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Ring-fencing public health funding may be a barrier

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Local Government Improvement and Development’s Rob Whiteman gave his take on what the public health white paper means for councils in LGC’s sister magazine Health Service Journal

The reason d’être of local government is that elected councillors best represent residents’ concerns and preferences and although we have long argued that an elected body should hold the ring on healthcare commissioning we recognise that the shift to GP commissioning is localist in nature, that is pushing decisions as close as possible to the users of services.

And of course we welcome that councils will take the lead on the health of the public in their localities which recognises the strategic role of councils to address the broader determinants of health and wellbeing to tackle health inequalities. I use the term health of the public with care. This is not the same as the current public health function nationally or in primary care trusts; and we recognise that the NHS will continue to need a public health perspective to underpin commissioning and to support the Chief Medical Officer’s government-wide brief.

What interests us is the enhanced capacity it will bring into councils to develop and expand their existing work. This will, for example, build on the vast range of activity we have supported through the Local Governance Improvement and Development healthy communities programme. I am confident that councils will come up with creative ways of doing this and not just absorb things as they stand. All tiers of local government will play an active role, for example in two-tier areas district councils have a vital role to play given their responsibilities in relation to housing, planning, regulation, environmental health, and leisure; whilst unitary and county councils bring the weight of children’s and adult care services to work in a reconfigured way with public health specialists.

However, while the new arrangements will strengthen these synergies there is a risk that taken together with the new commissioning architecture, including the NHS Commissioning Board and the Public Health Service at national level, it may lead to a division between healthcare and public health improvement. The separation of functions could detract from a coordinated approach linking interventions from prevention to health treatment.  It could also result in commissioners and providers of health services no longer being seen as agents of public health improvement.  We must in the coming months make clear how Health and Wellbeing Boards will create strategic alliances between GPs and councillors to represent both clinical interest with local leadership and vision for the area.

The Government has recognised that councils will require additional resources to undertake the public health role. Councils face an average revenue support grant reduction of 28 per cent over four years but front-loaded to next year. We know that many councils will face cuts in RSG and specific grants taken together of 35 per cent with as much as 15 per cent being taken next year.

This doubtless made the imposition of a ring fence for public health attractive to DH but in the medium term this is counter productive because it creates a risk that local authorities see it as the total resource with which to fund public health and health improvement activities currently supported by mainstream budgets; services such as housing, early years support, transport, leisure and recreation already make a significant contribution to public health and health improvement.

Experience from the Total Place pilots shows that ring-fenced funding can be a barrier to adopting a whole-systems approach to achieving the best outcomes. For example, areas that focused on drug and alcohol misuse found that ring-fenced specific funding for drug treatment meant that they were only able to treat “half the person” and not address both the alcohol and drugs misuse. The pilots therefore strongly recommended that that ring-fences need to be more flexible or removed altogether because far from protecting resources ring-fence may have the reverse effect on value for money. 

But the cultural aspects of transformation – the manner in which it is done – are as important as structural changes. Localism is about genuine local choice, innovation, risk and prioritisation. It is very important that the new National Public Health Service, with broad outcome-based priorities, respects and promotes local choice in its work. There is the risk that local priorities will be either undermined or overridden by national imperatives.

Similarly, any centralised or rigid approach to evaluation runs the risk of replicating the previous set of national indicators, which could force councils to focus on what can be measured rather than long-term health improvement.  There is currently a lack of baseline data and the timescale for realising the benefits of many public health interventions can be long-term.

Finally, the majority of directors of public health are already joint appointments and we welcome their transfer into councils, but we question whether they need dual accountability to local authorities and to the Secretary of State through the Public Health Service.

The Local Government Group will continue to stimulate a dialogue between the local government sector, as the enablers and brokers of services, and central government and key stakeholders to ensure that the development of policy in this important area builds upon current best practice. When the proposals, or any changes along the way, are implemented we will be keen to make a success of this because the health and wellbeing of its residents and achieving efficiency for the public purse are at the heart of each council’s relationship with its citizens.   

Rob Whiteman is managing director of Local Government Improvement and Development, Local Government Group

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