- Tackling the full extent of future demand requires a shift in focus and a far greater emphasis on prevention and early intervention
- Public health has a fundamental role to play in this – investing in public health helps to deliver the wider prevention agenda that is critical to our health and care system overall
- Council services – including those provided by district councils – support people’s wellbeing, as do those of councils’ many local partners
As we have set out, adequately funding social care is a key part of the solution for a more secure long-term future for health and wellbeing. But if we are to really tackle the full extent of future demand with quality services we need to refocus our efforts on intervening earlier and preventing needs developing in the first place (or slowing their escalation). This is better for people and better for the public purse. Promoting healthy choices, protecting health, preventing sickness, intervening early to minimise the need for costly hospital treatment, supporting people to manage their own conditions or ‘self-care’, or providing support to unpaid carers requires the input of many council services and many of councils’ local partners.
The role of public health
The public health challenge in numbers…
Two thirds of adults and a quarter of two to 10 year olds are overweight or obese. Treating the consequences of obesity costs £5.5 billion to the health and social care system and has significant impacts on the quality of lives of people.
The proportion of adults who are overweight or obese is predicted to reach 70 per cent by 2034
Alcohol-related crime accounts for about 920,000 violent incidents each year – accounting for 47 per cent of violent offences committed. The total annual cost to society of alcohol-related harm is estimated to be £21 billion. The NHS incurs £3.5 billion a year in costs related to alcohol.
Trips and falls cost the NHS more than £2 billion each year, with a 35 per cent increase in acute care costs in the year following a fall.
Loneliness and social isolation are as damaging to our health as smoking 15 cigarettes a day.
Local government is unanimous in its support for taking leadership of public health and working with local partners to achieve shared priorities. Councils are committed to making a difference to the lives of people in local communities by helping them live longer, healthier and more fulfilling lives. But this can only be achieved if we do things differently and resource public health services appropriately as part of wider investment across the system to help embed community-based prevention at all key points, including social care, the NHS and the voluntary sector.
In the 21st century, a huge part of the burden of ill health is avoidable. About a third of all deaths are classed as premature – that is they could have been prevented by lifestyle changes undertaken at an earlier time of life. The World Health Organization (WHO) estimates that almost one third of the disease burden in industrialised countries can be attributed to four main behaviours: smoking, alcohol intake, poor diet, and lack of physical activity.
Without investment in prevention and early intervention, we will only ever see a continuation of the current vicious circle in which inadequate investment in these areas puts increasing pressure on hospitals, which then attract scarce resources. To put it another way, we need to tackle the cause of the pressures on hospitals and their budgets, not just keep treating the symptoms. Adequately resourcing public health is a sound investment precisely because it helps deliver the wider prevention agenda that is critical to the stability of our care and health services.
But when considering the cost of that illness it is not just the bill for treatment and care that should be taken into account. The economic consequences of premature death and preventable illness are considerable, too. These can include loss of productivity in the workplace and the cost of crime and antisocial behaviour.
“If the nation fails to get serious about prevention then recent progress in healthy life expectancies will stall, health inequalities will widen, and our ability to fund beneficial new treatments will be crowded-out by the need to spend billions of pounds on wholly avoidable illness”
NHS Five Year Forward View, 2014
This is not a new argument. In 2002, the Wanless Report put forward a strong case for investing more in public health, estimating that effective public health policy could save the NHS £30 billion a year by 2022/23. The report warned that, without investment in preventing ill health and changing our model of care services, the NHS would be financially unsustainable by 2014. This has come to pass. Spending on NHS care has more than doubled from £61 billion in 1994/95 to over £140 billion in 2016/17 (at 2016/17 prices). And even this has not been enough. Latest performance information from NHS Improvement shows that, for the year ending 31 March 2018, providers reported an aggregate deficit of £985 million. This was worse than both the forecast deficit at 2018/18 quarter three (£931 million) and the deficit in the previous financial year (£791 million).
