The vision for a transformed public health system was clear then - and it hasn't fundamentally changed since. The then Department for Health's aspirations for the transfer of public health to local government in 2013 matched very closely with current health and social care secretary Matt Hancock's present commitment to prevention.
In 2013 the aim was for local authorities to ‘create a 21st century public health system based on localism, democratic accountability and evidence'. That transfer of responsibilities took place. Fast forward to 2019, and Mr Hancock says he sees local councils ‘taking the lead in improving health locally through innovation, communication and community outreach'.
But on the questions of responsibilities and funding the messages coming from the centre to the sector on its future role in public health service delivery are mixed ones.
January's NHS Long Term Plan suggests a stronger role for the NHS in commissioning services including sexual health, health visitors and school nurses. These are roles currently funded for councils from the Government's public health grant.
It is also important to pay attention to the warning by the president of the Association of Directors of Public Health Dr Jeanelle de Gruchy that council public health budgets have been cut by £700m since 2014/15, including £85m this year. There are also concerns that suggested changes to council funding for delivering public health could hit some councils including Durham CC particularly hard.
What has the transfer achieved? The County Councils Network (CCN) commissioned Shared Intelligence (SI) to review the impact of the transfer in county areas - basing its core evidence on a series of semi-structured non-attributable interviews with directors of public health (DsPH) and other local stakeholders in 14 county areas. Separately, CCN recently commissioned LG Futures to do an analysis of public health funding since the transfer in 2013, and the report includes some of the findings.
Local authority interviewees were positive about the impact of the transfer. They said public health teams are mobilising the wider determinants of health by ‘working across the full range of council functions to improve health and wellbeing'. They report that ‘councillors are acting as powerful advocates for public health and that local authority commissioning and procurement expertise is benefiting commissioned services'.
The review said its interviews suggest the transfer has led to a strengthened use of evidence, particularly in social care. ‘Good evidence can change minds and attitudes', said one public health portfolio holder.
Exposure to councils' commissioning and procurement expertise is ‘seen by many DsPH as ‘an unanticipated benefit of the transfer'.
But overall health stakeholders are not so positive about the impact of the transfer. The independent review, Learning the lessons from the transfer of public health to councils, said: ‘They point to the consequences of reductions in council resources and a growing gulf between their organisations and public health teams in local councils.'
The backdrop for the transfer, ‘as with all local authority services since 2010' has been the impact of austerity. Public health ‘did not escape funding reductions, despite the transfer being accompanied by "a ring fenced grant"'. The level of public health grant for local authorities peaked in 2015/16 at £3.46bn, with the transfer of children's 0-5 services. This has ‘fallen year on year to an indicative £3.13bn in 2019/20. For counties, public health grant peaked in 2016/17 at £1.186bn and fell to £1.072bn in 2019/20.'
Current spending plans ‘suggest there will be a £0.7bn real terms reduction in the public health grant between 2014/15 and 2019/20'.
Based on the research, SI identified four factors which ‘can act as drivers of, or barriers to, an effective public health function in local government'. They are:
- The position of public health in the local authority matters – whether the director of public health reports directly to the chief executive
- Devoting capacity and time to developing and maintaining links with health commissioners and providers
- The relationship with district councils in two tier areas; in some places public health is acting as a catalyst for improved relations – while in other places poor relationships are getting in the way of mobilising the wider determinants of health
- Geography and coterminosity - or even a degree of it – helps
On 1 April 2013 responsibility for public health returned to local authorities almost four decades after the NHS took over most public health functions. This review suggests county authorities are well placed to play a key role in driving preventative activity as envisaged in the NHS Long Term Plan.
But the review urges the CCN to support and share learning between its members to ensure the factors identified above ‘act as enablers of an effective public health system rather than as barriers to it'. It also calls for substantive discussions between local government and the health service both nationally and locally to ‘reboot the relationship between public health in local councils and health providers and commissioners'.
The report Learning the lessons from the transfer of public health to councils, can be viewed here.
