Councils Can be trusted with Public Health
This is an extended version (for the public health dorks and nerds) of a piece which appeared in LGC . Thanks to LGC for permission
Jim McManus and Greg Fell
Jim McManus is Director of Public Health for Hertfordshire and Vice-President of ADPH. Greg Fell is Director of Public Health for Sheffield and Hon Secretary of ADPH.
Much of those bits of Public Health that were in the NHS have now been back in local government in England since 2013. The Health Select Committee acknowledged evidence from Public Health England that 80% of outcomes for which local authorities were responsible either stayed the same or improved despite significant cuts to public health. The Local Government Association and County Councils Network both published reviews of how local government had delivered on Public Health. The Select Committee report on Sexual Health and the Government’s own review in 2019 both concluded there was no case to move commissioning away from Councils.
This week sees another, independent, report speaking into this field. The King’s Fund report The English Local Government public health reforms: an independent assessment The report assesses the transfer of public health to local government and reaches a number of important conclusions:
- Public Health Directors and their teams are well embedded and have helped make councils the home of prevention
- Strong links have been formed with different council departments, outcomes across the vast majority of indicators are good and there are widespread examples of innovation
- This is against the backdrop of significant cuts to local government and public health specifically; as well as other key areas of spending like welfare, early years and criminal justice
- The report says there is a cllear agenda for the 2020s – focusing on keeping performance and outcomes strong, working council-wide to shape healthy places and continuing to improve collaboration with the NHS and other partners
- The report says that to achieve improvements in public health, the Government must increase spending with a long-term settlement and develop a coherent policy agenda to address the social determinants of health and wellbeing across Whitehall departments
The report systematically looks at what has been achieved and builds on earlier reports, reviews and studies. And it’s independent. There are some crucially important lessons from this report.
First, the transfer was about much more than lifting and shifting a bunch of services. The King’s Fund points out that the Government itself said in 2010 that “to… avoid the problems of the past, we need to reform the public health system. Localism will be at the heart of this system, with responsibilities, freedoms, and funding devolved wherever possible.” The Public health reforms “had a wider purpose, for public health teams to influence and support wider local government decisions that impact the public’s health.” Our health starts and ends way beyond the walls of hospitals and clinics – the education we get, the places we live in, the amenities we can enjoy, the work we can earn from and the environment we live in are all crucial. These are the areas where councils can influence. And the report concludes “the move to local government for many public health services was the right one. More important still, in the long term is the opportunity this has to influence wider local government policy and decisions; now is the time to make good on the opportunity in the context of the development of place-based population health systems. “
Second, there was undoubtedly a job of transformation to do on some services. This has undoubtedly been difficult for some and hard work for all. The Economist in May 2019 reported that sexual health, largely because of the burning platform of significant government cuts to the public health grant against burgeoning demand, has been the sector of health care which has perhaps seen most innovation in the last six years. Where that has worked that has been down to local authority commissioners and provider partners working together. The Economist concluded this probably would not have happened at the same scale and pace in the NHS. The narrative that all was fine in the NHS was simply not true, however great the NHS is. We all – from whatever sector – need to improve.
Third in my view comes the issues of connections and systems approaches. Most public health services have far more links with council services than they do with other NHS services. Health Visitors and School Nurses, for example, are now working in integrated early years or young peopes’ services in many areas.
None of this is saying the cuts to public health were a good thing. Quite the opposite. While they forced innovation, they undoubtedly had consequences. The report itself says that the transfer cannot be considered in isolation to the cuts…and that the reforms led both “to significant innovation” but “ there has been some fragmentation of commissioning and provision, particularly in those service areas that are interlinked with NHS provision, for example, sexual health, and drug and alcohol services.”
So we now have a series of reports and reviews, this being the most systematic, which concludes the transfer was broadly right. Ever since the transfer we’ve had a slowly declining number of commentators and agencies – who have never tired – despite lacking any decent evidence – of lining up to say the transfer was a mistake, everything was better before 2012 and using the words of one national organisation, called for the “failed experiment in commissioning” to end. This report has already invoked the noise of those who will never be happy until someone they agree with concludes we should send it all back to the NHS.
This report confirms my resolve to give them no more air time. Despite the cuts, this report shows their calls have missed the point, and it would be folly to heed their counsels of despair.
Significantly, the King’s Fund in 2019 joined forces with every major Health Think Tank and over 55 national health charities and expert bodies calling for Government to reverse the public health cuts and invest in Public Health. And its report concludes that “the reforms, however, coincided with austerity where local government funding, in the specific public health grant and more widely, was not prioritised by the government compared to NHS funding, receiving real-terms cuts from central government. There now needs to be an increase in funding from central government, at least an additional £1 billion for the public health grant every year from 2020/21, to keep pace with population growth and inflation. “
The question we should all be asking ourselves now is how do we truly gain the most benefit this report can give us? I suggest four priorities here:
First, I call on everyone to join the growing number of national leaders calling for government to recognise the good sense of investing in public health (and in local government services more widely) as essential to achieving a healthy population. This report must be an impetus to renew this coalition for public health funding.
Second, while Public health teams have integrated well into local government, there remains much opportunity to influence economic development, growth and planning. Being in local government is no easy ride given austerity. But if we want to influence wider determinants – and any public health professional who doesn’t needs to ask themselves why they are still in public health – then local government remains the primary place to be.
Third, the impetus for improvement, to do better. The report says that now the reforms are embedded “ more attention now needs to be paid to outcomes and tackling unjustifiable variation. More effort is required to understand how local government public health efforts change population health outcomes including: understanding the contribution to change in complex systems; benchmarking and productivity between local areas; and more effort by the National Institute for Health Research and others to support evaluating practice ‘on the go’.” STPs and ICSs should be taking this every bit as seriously as local government.
Giving local government every chance to succeed features strongly in this report. That ranges across ensuring future funding mechanisms do not “unintentionally put public health spending and outcomes at risk” to calling for Public Health England to “do more to support local government to define, diagnose, and tackle unjustifiable variation in practice and impact on population health outcome”. The leadership role of Directors of Public Health and their staff “will be critical in shaping successful place-based population health systems. “ Are councils really using this to best effect?
Finally, there remains an opportunity to rebalance effort across the system. The report says “there are opportunities for a greater focus on prevention in the NHS long-term plan and the government’s prevention consultation paper. But the NHS and central government need to ensure that these changes are consistent with the wider context, a shift to place-based population health systems, where local government is a key player. “ There were some in previous reports who bemoaned the loss of public health from the heavy clinical focus it certainly had in several NHS roles I worked in. What the King’s Fund makes clear is that rebalancing to ensure we address place and wider determinants and reduce the dominance of the clinical focus we had within the NHS is right.
I don’t agree with everything this report concludes. Health and Wellbeing Boards remain hugely variable in their influence, leadership and impact and I think the King’s Fund is too uncritical of the way population health management discourse risks creating a too strong emphasis on individual clinical preventive interventions, creating a clinical model of prevention the NHS can understand but the record of unwarranted variations over thirty years shows it is not great at tackling. But it would be a huge mistake if this report didn’t influence policy making across Whitehall and across local systems.