Raiding the public health budgetBMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g2274 (Published 27 March 2014) Cite this as: BMJ 2014;348:g2274
Local authorities across England are diverting ringfenced funds for public health to wider council services to plug gaps caused by government budget cuts, a BMJ investigation has found.
The BMJ also found that public health staffing in some parts of the country is being scaled back to save money. Professional organisations have warned that public health’s voice may be drowned out in local government and that its workforce is spread too thinly.
The investigation found examples of councils reducing funding for a wide range of public health services, including those for substance misuse, sexual health, smoking cessation, obesity, and school nursing.
The BMJ found that many local authorities have deployed public health funds to support wider council services that are vulnerable to cuts, such as trading standards, citizens’ advice bureaux, domestic abuse services, housing, parks and green spaces, and sport and leisure centres.
The national authority, Public Health England, said that it supported local authorities making tough decisions and that it was right for public health grants—totalling £2.8bn (€3.3bn; $4.6bn) across England for 2014-151—to be used to leverage wider public health benefits across the far larger spend of local government.
But some doctors have warned that public health could be diluted and could suffer as a result of the cuts, with the overall pot being spent on public health services effectively shrinking. One leading clinician described the redeployment of public health funds to wider council services as “robbing Peter to pay Paul.”
“There is a long history of public health budgets being plundered by organisations that are having financial difficulties,” said Gabriel Scally, formerly the Department of Health’s regional director of public health for the south west and now professor of public health and planning at the University of the West of England, Bristol.
He said, “This time it isn’t NHS managers who are playing fast and loose with public health budgets, it is local authorities. Of course, local authorities are having their budgets reduced, but the Department of Health has provided that funding to local authorities to spend on public health, not to be siphoned off to prop up other services.”
Public health services and their directors and staff were transferred from the NHS to local authorities in April 2013 under the Health and Social Care Act 2012. The government’s intention was to shift the emphasis from treatment services towards a more preventive agenda that tackled the wider social determinants of ill health.
But although the government agreed to retain and increase the ringfenced public health grant for two years (later extending it to a third year), local councils have faced huge reductions in their wider budgets, affecting areas such as social care and housing.
Local government is required to commission certain public health services, such as sexual health and the NHS health checks programme for adults aged 40-75, but is free to determine where most of the public health grant is allocated—and how much is apportioned where—according to local priorities set by “joint strategic needs assessments.”2
The representative body the Local Government Association has questioned whether the public health grant should stay ringfenced,3 and some sections of local government reportedly view the grant as a luxury in the current financial climate.4
Only 45% of respondents to a recent BMA survey of public health professionals working in local authorities and at Public Health England believed that the public health grant was being used appropriately in their area, while almost half (49.6%) believed that the grant was seen “as a resource to be raided” by local government.5
The BMA’s survey also highlighted fear about future staffing levels in public health, with just 12% of respondents believing that there would be enough substantive consultant posts available to serve the needs of the population in 10 years’ time.
The Association of Directors of Public Health told the BMJ that it was particularly concerned about a vacuum in public health leadership at the top of local government, with a quarter of director posts currently unfilled or filled by temporary appointments.
As part of its investigation the BMJ issued requests under freedom of information legislation to all 152 upper tier local authorities in England (most of which are unitary, county or city councils), asking for details of all services commissioned and decommissioned since April 2013 and for details of commissioning intentions for the coming year.
Of the 143 authorities that provided information, almost a third (45) have decommissioned at least one service since April 2013, while others have cut funding to certain services, the BMJ found. Many councils are decommissioning individual contracts for services such as sexual health and substance misuse and then recommissioning new integrated services to make efficiency savings.
Other authorities have decommissioned services that they said were not having the desired outcome on public health or delivering value for money.
In total, more than half of authorities (78) have commissioned or recommissioned at least one service since April 2013, and the pace of change is set to escalate this year as councils carry out root and branch reviews of services after the year of consolidation.
At the time of asking, most of the authorities said that they were yet to finalise budgetary decisions, but they indicated that many more ambitious service changes would occur in 2014-15.
Among the areas using the public health grant to support wider council projects is Sheffield, which said that it had top sliced (removed) ] 11% of the value of contracts on almost all the services commissioned from the public health grant last year, with a few exceptions (box).
