Public Health has been a huge item of council spending since this responsibility was handed over to local authorities from the NHS in 2012.
Even with the reduction this year of £200 million, the total comes to £2.6 billion for the “upper tier” authorities this year – and that’s before a tranche of extra money is added to cover the public health responsibility for children aged 0-5 which pushes the total to over £3 billion. Yet how rigorous are councillors in ensuring that it is effectively spent? How much goes on practical measures, for example, vaccination? How much goes on bureaucracy and ineffective, nannying, campaigning?
If the money wasn’t spent, what evidence is there that we would really see more people smoking or fatter children?
Cllr Simon Cooke has reflected on what a Conservative public health agenda would focus on. It is far from being the current reality even in Conservative councils.
The (supposed) requirement for the spending to be ring fenced hasn’t really helped. Councils have raided the budget a bit to fill gaps in their General Fund caused by reductions in Government grant. Thus a bit of spending on voluntary sector grants or subsidising a swimming pool that would otherwise have been cut is maintained. But then a Council thinks it had better not push its luck. So perhaps takes a few hundred thousand, leaving the vast majority of the Public Health budget being spent (or misspent) much as it was when it came under the remit of the NHS.
If, for example, a council was to take seriously its remit to reduce health inequality there would be a range of policies that would be much broader than the narrow way Public Health is currently defined. Some of these policies would not necessarily cost any money – such as reducing the number of children in care and redeveloping council estates to reduce the number of tower blocks.
The Reform think tank have suggested a switch in approach. The emphasis should change from a “general signal” that is “too broad brush and fails to create a new sense of responsibility among individuals….The better way is to look to incentives – to move from exhortation to motivation.” The report adds:
“The whole idea of “public health” should change to “personal health” – with the aim of making individuals responsible for their own health, with employer support.”
What about lower Business Rates for firms that do a good job in keeping their staff healthy? I’m not even sure the rules would allow the Public Health budget to be raided in that way – even though that sort of nudge and partnership with the private sector could work well. Lower unemployment would also be a factor in improving health.
What about councils doing more to set their own house in order with measures to reduce sickness absence?
Mind, the mental health charity, has recently undertaken some research which finds that the council spending on mental health – at £40 million – is pretty derisory in relative terms. A powerful point. Yet just as important is how that £40 million is spent.
Loneliness is a big cause of mental illness and one that councils could do more to tackle by working with volunteers and local churches. More fundamentally councils have been a major cause of loneliness by building tower blocks and other examples of “social housing” which has proved anti-social in its impact. Correcting this approach is crucial.
Children’s mental health is an area where council’s could use Public Health funds to help schools. Mind regard Hertfordshire County Council’s Penn Resilience scheme as a success. It provides workshops which have alleviated depression and anxiety in Year 7 pupils. So that is an example of the money been spent in a practical way – but it is a rare example.
£160 million is spent by councils on smoking cessation. For Leeds City Council the programme included someone dressing up as a kangaroo and going round a shopping centre telling people smoking was bad for them.
Some of the money meant for smoking cessation has been diverted into political lobbying (in contravention of the rules that Council funds should not be spent in that way).
For example Public Health Action/Smoke Free South West has been paid over a million pounds this year (from Bath and North East Somerset, Bristol, Cornwall, Gloucestershire, Plymouth, Somerset, South Gloucestershire, Swindon, Torbay and Wiltshire councils). The organisation is quite open about its lobbying activities – for instance in support of plain packaging.
Similar concerns arise with FRESH North East and Tobacco Free Futures.
My own council is spending £924,000 on anti-smoking campaigning and activity of various sorts. I suspect those who quit would have quit anyway. I would focus on giving as much assistance as possible to pregnant women trying to give up smoking (including hypnosis if they are willing to to try it) and scrap all the generalised nagging.
Hammersmith and Fulham Council is also spending £777,000 this year on:
“Delivery of personal health plans – individual goal oriented planning and support for 1,560 people a year and 1,800 community health checks delivered each year; the service helps people to lose weight, become more active, reduce alcohol use, stop smoking and eat more healthily, and is focused on areas of deprivation.”
That sounds like measuring inputs more than outputs. Have these 1,560 people actually lost weight, drunk less or stopped smoking?
