Should public health cash be ring-fenced?

The Conservatives want to put a stop to raids on public health budgets, but achieving this is no easy task. Jonn Elledge reports.

The public health budget has been raided in the past
The public health budget has been raided in the past

Public health, complains Professor Richard Parish, chief executive of the Royal Society responsible for it, is something of a 'Cinderella service'. The growth of migration, lifestyle factors and climate change, he says, have left the world facing 'the greatest public health challenges in human history'.

Yet the NHS has a nasty habit of raiding the public health budget to pay for everything else. Primary care organisations (PCOs) face many competing priorities.

As a result, interventions to deal with obesity or alcohol abuse, that will not deliver results for years, tend to get pushed to the back of the queue. According to Sir Derek Wanless, since 1997, while NHS medical staff increased by over 60 per cent, the number of public health doctors dropped.

A Conservative solution
The people likely to form the next government believe they have a solution. The Conservatives say they would trim political control of the NHS, turning the DoH into a department of public health, and making preventative measures the responsibility of the secretary of state rather than a junior minister.

Backing this up would be a pot of cash ring-fenced for public health, which would, in time, be taken out of PCOs' hands. As a result, David Cameron recently told an audience in Lancashire, 'money for long-term change won't be siphoned off by short-term demands'.

The idea has received mixed reviews. 'An awful lot of funding has been diverted to the mainstream NHS,' says NAPC vice-president Dr Peter Smith. 'A ring-fence is a good idea.'

But questions remain about how this would work. First, there's the problem of defining exactly what public health is. Would the ring-fenced budget include health visiting, for example, which is long-term and preventative, but often operates as part of general practice?

How about emergency measures like swine flu vaccinations? They are clearly a public health intervention. But if they were funded from a separate public health budget, would not that mean cash ostensibly ring-fenced for long-term interventions still ended up getting diverted to current spending?

Dr Smith adds that the evidence base for many public health interventions is 'sparse, because so many of them are long-term'. Ring-fencing public health might mean funding schemes for years that turn out not to work, while other treatments may be denied funding.

There's also a more philosophical concern for the Tories. The party has promised to abandon Labour's control-freakery, and let clinicians decide which services are right for their area. Yet a ring-fenced budget might force PCOs to fund interventions inappropriate for their population.

Special treatment
GPC negotiator Dr Chaand Nagpaul rails against giving public health special treatment. 'The one budget that's been raided time and time again is primary care,' he says. 'We've repeatedly asked for it to be ring-fenced, and been told "we don't do that".'

Specifying public health as a priority in commissioning guidance could help, he argues. Cutting obesity and alcohol abuse might require a more radical approach from the Conservatives: 'If they have a genuine commitment to public health they need to question their commitment to market forces.'

While the health secretary remains ultimately responsible for the NHS, it's hard to see public health staying top of their agenda for long: hospitals will always require more cash - and generate more headlines.

Professor Parish calls on the Tories to go further, and make the cross-departmental public health budget the responsibility of the Treasury or the Cabinet Office. Then, at least, it would be safe from the wandering hands of those PCO chiefs.

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