The authority said that this allowed it to allocate approximately £3m worth of funding from the public health grant to pay for services such as breastfeeding peer support, early years preventive health activity, and domestic abuse work, among other services. These services were previously funded by local authority money, but councils are justifying using the public health budget to fund them because they say that these schemes also involve health issues.
The authority explained, “The rationale for the top slicing was in order to release funding to pay for public health activity previously paid for by city council mainstream revenue funding, which otherwise would have been vulnerable, due to the significant reductions in central government support to local government.”
Sheffield said it anticipated further efficiency savings in 2014-15 from the likes of drug treatment and sexual health services, alongside a reduction in public health staffing at consultant and non-consultant level, achieved through “a combination of deleting vacant posts from the establishment as well as a small number of (voluntary) redundancies.”
It added, “This, together with a small increase in the public health grant overall, allows for a further increase in the amount of the public health grant being allocated to programmes previously funded by mainstream council revenue budgets, with in addition approximately £1m investment in a range of programmes intended to address the root causes of ill health in the city.”
Elsewhere, Derby City Council said that it would “continue to invest in prevention, early intervention and enablement,” but admitted, “We have had to make difficult decisions to reprioritise aspects of public health spending to better support statutory council services.”
The BMJ found numerous other examples of local authorities disinvesting in certain public health areas and using savings to support wider council services (box).
Several councils told the BMJ they had decommissioned services that they judged were not having the desired effectiveness in terms of outcomes.
Sandwell Council in the West Midlands told the BMJ it had saved £2m through loss of staff under its mutually agreed resignation scheme since April 2013 and through a reduction of “ineffective community contracts and grants.” It is using the savings to make new investments in areas such as housing and alcohol.
John Middleton, vice president of the Faculty of Public Health and director of public health for Sandwell Council, said that most local authorities were redeploying public health budgets to other areas but said that some were acting more crudely than others.
“I don’t know any local authority that isn’t dipping into the public health budget to prop up other services,” he said.
“My own is no different, although we are taking the opportunity to remould those services in a more evidence based and public health focused approach.
“It’s not wrong to apply public health funding [to other areas], but some councils have just done it very crudely. Some people are being asked to take quite large cuts: 30% cuts on health checks, that kind of thing.”
Duncan Selbie, the chief executive of Public Health England and the country’s chief officer accountable for monitoring where funds are spent, was unapologetic about the decisions being made by local authorities in times of economic austerity.
“When money is tight you do have to think harder,” he told the BMJ. “We’ve had a shed load of money gone into the NHS. And today we have gaps in life expectancy and quality of life as wide as they were 40 years ago.
“I welcome local government reviewing where the money has been spent. Local government [bodies] are pretty advanced in looking at outcome based commissioning, and of course they will be looking for more value.”
He admitted, “Some of this will be uncomfortable. It’s not about maintaining a direct line from where we’ve been before. Where we’ve been before was a shameful [low] level of investment in prevention and early intervention. Local government will not be taking lessons from the NHS on this.
“The duty is to improve the public’s health, not to provide a public health service.”
He cited Sheffield as an example, explaining that the city’s public health grant accounted for just £30m of its total £1.3bn budget. “That £30m is about leveraging benefit across the £1.3bn to improve health.
“If you ask public health professionals what’s going to improve the health of people of Sheffield, it’s job creation, decent neighbourhoods, a good start to life, children being ready for school, companionship, [and] not being isolated.
“The biggest single contributor to good health at population level is economic prosperity,” he said.
Robbing Peter to pay Paul
But some clinicians said they were concerned that the removal of public health functions from the NHS would weaken public health overall.
After examining the information supplied to the BMJ, Scally said he was concerned that money was being taken out of areas such as smoking cessation services and school nursing to prop up other council services.
“It’s robbing Peter to pay Paul. They maintain that NHS funding will be protected, but it is being used for non-NHS purposes,” he said.
“With many of these things, it could be regarded as a reasonable place to invest, but the fear will be this is to make up for the local authority taking their own previous funding out of these areas. So the net result is that public health suffers.”
