At a recent University of Birmingham conference, Public Health: healthy lives out of austerity, we heard first-hand the challenges faced by Public Health professionals in their new Local Authority environment. Funding cuts of £200m from 2016/17, the proposed removal of the ringfencing of their grant from Public Health England, continuing cuts to wider services, the move to business rate retention in Local Authorities, relationships to Clinical Commissioning Groups (CCGs), and the move to combined authorities to name just a few.
The public health system, and the professionals involved are still very much establishing themselves in their new local authority environment. To add to the challenge, various statutory, professional, financial, and importantly political accountabilities remain in a state of tension, while the evaluation tools and justifications for public health interventions in their new context are still being worked out.
In April 2013, we saw teams of public health professionals making the difficult transition into local government from the NHS. Under this new system directors of public health (DPHs) became responsible for a public health budget in their local authority, spent variously on public health professionals and commissioned services across a range of mandated and optional areas of health and wellbeing. Nationally, this funding came to £2.7bn in 2014/15, and after an initial rise this is now being reduced by £200m in 2016/17 then by a further 3.9% pa through to the end of this parliament. But these cuts, announced just last year, are relatively modest in light of the 40% real terms cuts over the last parliament to local authority budgets, and the likelihood of further reductions in the future. The legacy of reform after reform also leaves significant inequalities of provision across the country, so that public health practice, particularly in metropolitan areas, is increasingly required to find new ways to deliver better public health out of austerity.
Public health professionals have had to be nimble and adaptable to new audiences in communicating the message of health prevention and ‘spend-to-save’ to a wider, increasingly non-medical, group of stakeholders. While teams still work extremely hard to bring a rigorous evidence base to support their interventions it is often now the ‘human story’, ‘trust’, and political priorities that can influence how public health professionals are really valued.
Public health teams are rising to these challenges by making greater use of joint roles, positions on strategy boards, and gaining influence over wider commissioning decisions. This greater influence is clearly central as specific funding is reduced, but equally this goes to the heart of the question of identity of the public health professional. If ‘everything is public health’, and public health is to be brought into ‘everything we do’ in local authorities, how can a public health department justify a separate ringfenced budget?
Many professionals answer this by pointing to the unique expertise they can bring across council services, the scientific rigour their methods can produce, as well as to the statutory services they are required to commission, but this point will be further tested should the ring fencing of the public health grant finally be removed in April 2018.
There were some positive responses from professionals at our conference to the idea of a Better Care Fund-style pooled budget, between CCGs, councils and other partners, as the role of financial accountability at the local level becomes ever more important. They pointed to the need for alignment of strategic objectives along the entire care pathway, while maintaining a central role for directors of public health. Participants in my doctoral research on public health also point out that genuine savings and efficiencies on commissioned services have already been released since moving to Local Authorities, but that greater links with partners are still needed, especially CCGs.
As public health professionals will be well aware, the public’s health and wellbeing is dependent on a very wide range of factors, and while their specific budgets may only be modestly cut, the public’s health is also affected by wider loss of services, cultural factors and life style choices. We saw an example of the impact of authority funding restrictions at our conference in which a third sector provider, specialising in bring up the skill levels of vulnerable groups and taking them into employment, had lost the majority of their funding and was facing closure. The loss of such services can hugely affect the broader network of public health provision across the local economy, but with funding challenges set to continue such changes may represent a shift from service provision to public health as a network of influence and advisory services.
Work remains to be done in establishing the value of public health professionals across councils, in recognising the value of preventative action, wellbeing, quality of life, and the importance of interventions that cannot easily be measured – at least in the short-term – in pounds and pence. This work will need to become ever more outward looking and collaborative to remain effective.
James Brackley is a lecturer in Accounting at the University of Birmingham Business School teaching audit, financial accounting, and public sector accounting courses. He is also working on a PhD project at the University of Birmingham on Public Health activities in local authorities, with a particular focus on accountability and professional identity.