This statement sets out our key priorities in advance of the Budget 2020. The full statement can also be downloaded here.
Summary of key recommendations
- Investment
in public health must be increased. The Spending Review must deliver a
sustainable package for public health in local government. The Public Health
Grant needs at least £1bn more a year to reverse years of cuts to public health
funding.
- The
Government should adopt a ‘health in all policies’ approach to decision-making
and policy development, assessing the long-term health impact for all policies.
- The Government should make tackling the
social determinants of health and building wellbeing into policy decision
making and funding allocation a cross-government priority, supported by a new
‘health index’ and better utilisation of existing ONS wellbeing statistics.
- The
Government should implement a minimum price of 50p per unit of alcohol.
- The
Government should reintroduce the tax escalator on alcohol at 2% per annum
ahead of inflation.
- The
Government should implement a tax or levy on tobacco manufacturers to help
cover the cost of smoking to the NHS and wider society.
- The
Government should increase the tobacco tax escalator from 2.5% to 5% above
inflation.
- The
Government should reintroduce binding national targets to reduce child poverty.
- The Government
should incentivise the use of low-emission vehicles and Vehicle Excise Duty
should be adjusted to reflect the impact of diesel vehicles on levels of
nitrogen dioxide in the atmosphere.
- The
Government should commit to a cost-benefit analysis of a national diesel
scrappage scheme in England.
- The
Government should prioritise active travel in transport policy and continue to
invest in infrastructure for active travel.
Investment in public health must be
increased
The public health grant has been cut by £850 million since 2014/15
and between 2010 and 2020, councils will have lost almost 60p out of every £1
the Government had provided for services. At the same time additional demands
continue to be created. For example, in 2018 there were 3,561,548 new
attendances at sexual health clinics in England compared with 2,940,779 in
2013, an increase of 21%.[i]
With
population growth factored in, £1bn a year will be needed to restore funding to
2015/16 levels, according to the King’s Fund and the Health Foundation.[ii]
Reductions to funding for public health represents a short-term
approach and ignores the much larger long-term costs associated with not
investing in public health. Inversely, there are great dividends to be paid,
both to the economy and society, through investing in public health
initiatives. A systematic review identified the median return on investment for
local public health interventions as 4:1.[iii]
Further analysis of the public health grant demonstrates that prevention is
indeed cheaper than cure and that cuts to public health grant funded services
directly impact on downstream NHS demand.[iv]
Directors of Public Health have been acting to manage the cuts and
the increasing demand and at the same time modernise services. Since taking
over responsibility for public health in 2013, councils have maintained or
improved 80 per cent of the public health outcomes of the nation. However, this
cannot last. Further reductions in public health services – including sexual
health, smoking cessation, substance misuse and health visiting services – are
now inevitable if the Spending Review does not deliver significant and
sustainable investment in public health. Reductions in overall local authority
budgets are also adversely impacting on health and wellbeing locally.
In addition to impacting the ability of local authorities to
deliver vital public health programmes, cuts to the public health budget risk
undermining the role Directors of Public Health play in addressing the social
determinants of health and delivering a place-based population health approach.
The experience and skills of Directors of Public Health are essential in
contributing to emerging policy challenges, such as serious violence and air
quality, and system reforms, such as ICSs. However, this role cannot be
adequately performed without enough resources and staffing capacity in public
health teams.
Recommendation: Investment in
public health must be increased. The Spending Review must deliver a sustainable
package for public health in local government. The Public Health Grant needs at
least £1bn more a year to reverse years of cuts to public health funding.
Health in all policies
In 21st century Britain, life expectancy is
stalling, and health inequalities are rising; with the gap in life expectancy
between the richest and poorest areas of England and Wales widening over the
past decade. Whilst health services, delivered by the NHS and public health
teams in local government, play an important role in keeping us healthy, it is
the economic, social and environmental conditions we live in – what are often
referred to as the social determinants of health such as poverty, education,
housing and more broadly the kind of ‘places’ we call home – that truly define
our health and wellbeing.
It is apparent from the Marmot
Review: 10 Years on report that we must see
vastly more action in the next 10 years than we have seen done in the previous
10 years. It is clear that progress is only possible when we address the causes
– not just the symptoms – of ill health.
We would urge the government to adopt a
health in all policies approach to policy making including Budget decisions and
to consider the impact of any tax or benefit changes on health and health
inequality. We need to see a shift in focus across government to prevention and
early intervention. This is not only because of the expense and distress caused by
preventable disease but also because of the importance to individual lives,
communities, the economy and the sustainability of the health and care system.
