The public health function should be moved back to the NHS

This is a call that crops up an awful lot. It is not a view that is held by many of the public health profession.

I should be clear the below is no sleight on the NHS itself, nor my NHS colleagues. It is an observation, having had experience of public health in both the NHS & Local Government, on the best home for the function.

Here, for the record, I set out a few thoughts

1. On the rationale and aftermath of transfer

Read Eugene Milne’s blog. Especially the points about confusion about what PH is / isn’t and the reinvention within the NHS (not resourced though)

2. On the PH Grant

Of course cuts to the public health GRANT are a false economy, and in effect cuts to the NHS. We all know this. We can cut it less and sack more social workers if you’d like? Few votes for that either.

2a. stop smoking services seems to be the focus of a lot of current angst

DsPH don’t need reminding of the harm caused by tobacco and it’s deeply patronising to suggest that they don’t care about it or they need reminding of the evidence that supports action.

It is worth saying that there is no clear relationship between declining smoking prevalence rates and investment in smoking cessation services funded by the state – cultural and policy interventions may be more effective. Paradoxically I think smoking prevelance has declined as has smoking cessation funding – but this is because tobacco control policy and strategy has become more effective.

#publichealth services are mostly trying to buy back the health that is lost due to public policy failures. Smoking rates in Scotland dropped from 31% in 2003 to 21% in 2016, it coincides with a 28% reduction in the use of NHS Scotland stop smoking services, whose use has continued to decline by a further 5% every year since. The cuts experienced in England reflect similar changes in services in the devolved nations.

The same might be said in any area of service funded by the grant.

2b. Of course there’s been some “budget raiding” in many towns.

Less than you’d think (notwithstanding some notable and well published exceptions). It’s also often highly appropriate for investment in upstream interventions that benefit individuals, populations and the NHS. I can give you many local examples. I’m happy I meet my legal responsibilities, ensure statutory functions and keep the wheels turning.

Furthermore, consider raiding in context of a) cuts in LA finding over the last 7 years or so. If you can keep the lights on with a massive cut in your budget, well done. It’s what all but 1 authority has managed to do but worrying signs ahead

2c. “it was better in the glory days”

read Jim’s blog. Mainly focussed on sexual health, same could be said of anything

There’s a lot of selective memory out there. Raids on public health budgets are not new. In 2005 Sir Liam Donaldson devoted a whole chapter of his chief medical officer’s annual report to this area

There were no “golden years” of public health funding between 1974 & 2013 …indeed before transition back to local gov, no actual defined separate ph budget in the NHS, merely ” choosing health” monies which were the 1st to be raided to prop up acute demand.

So whilst cuts to the bag of cash are a bit silly, it is a government policy. Complain about that to HMT & DHSC, their agenda. Happy birthday BTW to the NHS, it seems Whitehall CAN find cash when needed. I doubt there will be a birthday present for social care which is also 70, or the National Assistance Act or the abolition of the poor law.

3. the Grant is not “public health”

We all know know 80% or so of what determines health is outwith the NHS, it’s not going to get influenced from outside.

Local Govt is responsible for a vast array of services, has thousands of responsibilities and duties, almost all of which are “public health” in some way shape or form.

The job of PH in local govt is to improve health, not to commission or provide some services paid for by a bag of cash called the public health grant.

The Statutory Duty = to improve health of pop, not to provide some PH services.

Being “in” the organisation that’s responsible for many of the things that determine health in places we live matters. Being “in” local democratic organisations matter, and matters a lot

The asset stripping of local government is a public health disaster. The services funded by the ring fenced budget are small beer in the bigger context.

4. Concluding thoughts

PH in local govt was never a drag and drop exercise, change was always going to happen.

We can’t commission our way out of (insert public health topic) solely by focusing on the services within the Grant. We need to move upstream, if nothing else THAT was the point of the transfer.

My observation is that most of those who call for public health to be returned to the NHS haven’t worked in town hall public health. In my experience most of those telling me the transfer to local government was a disaster don’t actually know the history of public health, don’t understand its breadth, depth & scope, don’t understand the role of society & systems or that modern medicine is only possible if you have resilient civic functions like housing, education, environmental services, social care.

Next time someone at national NGO level or a royal college criticises local government over public health cuts or demands something moves to the NHS I am going to invite them to try doing the job at local level for a month..starting with balancing the books. #cutshaveconsequences

On the transfer of PH function from NHS to local govt, I’ve yet to find a DPH that agrees with the proposition to move the function back to the NHS. Including me.

Thanks to colleagues who contributed thoughts

Scott Lloyd, Jim McManus, Kate Ardern, Dave Buck, Paul Ogden

Others if I forgot them