Councils are thinking creatively about their public health responsibilities and asking the central question: how do we use all of our resources for council-commissioned or provided services (and not just the modest ring fenced budget) to improve the health of our residents? This discussion is leading councils to think differently about how they affect the wider determinants of health and challenge established ways of working. Where services are not delivering value or significant outcomes they are being decommissioned and replaced by services that can deliver on local government’s huge ambitions for local people.
The LGA has consistently highlighted that the potential contribution of public health is being undermined by funding constraints. Services and interventions that are vital for improving population health are not being implemented, or are being cut back, risking the future sustainability of the NHS. Council leaders have expressed particular concern that recent budget reductions will result in public health services that are inadequate for meeting the needs of the local populations they serve. And they have long warned that planned cuts by Government of £600 million between 2015 and 2020 are counterproductive and will only exacerbate the problems facing the NHS and social care.
The role of other council services and those of local partners
As we have outlined already, council services make an important contribution to supporting people’s wellbeing in the broadest sense. Within councils’ highways and transport services for instance, close on £2.2 billion is spent on road maintenance, street lighting, traffic management and road safety, parking and concessionary fares, which all help create environments that are accessible and safe. Further spending totally nearly £2.1 billion is spent on councils’ culture and related services, such as culture and heritage, recreation and sport, open spaces and library services. Such services help provide opportunities that get people out and about in their local communities. £332 million is spent on regulatory services that ensure high standards in trading, water safety, food safety and noise and nuisance protection. £266 million is spent on community safety measures and nearly £4.3 billion is spent on street cleaning, recycling and waste collection and disposal, creating communities that are safe, clean and accessible. As the Association for Public Service Excellence has said:
“The provision of high quality local neighbourhood services has a positive impact on the perception of an area, encourages physical activity in a community setting and fosters a sense of wellbeing with citizens. High quality neighbourhood services are complementary to social care, health services, police and fire services, education and housing. All other services thrive better in neighbourhoods that are deemed to be well managed, clean and safe.”
It is precisely these sort of universal services that have been cut deeper to protect adult social care. To reiterate an earlier point, sorting out the long-term funding of social care therefore goes hand-in-hand with sorting out the long-term funding of services that play an essential role in creating communities we want to live in and which support our wider wellbeing. This includes the many vital frontline services commissioned and delivered by district councils that significantly impact the wider determinants of health and mitigate pressure on primary and social care. Of particular note are housing adaptations which help keep people out of hospital and allow them to return home safely in cases where time in hospital is required. District councils are an equally important part of the equation when it comes to designing a system-wide focus on community-based prevention.
Housing more generally is a key component of health and care and the foundation upon which people, including those in vulnerable circumstances, can achieve a positive quality of life. The impact of poor housing on health is similar to that of smoking or alcohol and costs the NHS at least £1.4 billion a year, as well as creating housing worries that can end in homelessness for too many families.  The lack of available and appropriate general needs, social and private housing is putting pressure on supported housing provision, which provides a vital bridge between housing, support, care and health. Supported housing reduces cost pressures on public services by keeping people out of more costly health and care settings and providing the necessary support to address issues that might otherwise prevent independent living. Around £2.05 billion is spent on support and care services for people living in supported housing.  This comes from a variety of sources, including council adult social care and housing and homelessness funding.
It is not just councils that help support people’s wellbeing. There are an estimated 36,000 voluntary, community and social enterprise (VCSE) organisations that support and provide health and social care services. The vast majority (nearly 90 per cent) are small, community-based organisations supported by an estimated three million volunteers. This is an essential sector but one which faces its own pressures as demand for its services rises but state funding is constrained. This pressure is felt all the more by organisations that have relied, in part, on grants and contracts for their local councils, further reducing the impact of the local voluntary sector. A sustainable voluntary sector is therefore a key component of wellbeing. As the Richmond Group of charities notes:
“Funding for interventions and services that provide vital support for people with long-term conditions or that tackle our serious public health challenges needs to be more sustainable – moving away from the current situation in which as soon as public finances get tight, effective voluntary and community sector approaches get cut”
 See 83.
 HM Treasury Public Expenditure Statistical Analyses 2017