Better Health For All

• by Ben Barr Senior Clinical Lecturer in Applied Public Health Research, and David Taylor Robinson Senior Clinical Lecturer in Public Health Research
• Department of Public Health and Policy, Institute of Psychology, Health and Society, University of Liverpool

The chancellor has committed to the NHS plan, which says “the future health of millions of children, the sustainability of the NHS, and the economic prosperity of Britain all now depend on a radical upgrade in prevention and public health.”

Yet his announcement of a £200 million cut in public health funding, contradicts that statement and puts the NHS plan at risk. This 6.2% reduction in the public health budget will have adverse consequences for the health and wellbeing of the communities served, as well as increasing future demands on the NHS. Many public health services are cost saving, meaning that this action is likely to cost the Treasury much more than £200 million in the long run (1).

But will all areas be affected equally? This will depend on where the cuts fall, with the harm caused proportional to the absolute reduction in resources in each area. The £200 million cut is the equivalent to a reduction of just under £4 per person in England. Quality Adjusted Life Year (QALYs) (1) are calculated by estimating the years of life remaining for a patient following a particular treatment or intervention and weighting each year with a quality of life score. A cautious estimate of the cost effectiveness of public health interventions is £633 per QALY gained, which would indicate a potential reduction of 600 QALYs per 100,000 population or 32,000 QALYS in total. Previous austerity measures, in particular cuts to local authority funding, have not been applied equally, but have hit the poorest hardest (2). Public Health England is to consult with local authorities on how these new cuts will be implemented and it remains to be seen where the axe will fall.

Figure 1 shows the likely impact of three possible scenarios for distributing the public health budget cuts across local authorities (LA):

1. a flat cut of 6.2% to each LA;
2. a Pace of Change (PoC) policy with the percentage cut distributed according to each LA’s distance from their target allocation in the PH allocation formula , and
3. a needs weighted cut, with the absolute cut in funds in each LA, inversely proportional to the level of need in that local authority. For example, an LA with twice the average level of need, as measured in the PH allocation formula, would receive half the average cut.

The effect of these three scenarios is shown for all local authorities, divided into five groups, from the most deprived 20% to the most affluent 20%, both in terms of the absolute cut in resources per head of population and how that translates into QALYs lost, assuming an average cost effectiveness of public health interventions of £633 per QALY.

The flat cut and PoC scenarios clearly have the potential to increase health inequalities. A flat 6.2% cut to all local authorities would have a greater adverse impact in poorer parts of the country. Somewhere like Blackpool BC would lose £9 per head of population, whilst Surrey CC would only lose £1.70 per person.

A Pace of Change model would have an even greater adverse impact on poorer areas. As more deprived local authorities are more likely to be over target, poorer areas would receive an even greater cut in funding in this scenario. Blackpool BC would lose £19 per head of population, whilst Surrey would lose only 70p per person. This would come on top of larger cuts in core local authority budgets that have already occurred in these areas, with Blackpool BC having lost £225 per head from its core budget since 2010, whilst Surrey CC’s budget has only been reduced by £53 per head (3).

There is evidence that each pound of public health investment results in larger health gains in deprived populations (4) and therefore each pound cut may have a even greater adverse impact in more disadvantaged areas. If that were the case this analysis would under-estimate the overall adverse impact of these funding scenarios on health inequalities.

The needs weighted option is unlikely to increase health inequalities. In this third scenario, since the level of cut in each LA was weighted by the level of need, the cut is lowest in the deprived local authorities that have the highest needs. In practice any policy that results in a higher absolute cut in resources from poorer areas as compared to more affluent areas is likely to increase health inequalities.

Cutting public health funding is likely to damage people’s health, increase demand on the NHS and cost more in the long run. But if these cuts fall hardest on the poorest parts of the country they are also likely to widen health inequalities. We already have some of the largest differences in health between regions, of any country in Europe. These result from and contribute to the massive economic divide between the richest and poorest parts of the country (5). Reducing rather than increasing these inequalities is not only a matter of social justice, but will also be necessary for the government to achieve its aim of rebalancing the economy.

References and further information

PoC policy assumes the minimum cut is set at 3% and the maximum cut rate is set at 15%. The local authorities that are most under target get the minimum cut of 3% and those most over target get the maximum cut of 15%. A number of local authorities who are relatively over target, but not the most over  target, receive a cut above 3% but under 15% depending on their position from target relative to all other local authorities.