We must invest in enabling people and communities to prioritise their long-term
health and wellbeing.
Wellbeing should be built into the fabric
of Government decision-making when it comes to both policy-making and funding
allocation. Wales has already made a vital step towards realising this
ambition, through the introduction of the Future Generations Wellbeing
Act . Similarly, in Scotland, there is now a vision for national
wellbeing in the form of the National Performance Framework . These
efforts must be matched in England – the proposal to create a ‘health index’,
alongside existing wellbeing data collected by the Office for National
Statistics, could provide a framework to drive change and embed accountability
across Whitehall.
Recommendation:
The Government should adopt a ‘health in all policies’ approach to
decision-making and policy development, assessing the long-term health impact
for all policies.
The
Government should make tackling the social determinants of health and building
wellbeing into policy decision making and funding allocation a cross-government
priority, supported by a new ‘health index’ and better utilisation of existing
ONS wellbeing statistics.
Supporting the implementation of the NHS Long
Term Plan
Directors of Public Health strongly support the plan’s renewed
focus on prevention, health inequalities and a population health approach. However
in order to implement the long term plan and deliver real benefits to patients,
the investment in NHS England over the next 5 years needs to be matched with
funding to ensure that social care and public health are able to play their
part in supporting people to live healthy, high quality lives.
The NHS’s priorities on prevention –
which includes action on smoking, obesity and type 2 diabetes, alcohol and air
pollution – are complementary to local government responsibilities for funding
and commissioning public health. The delivery of the NHS long plan will
therefore depend largely on the local implementation of the national objectives
and support for public health teams to deliver vital services – including
weight management services, drug and alcohol misuse services, sexual health
services and early years services.
Local partnerships are essential to deliver sustainable changes. The
delivery of the NHS Long Term plan and proposals in the green paper ‘Advancing our health: prevention in
the 2020’ depend on collaboration between the NHS,
local government and the Voluntary and Community Sector.Local
authorities have a clear and distinct role in improving the health of their
population and in convening the local system to work together through Health
and Wellbeing Boards. Local accountability matters and actions which have the
support of communities and which are actively promoted by councils have the
greatest chance of being sustained. New
structures and arrangements through Integrated Care Systems, provide a valuable
opportunity to work pragmatically across organisational boundaries, to join up
local systems and boost efforts to improve our populations’ health and
wellbeing. The Director of Public Health provides a key link between the
NHS and local authority.
Action needed on alcohol pricing
Alcohol is the
leading risk factor for ill-health, early mortality and disability among men
and women aged 15-49 years in the UK and the harm from alcohol affects a range
of other public health outcomes.[v] Estimates show
that the social and economic costs of alcohol-related harm amount to £21.5bn –
this includes the costs associated with deaths, the NHS, crime and lost
productivity.[vi]
As local commissioners of drug and alcohol
treatment services, Directors of Public Health are only too aware of the
devastating impacts that alcoholism can have on individuals and families.
Tackling harms associated with the consumption of cheap alcohol is a tangible
way in which the government can improve the health of many people, especially
the most vulnerable.
Minimum Unit Pricing (MUP) is a proven policy
mechanism to do this and is the number one policy priority for Directors of
Public Health.[vii][viii] MUP is
highly targeted to have the greatest impact on drinkers who consume alcohol at
a harmful level. However, it would have an imperceptible impact on the cost of
alcohol consumption for lower risk drinkers and would not lead to changes in
pub prices. Recent modelling work by Sheffield University and Cancer Research
UK found that over a 20 year period, a 50p minimum price per unit of alcohol in
England could reduce deaths linked to alcohol by around 7,200, and further
reduce healthcare costs by £1.3 billion. [ix]
MUP was implemented in Scotland in May 2018, and
will be introduced in Wales in early 2020. The initial figures from the official
Scottish evaluation on the quantity of alcohol sold per adult is encouraging.
In the first year the 50p minimum price was implemented, average consumption of
alcohol fell by 3% to the lowest level since records began in 1994. At the same
time, consumption increased by 1.5% in England and Wales, where MUP is not in
place.[x]
Furthermore, the government
should reintroduce the tax escalator on alcohol at 2% per annum ahead of
inflation. Research by the University of Sheffield found that cuts in alcohol
duty since 2012 have led to 2,223 additional deaths and almost 66,000
additional hospital admissions in England and Scotland between 2012 and 2019.
