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Many local authorities do not yet receive a proportion of public health funding that fairly reflects their needs according to the Public Accounts Committee's report published on Friday 6 March 2014.

• Report: Public Health England's grant to local authorities
• Report: Public Health England's grant to local authorities (PDF 321KB)
• Inquiry: Public Health England's grant to local authorities
• Public Accounts Committee

Chair's comments

"Good public health is vital to tackling health inequalities, reducing burdens on the NHS and creating an economically and socially active population.

That is why it is concerning that the Department of Health is not getting local authorities to their target funding allocations for public health quickly enough, with nearly one third of 152 local authorities currently receiving funding that is more than 20% above or below what would be their fair share.

Thirteen local authorities currently remain more than 20% below their target funding proportions.

The Department has decided not to change the grant distribution for 2015-2016, with the total amount remaining the same, meaning inequalities in funding will persist.

Local authorities are also presently constrained by being tied into contracts to which the Department had previously committed, such as for sexual health interventions, limiting their ability to respond to local priorities.

It is not clear whether the £2.7 billion public health grant to local authorities will remain ring-fenced. If the ring-fence is removed, there is a risk that spending on public health will decline as councils come under increasing financial pressures.

The Department should set out clear plans for how quickly it will move local authorities to their target funding allocations for public health and prioritise a quick decision on whether the ring-fence will remain.

There are still unacceptable health inequalities across the country – for example, healthy life expectancy for men ranges from 52.5 years to 70 years depending on where they live.

These inequalities make Public Health England’s support at a local level particularly important, but we are concerned that PHE does not have strong enough ways of influencing local authorities to ensure progress against all of its top public health priorities.

Given how important it is to tackle the many wider causes of poor public health, PHE needs to influence departments more effectively and translate its own passion into action across Whitehall."

Margaret Hodge was speaking as the Committee published its 43rd Report of this Session which – on the basis of evidence from Janet Atherton, President, Association of Directors of Public Health, Michael Brodie, Finance and Commercial Director, Public Health England, Dr Felicity Harvey CBE, Director-General, Public and International Health, Department of Health and Duncan Selbie, Chief Executive, Public Health England – examined Public Health England’s grant to local authorities.

Since it was created in 2013, Public Health England (PHE) has made a good start in its efforts to protect and improve public health. Good public health is vital to tackling health inequalities and reducing burdens on the NHS. We were impressed by the passion shown by PHE’s Chief Executive, and his determination to challenge Government to consider public health in wider policymaking.

However, we are concerned that the Department of Health (the Department) is not getting local authorities to their target funding allocations for public health quickly enough, with nearly one third of 152 local authorities currently receiving funding that is more than 20% above or below what would be their fair share. The Department decided not to change the grant distribution for 2015-16. Local authorities are also presently constrained by being tied into contracts to which the Department had previously committed, such as for sexual health interventions.

It is not clear whether the public health grant to local authorities will remain ring-fenced, and they need more certainty to better plan their public health programmes. If the ring-fence is removed, there is a risk that spending on public health will decline as councils come under increasing financial pressures. There are still unacceptable health inequalities across the country, for example healthy life expectancy for men ranges from 52.5 years to 70 years depending on where they live. These inequalities make PHE’s support at a local level particularly important but we are concerned that PHE does not have strong enough ways of influencing local authorities to ensure progress against all of its top public health priorities. Finally, given how important it is to tackle the many wider causes of poor public health, PHE needs to influence departments more effectively and translate its own passion into action across Whitehall.

The Health and Social Care Act 2012 made fundamental changes to the system for funding and delivering public health. Responsibility for commissioning local public health services returned to local authorities from the NHS. Local authorities now have a statutory duty to improve the health of their populations. The Department of Health (the Department) also created Public Health England (PHE), a new national executive agency. PHE is intended to have an authoritative and expert voice on protecting and improving the nation’s health. It provides local authorities, the Department and the NHS with advice and evidence on what works on public health interventions.

It also directly provides a range of central services, such as social marketing campaigns and health protection. PHE is accountable for securing improved public health outcomes. In 2013–14 PHE gave local authorities £2.7 billion via a ring-fenced grant to carry out their new public health responsibilities. The public health activities expected from the grant include encouraging healthier lifestyles and reducing the very large health inequalities across England, especially in life expectancy.

Conclusions and recommendations

Many local authorities do not yet receive a proportion of public health funding that fairly reflects their needs. In 2013–14, a third of local authorities (51 out of 152) received more than 20% above or below their target funding allocation–the amount that would be their fair share taking account of relative needs. The Department has moved local authorities closer to their target allocations and, in 2014–15, has reduced the number to 41 out of 152, 13 of which remain more than 20% below their target funding proportions.

However, the Department has decided not to change the distribution of monies in 2015-16, with the total amount remaining the same, meaning inequalities in funding will persist. Authorities are also locked into contractual commitments, for example on sexual health, which limits their ability to respond to local priorities. The Department has not announced longer term plans for making public health funding allocations more equitable although it has asked the Advisory Committee on Resource Allocation to review the public health funding formula.

