In advance of every major health strategy and public spending exercise, the public health community says further investment in the services we are responsible for will be key to addressing the challenges facing health and social care.
Theresa May’s promises of a multi-year funding settlement for the NHS to help the service plan for the future, and of a spending review of all departments in 2019, will be no exception.
We know that part of the answer to the long-term sustainability question has to be greater investment in prevention. It also seems obvious to us that getting public health services right is crucial if we are to continue to grow our economy as our population ages. And a healthy economy fuelled by a healthy population is an essential precondition for the maintenance of all public services.
So why haven’t these arguments yet translated into new investment in public health services? Why instead will we see a 21% reduction in the purchasing power of the local authority public health grant between 2015-16 and 2019-20?
The standard response is that there just hasn’t been enough money to go round. With the social care funding gap set to reach over £2bn by 2020 and a projected NHS funding gap of at least £20bn by the end of this parliament, funding for the ‘right now’ of episodic care will nearly always trump funding for the ‘will happen in 10 years’ time’ of prevention.
Another commonly heard response is that we need to work harder at building good public health into all government policies. Some believe that discrete public health budgets will then matter less. In fact, the government just used this very argument to hold firm on cuts to public health budgets made in the 2015 spending review.
The more cynical response is that local and national government struggles with prevention because of the short-termism inherent in the electoral cycle. But perhaps the hardest response for the public health community to hear is that we’ve just not told our story well enough, either to decision-makers or to the voting public.
Of all these responses, I struggle most with the cynical one. Local and national governments make long-term, strategic decisions all of the time, on all sorts of issues.
I also struggle with the response about resource scarcity. We know that in the context of overall local authority budgets, the ringfenced public health grant is substantial. We would contend, however, that £16bn for public health over the past spending review period is a very modest investment compared with the over half a trillion for NHS treatment and care over the same period.
So how should the public health community respond if we hope to get a better outcome this time around?
We can look to public health minister Steve Brine for a steer. While acknowledging that public health cuts have been harder than many of us may have imagined, he said very frankly at the recent Local Government Association/Association of Directors of Public Health conference that “we all need to get better and smarter at making the case for our share of resources, both locally and nationally, as strongly as we can”.
Yes, we need to have really strong evidence about the likely return on investment. But we also need to be able to show, as best we can, the impact on health and wellbeing outcomes this year from a decrease in funding last year. Then we need to be able to model the likely outcomes from increases or decreases in spending in five years’ and in 10 years’ time. And we need to communicate this modelling clearly, again and again.
I think we also need to show more effectively that we have the public’s support for further public health policy reform. As a Public Health Wales survey has recently demonstrated, there is widespread public support for the idea that the NHS should spend less on treating illness and more on preventing it in the first place. We need to better tell the personal stories that sit underneath the evidence and statistics – the positive changes in people’s lives and the impact that has.
And, fundamentally, we need to be clear that this isn’t about rehashing the case for a reversal of cuts to the public health grant. This is about making a case for the future funding of public health, and it is a vital case to make.
Professor John Middleton, president, Faculty of Public Health