What the chancellor’s cuts today mean for public health tomorrow
England’s health service is grappling with an ageing population coupled with a desire for people to live well for longer. In its attempts to address such pressures on NHS resources, the government wants people to take control of their own health and to focus more on preventive measures.
Yet earlier this month chancellor George Osborne announced plans to reduce public debt by £4.5 billion. Among the earmarked savings are £200 million in public health funding that will come from the Department of Health (DH) ‘non NHS’ budget.
Local Government Association chair councillor David Sparks says the cuts ‘will have an effect on councils’ ability to improve the public’s health and wellbeing, and reduce demand for hospital, health and social care services’.
A DH spokesperson says public health funding will continue to be ring-fenced and a consultation will be held on the proposals, but she could not confirm when it will start: ‘The NHS budget will remain protected, but difficult decisions need to be made right across government to reduce the deficit.’
Public Health England (PHE) chief executive Duncan Selbie says: ‘The announcement is a difficult ask of local authorities and we will support them through this as best we can.’
The cuts have been proposed despite the fact that prevention of ill health is a central theme of the NHS Five Year Forward View.
The document, which sets out a vision for the NHS, says ‘that the future health of millions of children, the sustainability of the NHS and the economic prosperity of Britain all now depend on a radical upgrade in prevention and public health’.
It outlines the need for ‘hard-hitting national action on obesity, smoking, alcohol and other major health risks.’
RCN public health forum chair Jason Warriner warns that the cuts could result in declining workforce numbers and a diluted focus on prevention.
He says: ‘If the government wants to focus on preventing ill health, it needs to have a continuous drive and recognise that prevention of ill health is not a quick win, but about long-term gain that arises from informing, education and raising awareness among the public.’
He is concerned that cuts will affect vulnerable and hard-to-reach patient groups the most, particularly those living in rural areas.
‘It could affect access to services because of potential closures of outreach clinics, satellite clinics, as well as cuts to specialist advice or social workers,’ he says.
‘If we stop focusing on prevention, in a few years’ time we will see costs going up because of the knock-on effects on ill health and the pressures this will place on the NHS.’
Royal College of Midwives director for midwifery Louise Silverton warns that sexual health and family planning services could be pared back following the cuts, resulting in a rise in unplanned pregnancies.
Ms Silverton adds that the cuts could reduce the provision of vaccination programmes and smoking cessation services, which would provide challenges for midwives.
‘If smoking cessations services are hit, midwives may struggle to refer on pregnant women who smoke,’ she explains. ‘This will mean that we may miss chances to not only improve the health of the mother, but also the health, including the adult health, of her developing baby.’
RCN deputy president Rod Thomson, also a director of public health, says the plans to cut public health funding represent a ‘significant U-turn’ on the government’s policy.
He adds there are huge disparities in the public health grants allocated by the DH and PHE and is concerned that many local authorities, particularly in rural areas, where the allocated grant is below what it should be per head of population, could be adversely affected by future funding cuts.
Urban areas often receive more money for public health. Westminster has received £133 per head in 2014/15, for example, compared with the national average of £51 per head.
He adds that the allocation is also disproportionate given that London boroughs can centralise and share services more easily than councils in other parts of England.
As well as anticipating that the cuts could mean the loss of nursing posts, he worries that in under-funded councils, there will be cuts to specific public health services.
Promoting positive mental health
Alcohol and drug misuse
Health and lifestyle advice
‘Non-mandatory services are most likely to be cut, including promoting positive mental health, physical activity, obesity prevention and dental health,’ he says.
‘For mandatory services, councils will consider what the minimum requirement is and seek to reduce the service to match the funding they have. This would apply to services such as sexual health, substance misuse, health checks, smoking cessation and school nursing.’
Responsibility for commissioning public health services transferred from the NHS to local authorities in 2013.
From October this year, the planning and commissioning of public health services for nought to five year olds – including health visiting services – will transfer from NHS England to local authorities. Funding for health visiting will be ring-fenced for 18 months and it will be mandatory for local authorities to provide health visiting services at the five key stages, including antenatal health and one-year assessments.
In May 2010, the coalition government set out plans to recruit an extra 4,200 health visitors by April 2015. Health and Social Care Information Centre figures show that in February this year there were 11,280 whole-time equivalent (WTE) health visitors, compared with 8,092 WTE in May 2010. The latest figure does not account for the number already in training.
Institute of Health Visiting director Cheryll Adams is concerned about seeing any backward steps in health visitor numbers, adding: ‘The number of health visitors is only just getting to where we need it to be.’
She says that even without public funding cuts, health visiting services are vulnerable because not all local authorities will understand the importance of providing a universal service.
Dr Adams says that one area of the health visiting workforce that could be at risk of cuts due to financial constraints is specialist roles.
‘It is short-sighted,’ she says. ‘By losing that specialist contribution you lose the benefits of good health outcomes. If a role such as a breastfeeding expert is cut, families do not get the advice they need. Breastfeeding numbers go down and admissions to hospital and infection rates go up’.