This has resulted in £341 million additional costs to the NHS. The same report
also shows that above inflation increases in alcohol duty, starting from the
forthcoming Budget could have dramatic benefits: Increasing alcohol duty by 2%
above inflation every year between 2020 and 2032 would result in 5,120 fewer
alcohol-attributable deaths in England and Scotland.[xi]
It would further reduce alcohol-related criminal offences by 263,084 in England
and 31,992 in Scotland over the period to 2032, reducing the cost to society by
£901m and £279m respectively.[xii]
Recommendation: The Government should implement a minimum price of 50p
per unit of alcohol.
The Government should reintroduce the tax escalator on alcohol at 2%
per annum ahead of inflation.
The tobacco industry should contribute to the
cost of smoking
Smoking is the single largest
cause of preventable death and one of the largest causes of health inequalities
in England, causing about 79,000 preventable deaths a year. The total cost of
tobacco to society (in England) is approximately £12.9 billion per year, and is
spread across the NHS, social care, employers and wider society. Revenue from
tobacco taxation does not cover this cost. Total tobacco revenue is currently
around £12.3 billion annually.[xiii]
The
ambition of delivering a Smokefree generation by 2030 will not be met unless
the Government is able to find a sustainable source of funding needed to deliver
a comprehensive tobacco control programme. As outlined in the Prevention Green Paper, the Government is
exploring options for raising funds from the tobacco industry via a ‘polluter
pays’ principle. This proposal is strongly supported by Fresh and over 120
other health-related organisations, including ADPH.[xiv] It
is also supported by members of the public.[xv]
The levy should be structured as a charge on each tobacco
manufacturer, designed to deliver a fixed sum annually to the DHSC (using the
Health Act 2006) to be used to fund high impact, evidence-based measures to
encourage smokers to quit, and discourage youth uptake. The funds should not
exclusively be put towards stop smoking services but more broadly for measures
which will reduce prevalence including delivery of national and regional public
education campaigns and work at regional level including on illicit tobacco.
Raising tobacco taxes is also one of the most effective mechanisms
for reducing tobacco consumption.[xvi] Modelling
by Cancer Research UK and the UK Health Forum in 2015 showed that, based on the
population data available at the time, increasing the tobacco tax escalator to
5% above inflation would accelerate the decline in smoking prevalence among
both men and women. Adult smoking prevalence would decline to 6% in men and
6.5% in women by 2035, compared to smoking prevalence estimates being 10% for
both men and women if the tobacco tax escalator remained at 2.5%.[xvii]
Recommendation: The Government should implement a tax or levy on
tobacco manufacturers to help cover the cost of smoking to the NHS and wider
society.
The Government should increase the tobacco tax escalator from 2.5% to
5% above inflation.
Action is needed to reduce child poverty
Child poverty in the UK is
rising. In 2017/8 there were 4.1 million children living in poverty in the UK.
This is predicted to rise to 5.2 million by 2022.[xviii]
Child poverty is associated with poorer health, social, psychological and
educational outcomes.[xix]
The government should restore national binding targets to reduce child poverty
and introduce a dedicated national child poverty strategy.
Recommendation: The Government should reintroduce binding national
targets to reduce child poverty.
Improving air quality should be a budget
priority
Outdoor air pollution costs the UK economy £20 billion per
year and has an effect equivalent to 40,000 deaths a year in the UK by
increasing risk of diseases such as heart disease, stroke, respiratory diseases
and cancer.[xx] [xxi]
A recent WHO report attributed a mortality rate of 25.7 per 100,000 to outdoor
and indoor air pollution in the UK. This is higher than mortality rates in
Spain, Portugal, and France.[xxii]
The proposals outlined in the
Clean Air Strategy need to be implemented, with further action required to
address the complex environmental and social factors contributing to poor air
quality. The government should incentivise the use of low-emission vehicles and
use fiscal levers to increase the use of less polluting vehicles, as well as require
housing developments to install infrastructure fit for future new technological
vehicles, making that switch easier for the population. The government should
lead the way by switching to lower polluting vehicles for the NHS and other
government fleet vehicles.
At the same time, the government
should prioritise active travel in transport policy and invest in
infrastructure for active travel. Prioritising initiatives that maximise the
benefits to both health and the environment represents best value for money as
well as having a greater positive impact overall.
