Comment

More than meets the eye

Saffron Cordery, director of policy and strategy at NHS Providers, examines the complex structures, processes, approaches and laws that make public health more complicated than it might seem.

Public health is often in the news. It’s an important issue, and by definition is something that matters to us all, because it concerns the wellbeing of the whole population. I’d say this is a relatively straightforward assertion. 

However, taken together, the commissioning, funding, and delivery of public health are far from straightforward. 

Until relatively recently public health was a function of PCTs (remember them?), organisations that went by the wayside with the implementation of Andrew Lansley’s 2012 health reforms. In parallel councils have a duty of wellbeing, to do what they possibly can to support their local populations. This fits well given their community leadership role, responsibility for social care, leisure provision, planning, local transport, education, and close relationship to housing provision. 

The 2012 reforms created the national body Public Health England, and gave local councils direct responsibility for public health. Structurally, it fits. But as we know, once you add in the money, things get more complicated, and then when you add in councils commissioning health organisations to deliver public health services it’s more complicated still. But why? Here are three thoughts: 

NHS finances 

We know that NHS finances have taken a battering, and this year the provider sector as a whole has finished the year with a £2.45bn deficit. What makes the headlines and gets people most worried are the financial challenges facing the acute sector and in particular waiting times in A&E departments. However, other types of providers – mental health and community trusts – are also in financial difficulty. Constrained funding from the NHS is one reason, but another reason is the fact that a proportion of their services have been commissioned and funded by local government. 

Local government and public health finances 

Since 2010, local government’s funding from central government has been cut by 40%. This has meant cuts across the country to what are deemed as ‘non-essential’ services, including libraries and leisure services. Last year public health funding took an in-year hit, as its budget was cut by £200m. On top of that, public health suffered a further hit in the comprehensive Spending Review settlement. Over the Spending Review period total spending on public health will fall from £3.46bn in 2015-16 to £3.1bn by 2020-21. 

NHS providers are now caught in a perfect storm where pressured local authority budgets lead to swingeing cuts on contracts for services such as school visiting and smoking cessation, and pressured NHS commissioning budgets mean providers can no longer absorb or cross-subsidise these cuts to their local authority contracts. But what impact do these really have on services on the ground? Well, they bring into focus two issues: that money and quality are inextricably linked, and that how services are commissioned, and by whom, really does matter. 

A pertinent example of this was highlighted in a recent Guardian article by Polly Toynbee who reported on the difficult position faced by one of our member organisations, South West Yorkshire Partnership NHS FT. Barnsley Council, now responsible for public health services for young people, put this service out to tender. However it cut the available funding for the contract by £1m, from £5.8m to £4.8m. The trust chose not to bid to run the service as it couldn’t guarantee a safe, high-quality service if it did so. The trust has had to walk away from a proportion of its income for the coming year and the council is running the service itself. 

How services are commissioned 

Mental health and community trusts are subject to more frequent tendering of their services than other healthcare providers, and they are commissioned by health and local government. This leads to a degree of financial and workforce uncertainty and in the extreme cases can undermine the ongoing viability of organisations. 

Recently NHS Improvement recognised this. It wrote to commissioners in the NHS to remind them that under the competition and procurement frameworks to which the NHS is subject, contracts did not always need to be automatically retendered as long as commissioners are transparent about the rationale for not doing so. However, councils do not sit in NHS Improvement’s span of control. This reminder does not apply to them. 

This is not a call to start changing structures right now; that is evolving through processes such as sustainability and transformation planning. However, it is a call to recognise that behind relatively simple assertions – that public health matters to all of us – lies a set of structures, processes, approaches and laws that make it much more complicated than it might seem.

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