Shot in the arm?

Early hopes that the NHS would be so effective in addressing acute ill health that it would quickly become predominantly a wellness service were soon dashed. It became clear that demand for acute and primary care services were higher than expected and the money followed this demand. Although the prevention of ill health has been an important part of NHS services during subsequent years, from vaccination programmes to weight loss and smoking cessation clinics, it has never been given the prominence of acute care.

The five-year funding settlement, which applies only to services purchased by NHS England and clinical commissioning groups – predominantly acute care – did little to dispel the feeling that public health lacked importance. The need to improve the overall health of the population was highlighted in the Wanless review in 2002 and 2014’s NHS forward view, but Office for National Statistics mortality data published in April show gains in life expectancy have stalled since 2011.

The NHS long-term plan did make public health a central plank of its vision for the future health service. Plans for public health include new hospital-based smoking cessation services to complement those commissioned by local authorities (see Stubbing it out, Healthcare Finance, December 2018). The new primary care networks will employ social prescribing leads, who could play a key role in preventative care (see Network solution, Healthcare Finance, April 2019). And the government is planning to publish a green paper on public health this year.

However, consideration of funding levels for public health, together with education and training and capital funding, will have to wait until the spending review, which is due to take place in the summer.

An announcement will be made in the autumn, when the spending review is expected to report and be published alongside the Budget. However, chancellor Philip Hammond has warned that the timing of the spending review will depend on the UK agreeing a deal to exit the European Union. The EU has agreed to an extension of the leaving date until the end of October. So, with the government cautious about making commitments without knowing how Brexit will affect the economy and its tax income, there is a chance that the political deadlock could muddy the waters over spending decisions.

The British Medical Association believes a squeeze on funding is restricting the impact of public health services – local services to support people in choosing a healthier lifestyle are unaffordable, particularly at a time of rising demand for hospital care.

In a report published in April, Prevention before cure: prioritising population health, the BMA said there was a link between public health funding and hospital admissions.

It said there are a number of issues affecting public health, including a continued trend of decreasing funding and, at the same time, increased hospital admissions where smoking, obesity and alcohol abuse are factors.

Since 2013, local authorities have been in charge of commissioning the bulk of public health services, including weight management programmes, smoking cessation and sexual health clinics. The Department of Health and Social Care provides grants directly to local authorities.

However, the BMA said grants have been cut by £550m in real terms since 2015/16, adding that the alcohol and obesity service budgets have been reduced by 10% over the past three years, while smoking cessation budgets shrunk by more than 20%.

Meanwhile, there has been a tenfold increase in obesity-related hospital admissions since 2006/07. Admissions associated with alcohol had more than doubled in the same period, while smoking-related admissions had also increased.

The BMA called for the spending review to reverse the £550m cuts in public health spending since 2015/16. However, it believes that while funding is important, it is not the only issue that must be addressed.

It said there must be a cross-government approach to addressing societal factors that influence health. This would recognise the importance of health in all policy-making.

More regulation is also needed to tackle lifestyle issues such as excessive drinking, smoking and poor diet – for example, by introducing minimum alcohol unit pricing across the whole of the UK.

The NHS could do more to place public health as a priority – for example, by ensuring all vehicles it uses minimise air pollution or by enforcing smoke-free hospitals and grounds.

The BMA believes the case for action is compelling. Its public health medicine committee chair, Peter English, said prevention can save the NHS ‘substantial sums’ in the long term by ensuring patients avoid conditions such as alcoholism and obesity.

Preventable ill-health accounts for an estimated 50% of all GP appointments, 64% of outpatient appointments and 70% of all inpatient bed days, according to the BMA. And 40% of the uptake of health services could be prevented through action on smoking, alcohol, physical inactivity and poor diet, it added.

Dr English said: ‘Unfortunately, we have seen a systematic pattern in the past decade of all parts of the public health sector being subjected to a funding squeeze that has left preventive healthcare in crisis. A lack of joined-up thinking and national standards has led to widening health inequalities.

‘These cuts come at a time when inequalities in life expectancy are widening. In England, males living in the most deprived areas are now expected to die 10 years earlier than those living in the least deprived, while for females the gap is seven and a half years.

‘We need to see the upcoming green paper as an opportunity to address these failures and put in place a well-funded, co-ordinated plan that provides patients with a preventive health system that meets their needs.’

Royal Society for Public Health senior policy and research executive Toby Green agreed that funding was a significant issue for public health services.

‘It is true that local authority funding is not the only vehicle for boosting the public’s health  – and indeed we welcome the extra focus on secondary prevention outlined in the long-term plan earlier this year – however, it is clear that failure to adequately fund public health teams may fatally undermine any increased spending on prevention in the NHS.

‘As just one example, local authority spending on smoking cessation services has fallen by a third over the past five years, and they are now a universal offering in only half of council areas in England. This flies in the face of good evidence that tobacco control services provide an astonishing return on investment when it comes to the wider healthcare sector, returning an estimated £11.20 for every £1 spent.

‘The future sustainability of the NHS depends on rejecting false economies and pursuing a sensible allocation of funds to local public health interventions – a strategy countless studies have shown to be highly cost-saving in the long term.’

Few would argue against the need for preventative care. Practitioners are hoping that the long-term plan and the forthcoming green paper will give public health a much-needed shot in the arm.