World-leading public health expert Professor Sir Michael Marmot says some of the benefits of moving public health to local government have been lost because of austerity, but argues now is the time to trust and back council public health teams.
In so many ways, Professor Sir Michael Marmot’s 2010 report Fair Society, Healthy Lives set out the case in favour of moving public health into local government.
The review made clear the link between health inequalities and the wider social determinants of health such as educational attainment, employment and the quality of neighbourhoods people live in.
But Sir Michael, Director of the Institute of Health Equity at University College London, said he was not actually personally pushing for it. “I sometimes get told it happened because of me. But I didn’t actually propose it. I was not trying to make it happen. On the whole though I was sympathetic to the argument for it.
“Local government is in control of so many of the levers that affect the wider social determinants. In the NHS the focus is on beds and NHS activity – so it means prevention can get limited to areas like screening. In local government you have childcare, school and housing. It seemed like a good fit to me at the time.”
Austerity ‘cost public health’
But he said the biggest problem with the reform is what subsequently happened to funding. “Austerity has cost public health – of that there is no doubt. It is not just that the public health budget was cut, the wider local government budget was cut and it was cut in the most deprived areas the most. It has been regressive – that is what the data shows.
“The result has been extremely damaging. Even the narrative about protecting the NHS budget is not what it seems.
If you take into account the ageing population you actually have small reductions in NHS funding per person.
“Just looking at a blanket figure for spending doesn't tell you enough. You have to take into account the greater need. When you do this you can see from 1979 to 1997 healthcare spending went up 2 per cent a year after you adjust for size and ageing of population.
“Between 1997 and 2009 it went up by 5.7 per cent. In 2010 it went down by 0.7 per cent and then the next five years minus 0.3 per cent. The increase was negative after 2010. That is clearly inadequate.
“And that cost us in the pandemic. If you look at evidence from previous pandemics the impact is very much influenced by pre-existing inequalities in society including those in health.”
‘There’s a lack of trust’
There were other elements of the reforms that Sir Michael was in favour of too, but where he also has concerns about what has subsequently happened. He said the creation of Public Health England with its twin responsibilities for health protection and promotion sitting outside government was a “good idea” and provided a good partnership at a national level to support the work of directors of public health.
“I was disappointed when they dismantled it – I cannot see how that was a good idea in the middle of a pandemic. And I am concerned that you now have health promotion sitting within the Department of Health and Social Care. At least PHE were quasi-independent.
“Will the Office for Health Improvement and Disparities really challenge the government robustly? I think there is a risk they won’t and that makes it harder for the public health community to make the progress on health promotion that we need.
“The problem for local government is that central government does not seem to trust it. Take what happened with test and trace in the pandemic. Why wasn’t that given to directors of public health?
“Instead ministers chose to trust management consultants when public protection and managing outbreaks of disease was what local public health teams were meant to do. We can’t say for sure they would have done a better job, but they cannot have done worse.”
Back public health – it will pay off
Sir Michael said it is now clear local government public health teams needed to be given more responsibility. “It is only through allowing directors of public health and their teams the freedom and investment that we will see progress.
“We can see this through the work of Marmot cities which we have supported. They show what can be achieved with directors of public health bringing the voluntary, private and public sectors for the community good.”
He said the move to integrated care systems offers an opportunity to build on what is working locally. But – as in 2010 – the key will be focussing on the six priorities:
- Giving every child the best start in life
- Enabling all children, young people and adults to maximise their capabilities and have control over their lives
- Creating fair employment and good work for all
- Ensuring a healthy standard of living for all
- Creating and developing healthy and sustainable places and communities
- Strengthening the role and impact of ill-health prevention.
“We are facing huge challenges following the pandemic. The cost of living crisis means people cannot afford to eat or heat their home. If we don’t take concerted action, the impact on health will be catastrophic. I would love to see council public health teams given the backing to make a difference to people’s lives.”