Public health reforms won’t mitigate the cuts

Among the places least resilient in coping with the Conservative led coalition government’s public spending cuts in England is the northern town of Middlesbrough, where 33% of jobs are in the public sector and 21% of the population of working age are claiming benefits because they are out of work. Previous Labour administrations used growth in public sector jobs to help tackle worklessness, bringing many women, in particular, into the workforce. Now women will bear the brunt of public sector job cuts. The scenario coincides with the latest life expectancy figures, which show a fall in female life expectancy in Middlesbrough.

How much will places like Middlesbrough be helped by this government’s reinvention of public health with its own separate budget and a new home in local authorities rather than the NHS? Certainly, this budgetary transparency contrasts with the last Labour period, when it was impossible to establish how much was being spent on public health and tackling health inequalities. The last Labour period was also a time of growing medicalisation in public health, when the race to hit 2010 targets for reducing health inequalities saw efforts increasingly focus on finding the undiagnosed so called missing millions who need medical treatment. Social determinants are now to receive more attention.

Local authorities’ ringfenced budgets, however, will be a fraction of their existing spending on public services such as housing and education, which are fundamental to good health—especially to the health of the poorest. Although directors of public health will be employed by local authorities, their influence over these large council budgets will be small and compromised by deep cuts and the continuing trend of handing budgets from multipurpose local authorities to single purpose housing companies, schools, and social enterprises. Public health will be one of many opposing priorities when making decisions about cuts to these services, and the devolution of budgets to single purpose and often competing organisations means that the public good may be trumped by organisational self interest.

Self interest, though, is something that the Conservative led coalition feels comfortable working with. Among a proliferation of so called nudge initiatives based on this rather dismal view of human nature are conditional payments. These incentivise healthier behaviour among those who otherwise cannot stop themselves eating junk food, smoking, and sitting in front of the television rather than jogging round the block. These are people who, the theory goes, respond to short term reward, otherwise seeing little point in changing what they do for the sake of their future health when that future offers little. Paying them now for behaving better seems to work, for drug misuse and smoking at least, where the odds of success are raised by as much as 50%.

What better than to spend ringfenced public health funds on something that actually seems to work? But this is hardly public health coming home to its roots in major programmes of improvement, because these payments are far too low to change the material circumstances of the overwhelmingly poor people whose health would most benefit from a healthier lifestyle. Conditional payments just continue paying for the problem.

I have heard public health directors welcome secretary of state for health Andrew Lansley’s emphasis on the social determinants of health inequalities. Housing, for instance, is back on the agenda. Yet this is largely about individualistic solutions, such as supposed innovatory schemes for repairs on prescription or fuel poverty referrals for home improvements. These too might be seen as good candidates for spending from local ringfenced budgets, but at population level are likely to have little impact.

A housing measure with a population impact, and on the industrial scale that we might expect from a public health initiative, is the last Labour government’s Decent Homes programme. In all, £30bn ($48bn; €35bn) was spent on transforming material conditions in England’s social housing estates by insulating walls and roofs, installing modern central heating and double glazing, and renewing kitchens and bathrooms. Much remains to be done, especially in the private housing sector, but strangely this initiative was not presented as a public health programme and is among the large, transformative, and redistributive programmes that Labour never really trumpeted. Compared with £30bn for a housing intervention alone, the total public health budget of an estimated £4bn will struggle to make a difference.

What that difference should be is now unclear as well. The last Labour government had explicit and measurable national targets for narrowing inequalities in life expectancy, infant mortality, smoking, and early deaths from circulatory disease and cancer. Under the coalition government’s so called localism agenda there will be no national targets, only local outcomes that—if a local authority chooses to prioritise their delivery—will be rewarded with a small budget premium when achieved.

As the UK economy falteringly grows its way out of the financial crisis, public health professionals need to join in the argument about whether the speed and depth of the coalition’s cuts to public spending are a necessary correction or a strategy to deliver a tax cut at the next general election. The latter will be at the cost of spending on public services important to the life expectancy of the people of Middlesbrough and other similar places likely to be many years behind economic recovery elsewhere.