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Questions raised over effectiveness of public health spending

The £2.7bn given to councils to spend on public health is not always being spent where it is most needed, the National Audit Office (NAO) has revealed.

Core responsibility for public health shifted from the old PCTs back to local government under the Health and Social Care Act, with Public Health England (PHE) meant to support councils in encouraging healthier lifestyles and reducing the large health inequalities across England, especially in life expectancy.

The NAO says PHE, set up in April 2013, has made a good start, but it cannot yet tell whether its approach is achieving value for money.

In its review of PHE’s first year, NAO data analysis revealed that there are some areas where spending “may not be being targeted to where outcomes are worsening”.

For example, between 2010-11 and 2012-13 alcohol-related admissions to hospital increased by more than 6% in 26 local authority areas. These 26 councils spent on average 6% of their public health spending on alcohol services for adults. This was significantly less than the 9% spent by the 26 local authorities where alcohol-related admissions reduced the most. Further analysis is needed to understand such variations, added the auditors.

It was also highlighted that local authorities in 2014-15, overall, had reduced their budgeted spend on sexual health, drugs and alcohol services to 52.8%, down from 54.3% of their public health spending the year before.

Margaret Hodge MP, chair of the Public Accounts Committee, said: “We all know that prevention is better than cure. Good public health is critical to reducing the burden on local health economies and the wider NHS at a time when the health service is facing unprecedented financial challenges, as well as improving the lives of individuals.

“The NHS spends an extraordinary £3.5bn a year on treating alcohol-related harm - almost half the £8bn the chief executive of the NHS says is needed to plug the hole in its finances.”

Population health across England still varies greatly. Healthy life expectancy for men ranges from 52.5 years in Tower Hamlets to 70.0 years in Richmond upon Thames; for women it ranges from 55.5 years in Manchester to 71.0 years in Wokingham.

Hodge added: “There still remain unacceptable health inequalities that must be tackled – it cannot be right that a man living in Tower Hamlets has a healthy life expectancy 17.5 years lower than a man living on the other side of London in Richmond upon Thames.”

It is generally too early to tell whether public health outcomes are improving. But recent data on NHS Health Checks show improvement in service provision, with checks now being offered by every local authority.

Amyas Morse, head of the NAO, said: “PHE is accountable for achieving the public health outcomes the Department of Health wants, but it is local authorities who are responsible for delivering improved public health. The agency is developing a good relationship with its local stakeholders to whom it is providing tools, support and advice.

“There is a difficult balance to be struck between localism and the agency’s responsibility for improving health. The agency’s ability to influence and support public health outcomes will be tested further if the grant paid to local authorities were no longer to be ring-fenced.”

The report says PHE must provide stronger support for public health, and should consider how it would adapt its approach to local authorities if and when the Department removes the grant’s ring-fence.

The NAO also noted that while directors of public health felt that public health is generally well-placed within local authorities, staffing has been difficult pre- and post-transition. For example, at local authorities, interim positions still account for 16% of directors of public health, with those permanently employed at a level similar to that previously seen within primary care trusts. Unequal terms and conditions have also led to “significant dissatisfaction” among some public health professionals.

Council funding pressures are also having an impact. The NAO report says: “Some directors of public health talk about the pressure to use parts of the public health ring-fenced grant to fund existing public health services previously funded from other government funding, for example domestic violence support services. Local authorities are free to do this if they wish, provided that their spending and activity meet both their public health and other responsibilities. But the effect may be to reduce total public health spending.”

Duncan Selbie, chief executive of PHE, said: “This is a fair and balanced review by the NAO of our first year. Inevitably, there is more we can do to support the new public health system and we fully support their e recommendations.

“We take confidence from their opening assertion that we have made a good start.”

(Image: c. David Jones)

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