Commentary on a week of confusion in public health
Today’s top story: Selbie: Public health leadership ‘rationale’ unchanged
Today’s top appointment: Director set to become Camden chief
Today’s top viewpoint: Ian Miller: Councils can balance transparency, risk and returns
The world – as we know, but Donald Trump doesn’t – is too complicated to be divided up into ‘good stuff’ and ‘bad stuff’.
However, as surely as the US president believes Mexicans to be “bad hombres” (to use a genuine Trump quote), local government is united around the notion that public health’s transfer into its remit this decade has been a ‘good’ thing.
Incidentally, it takes a pretty dogmatic optimist to believe that the rest of this decade has been filled with ‘good stuff’ for councils. The demise of the housing revenue borrowing cap is a notable ‘good’ thing and the devolution movement seemed to be, at least until it lost momentum. Students of Soviet history who are still inspired by the notion of heroic super-worker Stakhanovite movement will no doubt be uplifted by council staff metaphorically single-handedly mining 102 tons of coal in a single shift to help their local population through austerity – but few would say it’s ‘good’ that they’ve had to do this.
Returning from this tangent, the reasons for public health in local government being a ‘good’ thing have long been apparent. To use the example of cliché, Joseph Chamberlain’s slum clearance and clean water for Birmingham was clearly a positive development.
More recently, the Health and Social Care Act 2012’s transfer of public health back into councils from the NHS, where it had resided for 40 years, offered a new set of possibilities. It’s easier to improve exercise take-up if you engage schools, children’s and adult services, leisure services, planners, housing, the transport system, businesses and parks. This is equally true of drug and alcohol misuse, poor diet and smoking. While public health had not been a priority in the health service, its transfer to local government meant it could be integral in the design of all local services.
However, there is a reason why local government’s return home hasn’t been as successful as it might have been: austerity. The halving of funding from central to local government, including huge reductions in the public health grant has dramatically lessened councils’ ability to invest in public health.
This was brought home just before Christmas when the Department of Health & Social Care sought to take advantage of the fact most titles’ newsrooms were winding down for Christmas to sneak out next year’s £85m cut in public health grant. According to the Health Foundation, public health has been cut £0.7bn in real terms between 2014-15 and 2019-20.
Public health’s stewardship has become an issue again this week after the NHS long-term plan, released on Monday, appeared to suggest a significant change.
The NHS and government – ie central, not national government – will “consider whether there is a stronger role for the NHS in commissioning sexual health services, health visitors, and school nurses, and what best future commissioning arrangements might therefore be,” the plan said.
There have been whispers across Whitehall for the past month of a possible bid to move public health back into the NHS.
Theresa May hardly seemed an enthusiast about councils’ role in public health when appearing on the Andrew Marr show on Sunday, continually evading a question about public health grant cuts with claims about the NHS’s prevention emphasis. Only belatedly did she concede that, “there’s public health funding that is dealt with and there’s a role for local authorities in some of this as well”, before continuing her NHS spiel.
The concept of yet more organisational upheaval is hardly one most directors of public health would welcome.
Wigan MBC’s director of public health Kate Ardern tweeted to say she feared that under the NHS once more it would be “neglected again - reduced back to being a biomedical set of lifestyle interventions plus stats & epidemiology”. This would have the effect of “losing the whole point” of local government being able to influence the wider social determinants of good health, she added.
Abdul Razaq, until October Suffolk CC’s director of public health, tweeted of public health’s potential transfer back to the NHS: “The definition of insanity is doing the same thing over and over and expecting different results – once said a very clever bloke.”
Today Public Health England chief executive Duncan Selbie sought to ease the angst, stating that “the rationale for local government to lead on public health remains unchanged”.
He insisted the review mentioned in the plan would in fact be “between the NHS and local government” and intended to “ensure that we have the best possible join-up between them”.
Notably he did add: “It is vital for the NHS, with its new focus on prevention, to work alongside an adequately funded and appropriately resourced local government [our italics].”
So is this a mere storm in a teacup? An example of how a badly worded document can cause trouble? Nope. A battle is raging for the future of public health.
As our colleagues on LGC’s long-time sister title put it on Monday: “Health Service Journal understands the NHS is ready to take these public health functions back from local government if the Treasury does not otherwise put sufficient money into public health via local government.”
So the centre fails to provide decent public health services and relinquishes its grip on it – only to appear to go out of its way to ensure these services are doomed to failure locally. This then gives the centre opportunity to extend its grip over them once more.
While we concede that NHS England and the government are not the same body, the thrust of LGC’s argument is valid. There is no logic to any moves to move public health back towards the centre.
Public health needs stability and resources to succeed – and anyone who fails to offer it this is quite simply a bad hombre. Or a bad señora, in the case of Ms May.
Nick Golding, editor