In the 2015 Spending Review the government announced it will increase NHS spending by £10bn per year by 2020. Nasrul Ismail argues that combined with cuts to funding for public health, the increase means spending is focusing on urgent care and undermines the prevention agenda. He explains that a more effective preventative policy would decrease financial dependencies in the long run, and so the government ought to have invested in it as well.
Two recent announcements could potentially shape the development of the UK health sector. On 4 November, the Department of Health announced 6.2 per cent cuts in public health funding for local authorities, which primarily delivers the health improvement and prevention programmes at the local level. It can be argued that the announcement was anticipated, given the magnitude of fiscal austerity. Less anticipated, however, was the Spending Review announcement that came 3 weeks later that there will be a £10bn increase in NHS spending in England. Hailed as the largest investment in health service since 1946, the additional funding will enable the NHS to offer 800,000 more operations and treatments, 2 million more diagnostic tests, 5.5 million more outpatient appointments and purchases of up to £2bn on new drugs. But what is the potential impact of such investment, considering the concurrent contraction of public health funds?
Whilst the expansion in NHS funding is auspicious in addressing urgent care, the simultaneous reduction in public health undermines a commitment to prevention. Yet prevention and proactive management of long-term conditions are more cost-effective than reactive treatment, in line with the upstream approach of public health. This is supported by joint research carried out between the King’s Fund and the Local Government Association which found that the average NHS spending per head was £1,742, whilst the average public health spending was £49 per head.
Furthermore, public health interventions can save avoidable costs on the NHS, such as £31 for every 10 minute GP consultation, £114 for every Accident & Emergency attendance, £235 for every ambulance journey to the hospital, and £3,283 for every inpatient stay in the hospital. In this context, health promotion initiatives such as substance misuse, smoking cessation, and obesity are capable of instigating individual behavioural change, which seeks to improve the health of the local population in the long term, thereby lessening financial strains upon the NHS.
Yet it is estimated that only 4 per cent of the total healthcare budget is spent on prevention, compared to 70 per cent spent on treating long-term conditions. The disproportionate focus on urgent care indicates that the funding streams for the NHS and public health are two separate entities, albeit with the same endpoint in mind: the health of the population. This is a ‘false distinction’, as Professor John Ashton once put it, particularly during the time of prevailing fiscal austerity, and it undermines the strategic role of public health in ensuring that the NHS is to be more financially sustainable.
Devoting more financial assistance to the NHS is an understandable strategy, as the government wishes to honour their 2015 general election promise that there will be a real-term increase in NHS investment by 2020. This is a politically popular strategy for both the health sector and the population. For the health sector, the government has endorsed the NHS five year forward view that comes with the funding commitment. For the public, such a move can overturn the general perception that nearly six out of ten people think health services will get worse compared to ten years ago.
Nevertheless, the increase in NHS investments should not have been made at the expense of the public health agenda. The work of public health should, in fact, run in tandem with the urgent care agenda as a system approach, particularly in empowering citizens to address behavioural changes and opt for healthier choices. The overemphasis on urgent care sends the wrong message that reduces public health initiatives to the “nice-to-have” wishlist, particularly when the schemes are designed to tackle the social and structural determinants of health in local areas. Whilst others argue that the economic climate ‘presents an opportunity for reforming and restructuring health promotion actions’, it is important to take into account widening health inequalities, so that sustainable investment in health is not forgone in the pursuit of short-term economic gains.
The increase in investments for the NHS and the cuts to public health funding are essentially giving with one hand and taking back with the other, and can potentially have a far-reaching impact for years to come. As the health sector operates by virtue of the systems approach, one alteration can disrupt the whole system in the long run. As such, the investments for health should have focused on the holistic view – from prevention to urgent care – to ensure that one emphasis is not at the detriment of another. Following this strategy the government could then be assured that they have attempted to make the best value-for-money investments possible within the health sector using the public purse.
Nasrul Ismail is a Visiting Research Fellow at the University of Bristol Law School and a guest lecturer at the School of Social and Community Medicine, University of Bristol. He can be contacted at Nasrul.firstname.lastname@example.org and tweets from @nasrulismail27.
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