Jane Hatfield, the chief executive of the Royal College of Obstetricians and Gynaecologists’ Faculty of Sexual and Reproductive Healthcare, recently warned that some local authorities were limiting or restricting access to sexual health services.6
Scally said he was concerned that the widespread recommissioning of services such as sexual health was being driven by financial concerns rather than a desire to improve outcomes.
“There are undoubtedly issues about the integration of sexual health services that could be addressed by recommissioning them, such as integrating the family planning and genitourinary medicine (GUM) services,” he said. “But in very few of those statements [in reply to the BMJ’s freedom of information request] do you get any indication that their plans for change are about improving things.
“All they’re doing [in Sheffield] is substituting £3m of public health money for their previous funding. That seems to me to be not appropriate.”
Jeremy Wight, director of public health at Sheffield City Council, said that local government was being forced to act “creatively” because of the sheer scale of cuts to wider services.
He said, “Local authorities have for many years, in various ways, funded programmes and activities which have either explicitly or implicitly benefited public health through their mainstream revenue funding. It is the very significant cuts in this funding—particularly in the northern metropolitan authorities—that is leading us to have to use public health grant funding creatively. For the government to say that public health funding is being protected or increased is only true at a very simplistic level. The wider substantive cuts to local authority funding are very damaging to public health more broadly.”
Wight added, “We have tried to assess the cost effectiveness of the different proposals, and if there are alternative new uses of the public health grant that deliver greater public health benefit than the programme that would be ‘saved,’ then there would be a strong argument for using the money in that way.”
David McCoy, a public health physician and senior clinical lecturer at Queen Mary University of London and former director of public health in northwest London, said that there was “huge variability” in commissioning across the country, depending partly on the state of finances, each local authority’s view of public health, and a lack of clarity over what the ringfenced budget should be used for.
“There’s much room for interpretation, which also relates to the overlapping division of responsibilities between Public Health England, clinical commissioning groups, and local authorities,” he said. The fragmentation of commissioning budgets and of roles and responsibilities across the system as a whole is a dog’s breakfast,” he said.
The Faculty of Public Health has called on ministers and the National Audit Office to more closely scrutinise how the system is working.
A faculty spokesperson said, “We suspect that there are some authorities across the country that would not really bear scrutiny of their use of public health budget, and there will doubtless be some wide definitions of public health used to rationalise the use of public health ringfenced budgets in inappropriate ways. Demonstrating any poor financial practice in local authorities may be difficult. But scrutiny by parliament and NAO [the National Audit Office] would be welcome.”
The faculty said it was also anxious to see numbers and salaries of public health staff maintained, particularly for its fellows and specialists.
“We are concerned that some local authorities are seeking to recruit at lower than NHS rates for [some] consultants. In particular, current adverts are not sufficiently attractive for medical consultants,” the spokesperson added.
With the onus falling on Public Health England to scrutinise how the new system was working, Selbie insisted that he was on top of his brief: “There are always parts of the country where they are not quite keeping up. But they’re few in number, and we’ll work with them.”
In Sandwell, Middleton said that “the fresh eyes of council members” had allowed them to disinvest in some “rather ineffective” services, but he added, “[Some] councils are not sufficiently experienced in public health or sufficiently willing to give it the chance to deliver for them.”
Janet Atherton, president of the Association of Directors of Public Health and director of public health at Sefton Council, said that the number of director posts that were not permanently filled may undermine the ability of public health professionals to influence decision making. England has 132 permanent public health director posts, but currently 31 positions were vacant, she said.
“We do have concerns about the levels of vacancies. With major budget cuts you need to have good, stable public health leadership. Our skills are absolutely critical in helping councils manage the situation we’re in appropriately.”
Scally agreed, warning, “Public health staffing across the country is not at an enormously high level, so it’s really very disturbing that having been given these public health responsibilities one of the first things [some local authorities] are doing is getting rid of the public health professionals who provide them with advice and do the public health work.”
Despite these concerns, Selbie insisted that public health professionals would be able to exert more influence from within local authorities than they could in the NHS.
“The directors of public health are in the room having the argument [about] how to use the public health grant at a time of unparalleled financial pressure,” he said.
