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.
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