By Richard Clifton
Almost two years ago, Public Health England (PHE) began operating with a mission to improve wellbeing and reduce health inequalities across the country. £2.7 billion of ring-fenced grants were given to local authorities in 2013/14 to improve public health, including the provision of drug and alcohol treatment and related interventions. The National Audit Office (NAO) produced a report in December 2014 evaluating whether intended outcomes and value for money were likely to be achieved.
On the 20th January, the chief executive of PHE, Duncan Selbie, and three others (Dr Felicity Harvey from the Department of Health, Michael Brodie from PHE and Dr Janet Atherton from the Association of Directors of Public Health - ADPH) were called to give evidence to the Public Accounts Committee. DrugScope provided a short briefing to the Committee ahead of the evidence session, focusing on key findings from the forthcoming State of the Sector 2014-15 report and emphasising the breadth and depth of the contribution made to improved public health by the drug/alcohol treatment sector.
The committee voiced concerns about the allocation of public health resources. The committee cited a survey conducted by the British Medical Association (BMA) which suggested that some public health funding had been diverted to support services – not necessarily public health services as usually understood - that would otherwise have faced cuts due to reductions in local authority revenue funding. Margaret Hodge argued that this could potentially lead to a lost opportunity to improve public health.
Duncan Selbie insisted that the grants were not substitutes for general revenue funding, but that local authorities had flexibility to spend money where it was most required and the allocations were best decided at a local level. Importance was placed on authorities using public health grants to achieve beneficial outcomes at a local level and assessed against local need. There is a mandate for an equitable service, but services should be prioritised based on the needs of individual areas.
Witnesses were asked to explain PHE’s position in relation to NHS England, local authorities and the Department of Health. The committee focussed on a number of different aspects throughout the session: how PHE can work to influence local decisions; how it can influence national allocations, and around the role of mandation in ensuring the effective and universal delivery of services and interventions.
The committee also raised the matter of the ring fence around the public health grant. Having already expressed concerns about its porosity, members were keen to seek views on the future of the ring fence, given that is currently only guaranteed to be in place until the end of 2015-16. Although Selbie has previously called for the ring fence to remain in place beyond 2015-16, on this occasion the consensus among witnesses was that it was a matter for an incoming government.
Selbie argued that health and wellbeing should not be solely conflated with the NHS; and that public health must be considered within the wider context of both economic and environmental issues. In his view, economic prosperity was the biggest health driver and Margaret Hodge agreed that employment, education and housing are all important. However, the committee was keen to focus on areas PHE directly control and witnesses were asked about PHE’s influence at both a local and national level.
Drug and alcohol misuse initiatives receive a third of the public health budget, and so were discussed in a number of contexts during the select committee. While not being included as prescribed functions for local authorities, there are grant conditions in place for substance misuse – a matter that was of some interest to David Burrowes MP, who co-chairs the APPG on Complex Needs and Dual Diagnosis with Lord (Victor) Adebowale of Turning Point. Selbie stated that treatment for substance misuse was not included as a prescribed function due to the variation in need across different authorities and that prioritisation must therefore be local. Referring again to the NAO report, Margaret Hodge observed that when less funding is allocated to drug and alcohol misuse, outcomes are worse.
There was discussion about using the health premium to reward local authorities producing successful results in public health, for which drug treatment is the only national indicator. Like the grant condition, the health premium is new in 2015-16 and is seen as one of the key mechanisms to incentivise and maintain investment in treatment.. The committee expressed concern that the health premium, limited to £5m nationally, might offer only a modest incentive to improve outcomes. Dr Harvey agreed with the importance of an incentive programme and stated the premiums available would increase after a spending review.
Selbie was especially passionate about plain packaging for cigarettes and minimum-unit pricing for alcohol, discussing his desire for a tobacco-free country in the future. He stated that PHE fully support measures to reduce demand for and harm from the two substances due to compelling evidence, and it is down to parliament to pass laws and garner support for harm reduction measures.
As 2013/14 was the first full year of PHE, it was too early to identify if public health outcomes were improving, subsequent years should yield more meaningful data to compare against the baseline. The Public Health Outcomes Framework was acknowledged as a key development in this area. Other examples of effective interventions were provided: PHE’s emergency MMR catch-up vaccinations led to a reduction in the number of measles cases from 673 in the first quarter of 2013 to 70 in the same period of 2014. The ‘Stoptober’ smoking cessation campaign, designed and supported by PHE was successful as well, with a University College evaluation finding it to be cost effective and that it had saved 10,000 years of life.