Recommendation: The Department should set out clear plans for how quickly it will move local authorities to their target funding allocations for public health.

The Department has not yet decided whether the public health grant to local authorities will remain ring-fenced after 2015–16. The ring-fencing of grants to local authorities is unusual. There is a risk that spending on public health will decline if the ring fence is lifted and councils come under ever greater financial pressure. However, the Department has not yet decided whether the grant will remain ring-fenced after 2015–16 and said that this would be a decision for the new Government. The Department told us that the decision would be informed by further evidence of what has worked in terms of outcomes, and that at the moment “the jury is out” on whether to retain the ring-fence.

Recommendation: The Department should do all it can to provide more certainty to local authorities, by prioritising a quick decision on whether the ring-fence will remain. If the ring fence is lifted it needs to implement other levers to protect investment in public health.

PHE does not yet have a prioritised approach to influencing wider government policies. Many local and national government actions contribute to improving public health, for example having good housing, good education and a job are fundamental to living a long life in good health. The NHS and PHE have made good progress in placing a stronger emphasis on promoting good health and preventing poor health through their 'Five Year Forward View' which sets out the vision for the future health service.

We were also very impressed by the passion and commitment shown by PHE’s Chief Executive, and his challenge for government to take account of public health when making wider policy. PHE needs to engage Whitehall if it is to make maximum progress on its priorities. PHE has yet to be clear about its priorities for influencing Whitehall and we have yet to see whether it can achieve the impact needed. PHE has set out the evidence on some key public health issues, such as standardised cigarette packaging, but the government has yet to use all the evidence to affect its policy decisions.

Recommendation: PHE should set out a prioritised strategy for influencing Whitehall, and the measures to review its success.

PHE does not target its support sufficiently well to those local authorities that most need it. There are unacceptable health inequalities across England, with healthy life expectancy for men ranging from 52.5 to 70 years in different areas. There are real benefits of local authorities deciding their own local public health priorities so that they can focus on specific local needs. It is right that this will lead to variation in how local authorities choose to spend their grant, but we heard that some local authorities are not targeting their spending on areas of greatest need or where outcomes are worsening. PHE has developed tools to assist local authorities in selecting their priorities. PHE has not yet used these tools to identify those local authorities that would benefit most from PHE’s advice and support in prioritising and tackling areas of greatest need.

Recommendation: PHE should target its advice and support on those areas which would benefit most from such support. It should encourage local authorities to use the tools it has developed to improve public health outcomes.

PHE works through influence and cannot direct local authorities to act. PHE is accountable for securing improved public health outcomes. In October 2014 it published five health improvement priorities. Its success will be largely dependent on the work of local authorities, but its direct levers to affect local authority behaviour are not strong enough. The Department has set out some prescribed functions which local authorities must provide. The Department can attach conditions to the PHE grant given to local authorities. However, several of PHE’s public health priorities such as tackling obesity and reducing smoking are not included in either the prescribed functions or the grant conditions.

From 2015–16 there will be a new premium awarded to local authorities based on performance, which is designed to incentivise further improvement; but again it does not cover PHE’s priorities and, at £5 million in total, to be shared across the whole country, it is too small to make a real difference. PHE also has a 'Public Health Outcomes Framework' which covers a wide range of outcomes. The purpose is to increase transparency and accountability by bringing together disparate datasets and highlighting inequalities between local authorities. But although the majority of directors of public health are using the framework, there are still no data for some measures and data for others take a long time to collect.

Recommendation: The Department and PHE should identify how they will improve PHE’s influence with local authorities, focusing on how to make progress on PHE’s five health improvement priorities.

PHE does not provide local authorities with sufficient evidence or support to drive better decision making at the local level. Given the current financial constraints on local authorities it is important for them to make decisions based on good evidence about what works best. They want the evidence to know which interventions are most effective, for example in encouraging people to stop smoking or in reducing alcohol abuse. Local authorities have good access to national tools and reports with locally selectable data, for example the Longer Lives tool. But local authorities would value more assistance on economic appraisal and return on investment tools, to understand the relative impacts of different interventions and what works best.

Recommendation: PHE should continue to improve its support to local authorities, including helping local authority staff to understand the evidence base for what works best, and addressing the recommendations detailed in the NAO report.

The profile and impact of public health work in local authorities is undermined by high staff vacancy rates, particularly for directors of public health. PHE’s remit includes developing and supporting a skilled public health workforce. A strong director of public health in local authorities is vital to promote public health locally. However, about 20% of director of public health positions are filled by interim appointments, which weakens their impact and undermines consistency, training and development. PHE has developed a programme for aspiring directors of public health, and had some success in building a pipeline, but further progress is required. One problem with recruitment is unfavourable pay and conditions compared with previous terms for staff moving from the NHS. The Association of Directors of Public Health told us that there were issues with maintaining continuity of service which needed further work to encourage healthy movement of people between local government, PHE and the NHS.

Recommendation: The Department and PHE should set out how they are addressing vacancy rates in local authority public health teams, including tackling disincentives in the terms and conditions for public health staff moving from the NHS to local government.

Further information

• National Audit Office report: Public Health England's grant to local authorities
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