Public Health in Tough Times

What should public health look like in tough times – what are the strategies and actions that will do the most to tackle health inequalities and support the most vulnerable?

If you want to get a really good feeling for the scale of the challenge look at the latest publication from the Centre for Welfare Reform “A Fair Society? How the cuts target disabled people” this highlights that:

• Of the £75.2 billion to be cut by government by 2015 50% falls on two areas – benefits and local government – these two areas only make up 26.8% of government expenditure.
• Local Governments primary function (over 60%) is to provide social care to children and adults
• By 2015 local government and housing will be cut by £16.2 billion – a real terms cut of 41.9%
• Benefits for disabled people and the poorest will also have been cut by £18 billion a cut of about 20%

For comparison the Public Health budgets that will be passported over to Local Government for 2013/14 will be £2.6 billion and will rise slightly in 2014/5.

So the question for local government is what are the public health priorities now?

The local authority public health duties (what they can spend their ring fenced public health budgets on) are:

• improving significantly the health and wellbeing of local populations
• carry out heath protection functions delegated from the Secretary of State
• reduce health inequalities across the life course, including within hard to reach groups
• ensure the provision of population healthcare advice

Looking at the list I think that the economic and policy environment is such that as much of the budget has to be focussed on reducing health inequalities. Population based approaches are not a priority at the moment, health protection functions should be shared between local authorities and population healthcare advice can be paid by CCGs.

Working out what to do

In working out what actions to take it is important to watch out for dangerous diversions along the way. For example:

Demonisation – there is a real risk of falling into the paradigm that the coalition government is trying to create – treating the poor as ‘other’, as feckless. Jeremy Seabrook describes this consistent and dishonourable strand of our cultural history that goes back at least 500 years. It is dangerously easy to get sucked into promoting interventions that demonise the poor – as an extract from the recent LGIU/Westminster Council Report “A dose of localism the role of local government in public health” shows:

“Localisation of council tax benefit and housing benefit……provide an opportunity to embed financial incentives for behaviours that promote public health…When an exercise package is prescribed to a resident, housing and council tax benefit payments could be varied to reward or incentivise residents” 

This proposal was summed up crisply by the Daily Mirror as  ‘Overweight? Exercise or we’ll axe your benefits‘  I suppose it might feel better if high earners (senior civil servants, politicians, directors of public health?) were also told that unless they adopted healthy lifestyles they would have to pay more tax! Chance would be a fine thing.

Of course the proposal is unworkable anyway and not even very popular within the Conservative Party. See comments on the Conservative Home Blog

Disempowerment – the second diversion is disempowerment. Regulating the environment that poor people live in without giving them the chance to improve their circumstances. So we see  Diane Abbots (Shadow Public Health Minister) recent proposal to allow local authorities to ban fast food joints from around schools. This approach can be traced back to the well intentioned paternalism of people like Titus Salt who built an alcohol free model village for his mill workers. My point is that knee jerk responses to regulate the environment that poor people live in are tokenistic unless they are part of a wider plan to provide positive alternatives.

Positive Actions

What is clear is that local authorities are already coming up with positive actions at a system level that address health inequalities and this is what public health budgets need to be supporting. It is also not suprising that many of these actions are consistent with the priorities (Housing, Income, Employment and Mental Health) that were captured in the Institute of Health Equity Report ‘The Impact of the economic downturn and policy changes on health inequalities in London’.

Some examples:

Poverty

• Blackpool Council has decided to provide a free breakfast and mid-morning drink of milk to all its 12,000 primary school pupils. This seeks to directly addresss one of the effects of poverty – poor diet. The intervention is universal and system level and there is an evidence base that gives the local authority confidence that the intervention will work.

• The Islington Fairness Commission is implementing a wide range of actions that include:

• Adopting the London Living Wage – and requiring all of its contractors to adhere to this too.
• Commissioning a new welfare rights service in the borough. In 2007/8 a survey commissioned by Age Concern (Just what the doctor ordered – welfare benefits and healthcare) estimated that for every £1 spent on welfare rights services £10 was put into the pocket of clients.

Housing

The London Borough of Newham have taken action to improve the quality of private rented housing bringing in a licensing scheme for all private landlords

Co-production

Finally a positive proposal from the LGIU/Westminster report. Which recognises the importance of co-production with citizens and developing assets in communities – models such as Turning Points Connected Care Model are being picked up by local authorities bringing communities, commissioners and providers together to delvier radical reform of services. A description of the Turning Point programme and other People Powered Health projects is available here

What do you think?