven NHS England to attempt a kind of re-invention of the discipline. Having, encouragingly, talked up prevention in the Five Year Forward View, its approach has yet to reach first base. It lacks a grasp of the principles of screening (an argument, in fairness, made also about health checks), or the Rose hypothesis (i.e. shifting the population distribution of a risk factor prevents more disease than targeting people at high risk). In establishing a diabetes prevention programme, it opted for top-down commissioning of providers—often with no local presence—rather than building upon community assets and social value.
NHS confusion over public health reached its apotheosis in its court case over Pre-Exposure Prophylaxis (PrEP) for HIV. PrEP, it argued, was prevention and, therefore, public health and, (also) therefore, not its business. The court said otherwise. Prevention remains part of what the NHS should do. In the meantime, the NHS funded “Healthy New Towns”—an initiative than which it is hard to imagine anything more “public health.”
Part of the NHS reaction may be a backlash against clinical perceptions of budget-raiding by local authorities. Despite the Health and Social Care Act’s clarity that local authorities should determine the best interests of their communities, the NHS seems surprised when they actually do so. At times, there is a quite palpable sense of outrage that councils should choose to do other than what was done prior to 2013.
80% or more of 20th century mortality reduction resulted from factors other than health care. Yet society remains persuaded that we are on the threshold of a new era in which medicine drives that progress—as it has been for at least 50 years, while non-clinical factors continued to make most of the running.
I was told by a senior NHS colleague that parks are not an appropriate public health spend. The King’s Fund disagrees, as do I and, one must assume, does NHS England unless its Healthy New Towns are to have no parks (replaced, perhaps, by Diabetes Prevention Centres).
Local authority public health will get tougher with business rate retention and loss of the “ring-fenced” grant. No-one is yet clear how the former will operate, and the latter divides opinions. Avoiding inequalities if some authorities take public health more seriously than others will be a challenge. Yet we should not stifle the creativity that local accountability can bring.
The NHS reorganisation by stealth that has morphed from Sustainability and Transformation Plans, to Integrated Care Systems (ICS) needs to acquire local support that it currently lacks. The NHS cannot claim local engagement without genuine local responsiveness.
Local authorities are a natural vehicle for this, with a local legitimacy that the NHS lacks. The pace of change in public service configuration rarely awaits evidence but, if we are to move toward an ICS-based system, the terms of the shift need to be subject to proper and open discussion. Local authorities have a key role to play in this.
The experience of public health in local authorities forms a basis for some optimism despite austerity. Where it works, it works well. At a time when it is increasingly recognised that if we do the same things as we have always done, we will get the same results that we always got, the transfer of public health suggests alternatives are possible.
Eugene Milne is director of Public Health for Newcastle, honorary treasurer of the Association of Directors of Public Health, joint editor of the Journal of Public Health, and sits on the advisory committee on Resource Allocation and NIHR Public Health Programme Advisory Board. He is a visiting professor at Newcastle University.
Competing interests: None declared.