“These cuts would be happening anyway. Under the old arrangements, the director of public health would be sitting in a PCT [primary care trust] commenting on what the council was doing. They have more influence now.”
Public health service changes: for better or worse?
What some councils are doing and how they justify their actions.
The council plans to reduce investment in substance misuse, sexual health, smoking and tobacco, and obesity services this year and to reinvest £2m “to support wider preventative programmes that are under review due to council financial pressures.”
So far, agreement has been reached to support the delivery of domestic violence services, to reduce social isolation among older people, and to support carers of people with substance misuse problems.
Dave Allen, the county’s cabinet member for health and communities, said, “Rather than diluting core public health services, we believe our approach will only serve to strengthen them.”
It has consulted on a proposal to make a 30% cut in funding allocation for drug and alcohol treatment provision.
Haringey, north London
Haringey plans to make savings in 2014-15 from these areas: health intelligence (a cut of £50 000), the family nurse partnership (£24 000), one-off development support for school curriculum development (£30 000), prevention of obesity in adults (£24 000), its social isolation project (£30 000), evaluation of prevention services (£40 000), retendering substance misuse services (£20 000 saving), and using a portion of the public health grant increase as a saving rather than to commission new services (£25 000 saving).
North East Lincolnshire
It is making budget reductions in health trainer management costs, health promotion teams, smoking cessation activities, and contracts for sexual health. The authority said, “We are looking to shift resources more to a preventative agenda.”
The council plans to “adjust spending of £5.8m in line with the council priorities” through a combination of “service redesign, integration of smaller contracts into larger contracts, and some decommissioning.”
Chris Kenny, director of public health for Nottinghamshire County and Nottingham City, said, “Where we have reallocated public health funds to other council areas we have put in place robust measures to make sure that investment is in line with public health need. As with all parts of the public sector, there are pressures on budgets.”
A small proportion of its public health grant will be used to strengthen “additional public health programmes across the council,” including domestic abuse staffing, mental health (specialists in mental health working in citizens advice bureaux and specialist teachers working in schools), trading standards, licensing (tobacco and alcohol), and its employer assistance programme in occupational health.
Becky Pollard, the council’s director of public health, said, “Far from diluting core public health services, our strategy and ability to use our public health resources flexibly has created opportunities to strengthen public health and respond to local needs most effectively.”
The council reviewed expenditure “to identify funds for reinvestment in wider areas of public health,” including domestic violence, children’s public health services, and services for homeless people.
The council commissioned “internal council services” from the public health budget “to increase their contribution to public health outcomes.” Alan Higgins, director of public health, said that the council was commissioning “effective and large scale interventions to reduce inequalities in health.”
The local authority has planned budgetary reductions to school nursing, fall services, dental public health, and sexual health “in line with revised specifications and new levels of activity.”
John Radford, its director of public health, said, “Our focus is on maintaining the quality of services while seeking efficiency savings. It is incorrect to suggest that we would allow the service quality to lessen.”
Sandwell has saved £2m through loss of staff under a mutually agreed resignation scheme since April 2013 and through the reduction of “ineffective community contracts and grants.”
It is using the savings to make new investment in areas such as housing and alcohol.
The council has top sliced 11% of contract values in 2013-14 from most services commissioned from the public health grant, with the exception of school nursing, tobacco control, weight management, and community dietetics. This freed £3m to pay for services such as breastfeeding peer support, early years preventive activity, work on domestic abuse, activities to support and prevent the need for adult social care, and an adult physical activity programme.
It anticipates further savings in 2014-15 from the likes of drug treatment and sexual health services, alongside reduction in public health staffing at consultant and non-consultant levels.
The local authority plans to recommission services for smoking cessation, substance misuse, weight management, and sexual health into one integrated contract.
Money released will support areas such as home improvement initiatives, parks, green spaces and allotments, children’s centres, sports and leisure centres, supported housing, and mental health facilities.
Paul Watson, leader of Sunderland City Council, said, “While we’re continuing to invest in many of the traditional things that public health has always invested in, we also recognise that continuing to do things the way they’ve always been done isn’t necessarily the answer, especially at a time when NHS and local government budgets are under such enormous pressure.”
Cite this as: BMJ 2014;348:g2274