Similarly the £403,000 a year we spend on Community Champions:
“Two existing projects at £60,000 per year in Edward Woods and Old Oak; one at Parkview at £82,000 a year; 3 new projects to be launched in Shepherds Bush Green, Fulham Reach and North End Rd/Gibbs Green. Programme budget to cover training for volunteers, website, communications, conference.”
Hmmm.
£111 million of public health spending nationally goes on tackling obesity; a particular priority is childhood obesity. I have proposed using a modest sum to bring a Victorian drinking fountain next to a school in my Ward back into use. That would offer children an alternative to buying fizzy drinks from local newsagents.
But Hammersmith and Fulham Council focus is elsewhere:
“The H&F Tackling Childhood obesity budget of £145k for 2015/16 covers a third share of the budget for:
The programme team (Programme Manager, Business Support Officer (shared with the Dental Health programme), PH Research & Design Lead, Communications Officer and Engagement Officer) across the three boroughs.
Workshops to develop the Care Pathway/Customer journey (signposting residents to take up the Family Healthy Weight services recently commissioned) and the design and materials to publish the supporting toolkit for frontline staff across the councils, health services and VCS. H&F led on this work which will be completed by the end of this month.
The next stage will be to engage with officers across H&F to discuss opportunities to tackle childhood obesity then hold a number of workshops early next year to develop the first tranche of action plans. These will be signed off by lead officers and Members for implementation in 2016/17.”
In future there will be “Healthier Catering Commitment awards”, “nutritional advice…being delivered from local community venues” and “interactive supermarket tours”.
It all sounds like a waste of money although there may be some incidental benefit. Restoring the drinking fountain would cost £7,000 – so we could have 20 of them around the borough if we were to forego the assorted “toolkits”, “signposting” and “engagement officers” in just one year’s budget.
Nationally there is £664 million of the Public Health budgets from local authorities spent on sexual health.
So far as my own Council is concerned…
“The specific contraception services offers a wide range from provision of condoms, inter uterine devices, injectable and oral contraception, emergency hormonal contraception; diaphragm fitting and follow up.
“All contraceptive services are free to patients of child bearing age nationally and as such we are expected to deliver these services. Part of our commissioned provision is targeted at reducing teenage pregnancy.”
So free condoms for all – not just teenagers or those on low incomes. Hammersmith and Fulham Council spends over a million a year on “contraception” although this section of the budget also covers such items as health promotion programmes, training and education for sexual health professionals, “coordination of the abortion services”, “targeted outreach services” and a telephone helpline. There has certainly been a welcome fall nationally in teenage pregnancy. But is it really due to the free condoms, targeted outreach and telephone helplines? I suspect a broader change in social attitudes has more to do with it.
Part of the budget does have practical value – funding school nurses. But other items – awards schemes and glossy information packs – less so. How school heads must groan when they can’t get the money to fix playground equipment or provide a sports day, when brochures telling them about the importance of exercise arrive by the ton.
Reducing drug addiction would certainly be worthwhile. A big chunk of the Public Health budget is supposedly devoted to this – in my Council’s case there is £5.4 million concerned with “substance misuse”. But is it being spent in the right way? The Centre for Social Justice argues that the treatment that works is rehab. The CSJ is concerned that increasingly councils have been spending the money elsewhere. Providing heroin addicts with methadone and general publicity campaigns about the harmful nature of drugs are considered of dubious merit.
Altogether my council spends £22.7 million a year on Public Health – a quite staggering amount.
There’s £2.75 million on “behaviour change”, £777,0000 on “health trainers”, a million here, two million there. Nothing so far as I could see on tackling air pollution – although there are a number of things it could do.
I am not claiming my council’s record of ineffective spending in this area is worse than anyone else’s. I’m afraid it is probably all too typical. It was also doubtless the case that the NHS did an even worse job of Public Health spending.
Nor am I saying that all the Public Health budget is wasted – it merely appears that most of it is.
Finally, it would be entirely possible for public health spending to provide value for money. If it is was effective it could certainly boost the economy and reduce burdens on the NHS and the adult social care service.
The problem is that too many have fallen into the mindset that spending on Public Health is automatically worthy. For instance we have all these claims that each pound spent on public health will automatically save five pounds (or £10 or £20) on the NHS. A more rigorous less simplistic approach is required.
Those loudly proclaiming the merits of public health spending as an ideal, need to reflect a little more on just how the money is spent.