Other references:

(1) Owen L, Morgan A, Fischer A, Ellis S, Hoy A, Kelly MP. The cost-effectiveness of public health interventions. J Public Health 2012; 34: 37–45.
(2) Whitehead M, McInroy, N, Bambra C, et al. Due North Report of the Inquiry on Health Equity in the North. Liverpool: University of Liverpool and the Centre for Economic Strategies, 2014.
(3) Local Government Finance Settlement 2014-15 and 2015-16. .
(4) Barr B, Bambra C, Whitehead M. The impact of NHS resource allocation policy on health inequalities in England 2001-11: longitudinal ecological study. BMJ 2014; 348: g3231–g3231.
(5) Bambra C, Barr B, Milne E. North and South: addressing the English health divide. J Public Health 2014; 36: 183–6.

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• By Neil Squires
• Chair of FPH’s International Committee – soon to be renamed the Global Health Commmittee

There was a real buzz about Global Health in the Faculty of Public Health when I chaired a meeting of the International Committee on the 1st of June. The Faculty Board has approved a five-year Global Health Strategy (2015-2020), which will be launched in the pre-conference session on 23rd June, at the annual FPH Conference in Gateshead.

A survey of FPH members in 2014 highlighted that the majority of Faculty Members are interested in and commitment to supporting FPH’s engagement in Global Health, prompting a period of intensive work by the International Committee  to develop the strategy.

The benefits of thinking globally and acting locally to improve the public’s health have long been recognised, but the mutual benefits of supporting global action on health to protect health abroad and at home have never been more apparent than during the fight against Ebola.

The Global Health agenda is not new. It was recognised in the Department of Health’s, Health is Global outcomes framework for global health (2011-1015) that investment in Global Health is needed. Public Health England responded to the challenge in 2014, with the launch of its Global Health Strategy (2014-2019), setting out priorities for action.  But 2015, the target year for achieving the Millennium Development Goals (MDGs), is the milestone year in which FPH will launch its strategy.  The Strategy is an affirmation of the FPH’s commitment to Global Health and the Conference launch could not have been better timed.

Much of my public health career, before moving to Public Health England in 2014 and taking up the chair of the International Committee this year, has been spent working on global health for the Department for International Development (DFID).The priorities for global health which shaped UK international health priorities over the last 15 years have, in large part, been framed by the eight Millennium Development Goals, thee of which (MDGs 4, 5 and 6) focused directly on health.

The next 15 years, will see a shift in focus to the Sustainable Development Goals (SDGs), a much broader set of goals intended to be relevant to all countries, not just the poorest. The SDGs have just one health specific goal, but under this sit a broad range of health targets and indicators.

The health related targets aim to build on progress achieved against communicable diseases and add the rising burden of non-communicable disease, addressing health system challenges and working beyond the health sector to address the broader determinants of health to list of priorities.  The arguments put forward for including a target on universal health coverage in debates on the SDGs have been a very clear attempt to address inequality, which remains a major challenge to global health.

In developing the FPH Global Health Strategy, the priority was to identify the comparative strengths of thFPH and its membership, and address FPH’s strategic goal ‘to actively contribute to the improvement of global public health, through the organised efforts of FPH members’.

The strategy is built around a set of four core functions of FPH: advocacy, standards, building  workforce capacity, and knowledge, which are set out below.

Summary of four key functions of FPH

The strategy will be delivered through a number of Special Interest Groups (SIGs), which will be meeting in Gateshead on the morning of the 23rd, immediately after the launch of the Strategy. Special Interest Groups for Africa, India and Pakistan are all looking to recruit new members, and identify anyone with an interest in, and willingness to commit time to supporting action. Each group will be agreeing clear terms of reference and seeking to map current activities against the strategic priority areas set out in the Strategy.

If FPH is to have an impact at the global level, then it will be important to focus its activities on a limited set of priorities where there is a real potential to leverage action and change. Exciting opportunities to engage FPH members in India, Pakistan and in various countries in Africa are already being developed.

Other key news linked to the Board approval of the Strategy was agreement that the International Committee will change its name to the Global Health Committee (GHC).  The GHC will also be reaching out to other Royal Colleges in order to build support for more coordinated action on global health by taking on the chair of International Forum of the Academy of Medical Royal Colleges.

Again, a name change is proposed, with the hope that the Forum will become the Global Health Action Forum making real progress to coordinate approaches and work together on a range of global health issues.

So, the Global Health buzz is growing louder and I hope that rising levels of energy and enthusiasm generated developing the Strategy will galvanise Members with an interest to engage in one of the SIGs and help ratchet up FPH capacity to contribute effectively to improving global health.

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