For the first time in forty years, local authorities have direct responsibility for improving the health of their communities. Local government can reasonably be viewed as the natural leader on public health. It is, after all, well positioned to place health and wellbeing in the context of the wider social determinants of health, such as: the local economy; provision of housing; education and leisure services; and the levels of crime. It is also best placed to provide bespoke services that meet the specific needs of its local populations.
It is fair to say that granting local authorities greater responsibility for public health was largely welcomed on the ground and at a national level. The proposal attracted significant popular and political support, particularly when compared to the majority of the vehemently opposed structural changes enacted through the Health and Social Care Act 2012.
While popular in principle however, emerging evidence is highlighting the shortcomings in local authorities’ detailed knowledge of population health. A survey conducted by The Hepatitis C Trust highlighted that 75 per cent of local authority respondents did not know how many people in their area are living with, or at risk of, hepatitis C. This is just one example and there will be many more. Smoking, high blood pressure, obesity, physical inactivity and alcohol are five main risk factors for ill health and some of the major causes of premature death. In addition, poor mental health, substance abuse and musculoskeletal disorders are among the main drivers for disability. Local authorities will therefore need to be supported by the provision of robust data on prevalence and adopt evidence-based guidance and solutions that are cost-effective and best serve their local populations.
There is a tremendous task ahead for local authorities in terms of the scale and complexity of their new responsibilities and it remains to be seen how effectively the wealth of expertise from across local health economies will be engaged via the new Health and Wellbeing Boards. The well-publicised difficulties in recruiting Public Health England’s (PHE) key appointments to schedule and the late announcement of public health budget allocations in January 2013 have done very little to aid preparedness.
The extent to which patients are empowered to engage with the new system, via local Healthwatch and by feeding into Health and Wellbeing Board decision making, is also questionable. To become meaningful, support will need to be extended to groups where levels of health literacy and engagement have traditionally been lower. All patients should be empowered to obtain, understand and use health information; publishing health data and ‘nudging’ behaviour alone will not achieve this. An action that should be taken by local authorities is to place greater emphasis on levelling access to health information through community-based health education.
Around two thirds of local authorities in England may find themselves short of the money needed to meet their target spending per head on public health by the end of 2014-15, according to the two year settlements allocated to them by the Department of Health. Managing this potential risk, whilst making successful progress in tackling the root causes of health inequalities, will be crucial to delivering fairness in the provision of public health services.
The establishment of Public Health England has also been an important development. Duncan Selbie, Chief Executive of PHE, has suggested that the organisation must ‘redress a historic imbalance, by focusing as much on the prevention of ill health and the promotion of wellbeing as we do on ensuring effective, high quality and accountable clinical care and rehabilitation services’. In line with this, the 2010 landmark health inequalities review: Fair Society, Healthy Lives, authored by Sir Michael Marmot, highlighted that eradicating child poverty and supporting children in their early years is crucial to improving their long term health prospects. Child poverty rates are actually increasing under the current government, representing a significant failure.
Furthermore, the Government’s much publicised u-turn on minimum unit pricing for alcohol was heavily criticised by experts, who accused the Government of ‘pandering’ to the food and drink industries at the expense of improved public health outcomes.
Progress against the Coalition Agreement
Pledge: We will give local communities greater control over public health budgets with payment by the outcomes they achieve in improving the health of local residents.
Status: In progress – The Government legislated as part of the Health and Social Care Act 2012 to devolve control of public health budgets to local authorities. The first public health allocations were published in January 2013, however, the Government has received criticism that the allocations are unfair and go against ministerial pledges that funding would be specifically targeted at those areas with the worst health outcomes.
The Government has announced a cash incentive for local authorities, called the Health Premium, which will reflect progress made against public health indicators and the outcomes delivered. It will also reward areas with poor health profiles accordingly where more progress must be made. These payments, however, will not be allocated until 2015/16.
Pledge: We will give GPs greater incentives to tackle public health problems.
Status: Done - The Government states that it has published the Public Health Outcomes Framework, which will facilitate greater data transparency so that local areas can judge progress in tackling public health issues. In addition, at least 15 per cent of the current value of the Quality Outcomes Framework will be devoted to evidence-based public health and primary prevention indicators from 2013, giving GPs a financial incentive to tackle public health problems.
The National Institute of Health and Clinical Excellence (NICE) has also been tasked with developing public health guidance, which is viewed as a positive step. However, the resource constraints at NICE at present is impacting upon the timely production of this guidance.
Pledge: We will investigate ways of improving access to preventative healthcare for those in disadvantaged areas to help tackle health inequalities.
Status: In progress – The Government’s ‘investigation’ has largely been focussed on the publication of the Public Health Outcomes Framework, which it argues will help local areas judge their progress in tackling health inequalities. The Framework focuses on reducing differences in life expectancy, as well as healthy life expectancy, between communities.
However, there is concern that the current financial climate could inhibit investment in prevention and wellbeing services. The public health budget may be ring-fenced, but there is the potential for local authorities to divert resources to plug gaps in funding for services only nominally linked to public health and access to preventative healthcare, i.e. repairing potholes, leisure services, gritting roads. This may have implications for current levels of health inequalities. In addition, the Institute for Fiscal Studies (IFS) reported that in 2010, 2.5 million children were living in absolute poverty. By the end of 2013, the IFS predicts the number of children in absolute poverty will rise by 600,000, peaking at 3.1 million. This is a set back to the Government’s public health policy focus in the area of the wider social determinants of health.
Pledge: We will ensure greater access to talking therapies.
Status: Done – In February 2011, the Government published Talking therapies: A four-year plan of action, which was a supporting document to No health without mental health: A cross–government mental health outcomes strategy for people of all ages. The plan of action was accompanied by an investment of around £400 million over four years to make a choice of psychological therapies available for those who need them in England, including: older people; those with long term conditions; those with medically unexplained symptoms; people with serious mental illness; and children and young people. It aims to develop talking therapies services that offer treatments for depression and anxiety orders approved by NICE across England by 2015.
The Government announced in October 2011 that its investment in psychological therapies for children and young people with mental health problems would be £32 million; this has since been increased to £54 million. This increase is designed to help support training for all those who work with young people, such as teachers and social workers, and has been welcomed by mental health charities. The task now will be to capture outcomes of this initiative.