Raiding the public health budget

Decommissioning services

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.

“Top slicing”

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.”

Uncomfortable decisions

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.”

Scrutiny

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.”

Exerting influence

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.”