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
• University of Liverpool

To ‘save money’ to boost struggling health services the Chancellor has decided to cut funding for public health and prevention, reducing spending on public health as a proportion of all health expenditure from 3.5% in 2015 to 2.5% by 2020.

The government has reneged on its 2010 commitment to “re-balance the focus on the causes of ill health and ensure that public health funding is prioritised”. The flawed logic of cutting investment in cost saving preventative services, such as sexual health, family planning, smoking cessation, drug, alcohol and child health services is strikingly short sighted.

But what is even more worrying is that these cuts are likely to be greatest in the poorest areas with the greatest need, reversing progress that has been made to address health inequalities. From the late 1990s a systematic strategy was implemented in England to reduce differences in health between the most deprived parts of the country and more affluent areas.

One consequence of this strategy was to prioritise investment in public health in more deprived parts of the country, leading to levels of spending in these areas that are around two and a half times higher, per head of population, than in more affluent areas.

There is growing evidence that this strategy worked (1,2). Figure 1 shows decreasing absolute inequality in premature mortality between more affluent and more deprived local authorities (LAs) from the late 1990s onwards during the time of the health inequalities strategy. The strategy was associated with a reversal in the previous trend of increasing inequalities.

Figure 1: difference in under 75 year old mortality, between most deprived and most affluent 20% of LAs (Source: Office for National Statistics)

The chancellor’s spending review outlines an average real terms cut in the public health budget of 3.9% each year over the next 5 years. This translates into a cash reduction of 9.6% in addition to the £200 million cut that was announced earlier this year. The implications for individual LAs will depend on the way the funding formula is applied and the decision about “pace of change”.

The Department of Health is currently consulting on a new formula for the public health allocation.  The application of this formula will reduce the share of resources going to more deprived areas relative to more affluent areas. This is because it allocates about twice the amount of resources per head to more deprived LAs compared to more affluent ones, whilst currently these areas receive about two and a half times the amount of resources per head.

There are a number of ways the Department of Health could distribute these cuts across LAs. They could apply a flat 9.6% cut to each LA over the next 5 years. This was the approach taken to allocating the cut of £200 million announced early this year, with each LA receiving a 6.2% cut. This approach will tend to widen inequalities, since the same percentage cut for an LA in a more deprived area, translates into a higher cut per head of population, compared to a more affluent LA. This is because more deprived LAs, with higher needs, have higher baseline funding than more affluent LAs.

But this approach would not involve using the new formula at all, and one might wonder what would be the point of having an allocation formula if its not going to be used. So a likely option would be to distribute the cuts so that those LAs most over target receive a higher cut than those most under target; over time moving all LAs towards their target allocation.  Since, on average, more deprived LAs are more likely to be assessed as ‘over target’ according to the new formula, this will tend to lead to even higher cuts in more deprived areas compared to just applying a flat percentage cut to all LAs.

In fact, all of the likely scenarios will hit the poorest areas hardest. Figure 2 below shows the cuts each year from 2015 experienced by the most affluent and most deprived 20% of LAs under 4 scenarios, (1) applying a the same percentage cut to all LAs, (2) applying a higher cut to more “over target” LAs but setting the maximum cut in any year for any LA at 4%, (3) applying a higher cut to more “over target” LAs but setting the maximum cut in any year at 8%,(4) applying a higher cut to more “over target” LAs so that all LAs reach their target allocation by 2020.

Note that these scenarios do not take into account the government’s additional proposal to fully fund local authorities’ public health spending from business rates which could further reduce funding in the poorest areas.

Figure 2: planned cut in public health funds in most affluent and most deprived 20% of LAs under four potential scenarios for distributing the cuts (Sources: Local authority public health grant allocations 2015/16 – Spending Review and Autumn Statement 2015 – Duncan Selbie’s letter to LA CE)

The progress that has been made in recent years to reduce health inequalities shows that the level and distribution of public health resources makes a difference. Cutting public heath services in this manner makes no financial sense; it will harm the public’s health and will increase health inequalities.

1    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.
2    Buck D, Maguire D. Inequalities in life expectancy – Changes over time and implications for policy. The Kings Fund, 2015 (accessed Nov 30, 2015).