Recommendation: The Government should incentivise the use of
low-emission vehicles and Vehicle Excise Duty should be adjusted to reflect the
impact of diesel vehicles on levels of nitrogen dioxide in the atmosphere.
The Government should commit to a cost-benefit analysis of a national
diesel scrappage scheme in England.
The Government should prioritise active travel in transport policy and
continue to invest in infrastructure for active travel.
Association of Directors of Public Health
February 2020
[i] Public Health England, Sexually transmitted infections and
screening for chlamydia in England (2018) (2019)
[ii] The King’s Fund, Public health: our
position [https://www.kingsfund.org.uk/projects/positions/public-health] accessed 13 February 2020
[iii] Masters R, Anwar E, Collins B,
et al (2017). Return on investment of public health interventions: a
systematic review Journal of Epidemiology Community Health, 71, 827-834.
[iv] Stephen, M, Lomas J & Claxton K
(2019) Is
an ounce of prevention worth a pound of cure? Estimates of the impact of
English public health grant on mortality and morbidity. CHE Research Paper.
Centre for Health Economics, University of York, UK.
[v] Public Health England, Alcohol commissioning support:
principles and indicators: Guidance (2018)
[vi] Public Health England, Alcohol commissioning support:
principles and indicators: Guidance (2018)
[vii] Public Health England, The Public Health Burden of Alcohol
and the Effectiveness and Cost-Effectiveness of Alcohol Control Polices: An
evidence review (2016)
[viii] Association of Directors of Public
Health, ADPH English System Survey 2019 –
summary report (2019)
[ix] Angus, C., Holmes, J., Pryce, R.,
Meier, P., & Brennan, A. (2016). Alcohol and cancer trends: Intervention
Studies University of Sheffield and Cancer Research UK. Available at:
http://www.cancerresearchuk.org/sites/default/files/alcohol_and_cancer_trends_report_cruk.pdf
[x] NHS Health Scotland (2019) MESAS
Monitoring Report 2019
[xi] Angus, C & Henney, M (2019),
Modelling the impact of alcohol duty policies since 2012 in England &
Scotland. Available at: http://www.ias.org.uk/uploads/pdf/IAS%20reports/rp38102019.pdf
[xii] Angus, C & Henney, M (2019),
Modelling the impact of alcohol duty policies since 2012 in England &
Scotland. Available at: http://www.ias.org.uk/uploads/pdf/IAS%20reports/rp38102019.pdf
[xiii] Action on Smoking and Health, The Economics of Tobacco (2017)
[xiv] Annual
online survey by YouGov for ASH. Total sample size in 2019 for England was
10338 adults (and 12393 for GB). Fieldwork was undertaken between 12th February
2019 and 10th March 2019. The surveys are carried out online and the figures
have been weighted and are representative of all English adults (aged 18+).
[xv] Opinion research by YouGov for ASH.
Total sample size was 12696 adults. Fieldwork was undertaken between 16th
February 2017 and 19th March 2017 https://ash.org.uk/media-and-news/press-releases-media-and-news/12-years-on-from-england-going-smokefreesupport-for-the-government-to-do-more-to-tackle-smoking-is-continuing-to-grow/
[xvi] WHO. Article 5.3 of the WHO Framework
Convention on Tobacco Control
[xvii] Knuchel-Takano, A.,
Hunt, D., Jaccard, A., Bhimjiyani, A., Brown, M., Retat, L., Brown, K., Hinde,
S., Selvarajah, C., Bauld, L. and Webber, L. (2017). Modelling the implications
of reducing smoking prevalence: the benefits of increasing the UK tobacco duty
escalator to public health and economic outcomes. Tobacco Control,
27(e2), pp.e124-e129.
[xviii] The Institute for Fiscal Studies, Living standards,
poverty and inequality in the UK: 2017–18 to 2021–22 (2017)
[xix] Wickham S, Anwar E, Barr B, et al
(2016). ‘Poverty and child health in the UK: using evidence for action’,
Archives of Disease in Childhood, 101(8), 759-766.
[xx] Royal College of Physicians, Every Breath We Take: The Lifelong
Impact of Air Pollution (2016)
[xxi] Public Health England, Clean Air Day
– taking steps to reduce air pollution [https://publichealthmatters.blog.gov.uk/2017/06/15/clean-air-daytaking-steps-to-reduce-air-pollution/]
[xxii] World Health Organisation, World health statistics 2018: monitoring health for the
SDGs (2018)
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