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Health of the nation: how the pandemic highlighted the state’s role in preventing illness

7 min read

With major changes on the horizon, Kate Proctor talks to those on the frontline who believe the pandemic provides an opportunity to tackle public health inequalities.

Prime Minister Benjamin Disraeli once told Parliament: “The care of the public health is the first duty of the statesman.” While he may have been referring to Victorian sanitation, slum housing and disease, there has been consensus among governments of all stripes that the state has a role to play in helping citizens lead healthy lives. Disraeli’s solutions were foundational and transformative: running water, rubbish collection and housing for the poor.

Today, public health looks very different. At the start of the pandemic, public health took on the challenge of testing for the disease, while regional directors were given a key role in contact tracing. Pre-pandemic, people may have had their public health needs addressed through sexual health clinics, drug, alcohol and tobacco addiction support or even cookery classes to tackle obesity and cholesterol. But with coronavirus exposing huge health inequalities, it is clear there remains scope for improvement. The poor are more likely to catch the disease and studies have shown mortality rates are higher in deprived areas.

Frontline public health workers say their field of healthcare has suffered not only from a lack of funding, but as a result of being tied to the delivery of statutory services like tackling substance misuse and weight loss, meaning they lack the cash to truly innovate. Last year, the public health grant for England was £3.3bn; some estimate an extra billion a year is needed to deliver real change.

Many in the sector point to a 2019 study by the Centre for Health Economics, which suggested investment in public health was three to four times more effective than pushing the same spend into the NHS.

David Buck, senior fellow for public health and inequalities at health charity The King’s Fund, said: “The government talks a good game on public health and prevention, but it doesn’t always put its money where its mouth is.”

Following a series of cuts between 2015 and 2019, Buck said an extra £1bn in funding was needed a year just for public health spending to stand still. He added that while settlements had been maintained in the years immediately following the transfer of public health from the NHS as part of the Health and Social Care Act 2012, more than £700m was subsequently taken out of the system.

With entrenched health inequalities brought sharply into focus by the pandemic, change may be coming. The public health field is in flux following the government’s controversial decision part-way though the pandemic, to scrap Public Health England, set up eight years ago during the transfer of public health to local council control.

Critics questioned the timing of the move during a major health crisis. Yet the government is pressing on with creating a new independent body to fight infectious diseases, the National Institute for Health Protection. How the health improvement side, the area overseen by local authorities, will be affected remains to be seen.

Buck said the sector was awaiting the plan, expected this spring, with mixed feelings. “There may be a good case for the reforms but this wasn’t the time to announce it. There is an opportunity now for the government to be very clear about how it sees public health as a priority going forward, to plant its vision for the future.”

During Gordon Brown’s Labour government, there was a cross-departmental national strategy to tackle health inequality with tough targets on life expectancy, infant mortality and improving the health of different socio-economic groups. Buck, who worked for the then-government overseeing this strategy, said the approach had proved successful, and should be adopted again, updated for the 2020s.

Ian Hudspeth, chair of the Local Government Association’s Community Wellbeing Board, said despite the reduction in funding, councils had done a good job at improving public health in the years since they were given responsibility. He highlighted increased testing and treatment for sexually transmitted infection, with attendances at clinics up and new diagnoses down; a fall in teenage conception rates; decreases in the number of adults smoking cigarettes; and more children being measured to help tackle child obesity.

Like Buck, he is keen to stress how valuable public health funding is. “Forty per cent of avoidable deaths are as a result of tobacco, obesity, inactivity and alcohol harm, showing there is still much more to be done,” he said. “No new funding for public health in the recent Spending Review makes this incredibly challenging.

“Investing in these services now means we can help prevent residents from being more vulnerable to future outbreaks due to preventable health risks such as excess weight and other underlying conditions related to drug and alcohol abuse.

“If we are to build back better from this crisis and finally tackle our long-standing health inequalities, we need to start planning ahead now to meet the upcoming challenges post-pandemic.”

To do this, Hudspeth, who is Conservative leader of Oxfordshire county council, said public health spending needed to reach at least £3.9 bn a year by 2024/25 to match the growth in overall NHS funding.

Richard Watts, Labour leader of Islington Council, said the government had introduced some welcome public health measures in response to coronavirus, such as the cycle lanes rolled out in London. He remains concerned however about the lack of regulation on unhealthy foods, particularly those targeted at children. Having worked on the Children’s Food Campaign, which began campaigning on junk food marketing more than a decade ago, he is disappointed by the slow pace of measures brought in by successive governments to address the problem.

He said: “They talked a good game, but I’ve not actually seen any action yet. We see a cycle where governments try to rely on voluntary agreements with the food industry. It becomes quite apparent they don’t work and they need to introduce some quite strong regulatory controls.

The government talks a good game on public health and prevention but it doesn't always put its money where its mouth is.

“They just gear themselves up to do that, and then the government changes or the secretary of state changes and at some point we just need to crack on with this.

“We had some of the worst levels of public health in the world going into this crisis and that has had a horrible effect. It is important that there’s serious investment in public health now.”

The government increased its public health grant by £145m in the year 2020/21 to £3.3bn, and health secretary Matt Hancock has said there would be a renewed focus on public health in the upcoming health and care white paper – the first for more than a decade.

In a Policy Exchange speech about the future of public health, he said the government remained “passionately committed to health improvement” and the prevention agenda.

A Department of Health and Social Care spokesperson said: “The government is supporting Directors of Public Health and their teams to protect and improve the public’s health and wellbeing during the current pandemic and beyond.

“As part of the recent Spending Review we have committed to keeping the public health grant, meaning local authorities can continue to invest in prevention and essential frontline health services, serving the communities they know best.

“In addition to the baseline funding for public health, have also made over £10bn available to local councils to address the costs and impacts of Covid-19.”

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