Monday 1 July 2019

The 'public health' budget hasn't been cut enough

Earlier this year, the Local Government Chronicle asked me to write a response to an article by Jo Bibby complaining about cuts to the 'public health' budget. I don't know whether they ever ran it (it's not online), but here is her article followed by my reply.

Jo Bibby: Keeping us healthy is not just a job for the NHS

For years the British public have been told that staying healthy is entirely their responsibility – so much so that they are starting to believe it.

It’s no wonder that some people want to perpetuate this view. Much of the rhetoric about prevention places the responsibility for staying healthy firmly on you, me and our Fitbit. But this lets governments duck their responsibility to tackle the root causes of ill health.

The recently-published NHS long-term plan puts preventing poor health at its heart, including finding and treating disease earlier and calling on the NHS to help tackle unjust differences in health between the best and worst off. These steps are welcome.

But the numbers living with health conditions that could and should be avoided is rising. Whether we are talking about respiratory problems linked to air pollution, smoking or poor housing; cancers caused by obesity, tobacco and alcohol; or the increasing levels of depression and anxiety arising from myriad factors such as debt, loneliness and insecurity, they have two things in common.

First, they all have roots in the political choices governments make. And second, by the time they are on the NHS’s radar it is largely a case of mitigating the consequences of disease rather than prevention.

It’s not that the emphasis on prevention in the long-term plan is futile. Good NHS care can be the difference between your type 2 diabetes being manageable or it leading to your foot being amputated – the fate of over 6,000 people each year.

But just looking to the NHS to prevent ill health is akin to thinking that investing in prisons will reduce levels of crime. Of course, prisons have a role in preventing re-offending; they don’t stop people committing crimes in the first place.

Poor health is the consequence of circumstances that limit people’s ability to secure the basics for a healthy life – a home, a job and a friend – thereby increasing their exposure to multiple risk factors. Any government committed to the prevention agenda needs to be look far beyond the NHS.

Putting responsibility for keeping healthy on individuals alone sidesteps the root causes of ill health – poverty being common to most of them. It also diverts attention from the commercial interests of the food and alcohol industries.

Yet the degree of control any of us can exercise over our own health is shaped by the conditions we find ourselves in. Living in poorer conditions increases the exposure to factors harmful to health: poorly-paid and poor-quality work, inadequate housing, greater air pollution, a lack of green space and affordable, healthy food.

As highlighted by the Institute for Fiscal Studies, healthcare spending has risen from 23% of public service spending in 2000 to 29% in 2010. It is set to reach 38% by 2023-24.

Meanwhile, other areas of government spending that create the conditions for healthy lives have seen big cuts. Education spending has fallen by 8% per pupil in real terms since 2009-10, welfare changes since 2011 have cut incomes for the poorest households, and Sure Start and early years services have been cut by over 40% since 2010.

Perhaps the starkest illustration of disconnected policy making is the £85m cut to the public health grant announced before Christmas, when our analysis shows that they need an additional £3.2bn a year to meet demand and address inequalities.

This situation is no longer tenable. The number of years lived in good health is falling for people who face the harshest socioeconomic circumstances. This is despite record spending on healthcare and medical advances. As such there is a growing recognition that a healthier society is about prevention.

Tackling the issue facing millions across the UK of spending years in ill health will only happen through a comprehensive prevention strategy that harnesses the contributions of all areas of government.

This demands an industrial strategy that creates the opportunity for good quality work across the whole country, a more muscular commitment to regulating the food and drink industry – particularly where it impacts on children – and investment to bring back the social infrastructure that supports the most vulnerable.

The government’s forthcoming prevention green paper provides the chance to do this and it must be done alongside adequate funding for wider public services that have a direct impact on people’s health, including those delivered by local authorities.

Creating a healthy society is good for all of us. The additional spending for the NHS will help mop up the poor political decisions of the past but isn’t enough to create a healthy future.

Jo Bibby, director of health, the Health Foundation

Christopher Snowdon: Cut deeper 

Jo Bibby complains about cuts to the public health budget but never mentions how large that budget is. It is a very large sum indeed. The figure usually quoted is around £3.5 billion, but even that large number is an underestimate since it is only the amount given to local authorities. The operating budget of Public Health England in 2017/18 was £4.3 billion. In the context of this king’s ransom, a cut of £85 million is trivial.

I would like to see the government go further and take more money out of the ‘public health’ slush fund to give to frontline services. The usual argument against this is that prevention saves money in the longterm but this stitch-in-time narrative is a self-serving myth. There is plenty of economic evidence to show that most preventive interventions are not only costly in themselves but create further costs down the line when people develop other diseases. It is the ageing population, not the phoney ‘time bombs’ of obesity and alcohol, that has led to NHS costs skyrocketing in the last twenty years.

I am assuming here that preventive interventions are effective in prolonging life, but that is by no means certain. Despite the vast expense, there is little evidence that many public health initiatives, such as the fatuous Change 4 Life campaign, have any positive effect. Some public health initiatives, such as vaccinations and sexual health, are important and necessary but it is not obvious why these cannot be provided by the NHS directly. Monitoring and tackling infectious disease is a legitimate public heath goal. Pestering grown adults about their lifestyle is not.

Public Health England urgently needs auditing by independent academics to show that its billions could not be better spent on actual healthcare. The restructuring of public health in 2013 created a gravy train for single-issue zealots and left-wing political activists to masquerade as health experts, not least by appointing dozens of Directors of Public Health with an average salary of £150,000 in local authorities across the country. These pocket dictators make a nuisance of themselves in whatever way they can. Amongst their trivial obsessions is a fanatical desire to stop people smoking in hospital car parks and a keen urge to prevent new alcohol outlets and takeaway outlets from opening, as if any of this would have the slightest impact on the health of residents.

There is no doubt, as Bibby says, that financial security, sound employment and a good social life are beneficial to both mental and physical health. The question is whether public health professionals are in any way equipped to create economic prosperity, other than by constantly demanding the government spends money it doesn’t have. Not only do they lack the tools to tackle poverty and social isolation, they actively support  regressive policies such as minimum pricing and sugar taxes which are tailor-made to exacerbate them. It is thanks to their smoking ban that thousands of traditional venues for socialising, fun and friendship - pubs, bingo halls and working men’s clubs - have closed since 2007.

There is an almost comical disconnect between the grand political ambitions of the public health lobby and the policies they spend so much time and money campaigning for. We can all agree on the need to improve living conditions, help children get a good start in life and have a clean environment, but these are complex and expensive tasks which are not made any easier by pretending that they are public health issues. Faced with these massive socio-economic challenges, what does the public health propose? A ban on buy-one-get-one-free food deals. A calorie cap on vol-au-vents. Brown cigarette packs.  Smaller wine glasses. Putting 10p on a can of Coke. Banning Tony the Tiger.

By no means all of the public health budget is spend on such ludicrous schemes, but despite the supposedly savage cuts, it is notable that there has been no decline in the volume of nanny state hectoring in recent years. Quite the reverse.

If people wish to campaign for their pet projects, they should be free to do so, but the taxpayer should not be forced to subsidise them. As far as this taxpayer is concerned, the problem is not that the public health budget has been trimmed, but that it has not been trimmed enough.

Christopher Snowdon is head of lifestyle economics at the IEA

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