The House of Commons Health Select Committee has this morning published their first report looking at the Coalition Government’s public health reforms. While the top-line recommendations have focussed on the effectiveness of the Department of Health’s new Responsibility Deal with the food and drink industry, and the need for Public Health England to be “visibly independent of central government”, the report raises a number of further concerns relating to the powers, responsibilities and funding arrangements which are going to exist within the new public health system. Beneath the political headlines, it is these issues which will make or break the Government’s public health policy.
In its report the Select Committee welcomes many of the principles within the reform agenda and notes the importance of an active publichealth policy in reducing the overall burden on the NHS. However, as we have previously written about on this blog, the Committee notes the significant concerns amongst the sector about power, responsibility and accountability in the new system.
The Health Select Committee has warned that the introduction of a ring fenced public health budget runs the risk of councils ““gaming” the system and effectively raiding their public health allocations by “redesignating” as public health spending services that they are already providing from other budgets “. In addressing these points, the report calls on directors of public health to be under a statutory duty to ensure the funding is used appropriately. One of the most worrying findings of our recent report Ready for health? was the fact that 43% of local authorities did not have a definition of public health. The implications of this being that – given the very nature of public health – without a detailed understanding of what public health is local authorities will not be able to commission these services effectively, and may allocate their monies in areas perhaps not as closely linked with public health as they should be.
At a time when the pressures on local authority budgets are acute, the temptation to prop up existing council projects, rather than invest in additional public health interventions might be overwhelming. Far from being a ring fence to protect public health, the budget might become a slush fund for councillors looking for extra resources.
A challenge in establishing a ring fence is working out how much money should go in it. After all, fences can keep resources out as well as keeping them in. Stephen Dorrell’s Committee is also particularly scathing of the Department of Health’s current estimates relating to the overall public health budget. In its white paper Healthy Lives, Healthy People, the Department of Health estimated that the public health budget would be approximately £4 billion. A year down the line and the Committee has attacked the Government for failing to provide any clarity about how this figure was reached which, as a result, is “undermining confidence in the Government’s public health strategy and making service planning impossible”.
Again, our recent report has highlighted the complexity of disentangling public health budgets and the existing variations in the amount primary care trusts are spending on public health services – the very budgets which the Department of Health is seeking to use as the baseline for the ring fenced budgets. Responding to the Committee’s report, The King’s Fund has warned that this approach to allocating funds could exacerbate health inequalities, “entrenching historic underfunding” in more deprived areas.
Today’s report is further evidence of the challenge facing Andrew Lansley and his team in achieving healthy lives and healthy people. History has taught us that public health can all too often become the forgotten service and, while the Department of Health continues to consult on its public health reforms, anecdotal evidence suggests that public health programmes, such as obesity, are under threat as a result of budgetary pressures and a lack of clarity in relation to responsibilities during the transition.
Labour’s shadow health team have already described the report as giving a “damning verdict” on the Responsibility Deal. However, the Committee’s report indicates that it believes the objectives of the reforms remain sound. The challenge is not the objectives, but their implementation. Separating NHS and public health expenditure is proving far more complex than Andrew Lansley envisioned and there is some way to go before local authorities are ready for health.