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ADPH Submission Summary: 2021 Spending Review

Position statements · Public health funding | October 5, 2021

On 7 September, the Government formally launched the 2021 Spending Review (SR21), which will conclude on 27 October 2021 and set out the Government’s spending priorities over the next three years.

The purpose of this briefing is to provide an overview of the Association of Directors of Public Health (ADPH) position on the SR21. If you have any comments or questions, please contact the ADPH Policy team.


Before the pandemic, life expectancy was stalling, and health inequalities were rising; with the gap in life expectancy between the richest and poorest areas of England and Wales widening over the past decade. Covid-19 has further exposed and exacerbated the inequalities in our society.

Reducing health inequalities and creating better health and wellbeing cannot happen by magic or through ‘personal responsibility’ alone. ADPH is therefore calling for a serious step change in leadership and resources for public health as a foundation stone for the nation’s fightback from Covid-19.

The SR21 will need to be ambitious in proposing policy and investment that addresses the challenges of today and creates better health and wellbeing for tomorrow.

Themes and Recommendations

The ADPH is calling for the SR21 to focus on three themes.

  1. Valuing the role of place and local public health leadership 

The case for local government being the home of public health is stronger than ever. Even before the pandemic, independent reports over many years consistently set out the benefits and strong outcomes achieved by this move. Further progress is possible; however, this has been hampered by years of cuts both to local government as a whole and public health specifically.i

Public health grant allocations have fallen in real terms from £4.2 billion in 2015–16 to £3.3 billion in 2021–22. As a minimum, the government should restore the grant to 2015/16 levels by investing an extra £1.4 billion a year by 2024/25. ADPH is clear that a flat settlement or a small increase in cash terms, given increasing demand, ongoing Covid-19 pressures, the NHS pay rise and government ambitions, will in reality, be a cut leading to further reductions in services and capacity. New pressures and commitments should be fully funded and integrated into the public health grant. This includes recognising the medium-term pressures of the Covid-19 response and ensuring it is reflected in the public health grant allocations.


  • The Government should invest at least £1.4 billion more a year by 2014/25 in the public health grant to reverse recent cuts and support national policy ambitions. All new commitments should be fully funded.
  • The Public Health Outcomes Framework (PHOF) should be refreshed to ensure it continues to monitor the outcomes delivered by public health effectively.

  • Investment should be made in an improved public health Sector-led Improvement (SLI) offer to help support and share innovation and drive improved performance and outcomes in every area.

  1. Cross-government leadership to improve health and reduce health inequalities 

As much as 90% of our health is determined by factors outside traditional health services, such as the NHS. iiiii The remainder is largely shaped by what are often referred to as the social determinants of health. These factors include: our income, the education we receive, the housing we live in, the transport we use and the air we breathe. Wellbeing should therefore be built into the fabric of decision making across all government departments, with the ‘health index’iv used to provide the framework to drive change and embed accountability across Whitehall.

A cross government strategy to reduce health inequalities should also be developed, which adopts the principle of proportionate universalism and sets out binding targets for reducing and ending child poverty. The Government has further set out a range of ambitious national proposals through the Levelling Up White Paper which have the potential to address significant public health including smoking, drug and alcohol use, obesity and mental health. It is critical that these are properly funded with genuine investment and progressed collaboratively.

ADPH also supports additional investment for the NHS treatment backlog and for social care. We must both fund services to treat illness as well as the policies, interventions and services to create health and prevent illness.


  • Wellbeing should be built into the fabric of UK Government decision-making both when it comes to policy development and funding allocation.
  • A Health Inequalities Strategy should be developed with binding national targets to reduce and end child poverty. The Levelling Up White Paper must define what ‘levelling up health’ means.
  • National plans and strategies to improve public health need to be fully funded with new investment if their ambitions are to be realised. 

  1. Resourcing the new public health system and health reforms 

The public health system reform presents an opportunity to strengthen the health protection system, renew the drive to prevent ill health, reduce health inequalities, and promote the role of place-based leadership. However, for these changes to be effective, adequate resources must be provided to all parts of the new public health and healthcare system at a national, regional, and local level.

While ADPH has welcomed the increased recognition of public health teams, the pandemic has highlighted deep fault lines, including a local resource and capacity. Funding sustainable health protection and environmental health capacity at a local level, supported by accessible surge capacity, is crucial to enable continued work on the Covid-19 response and preparedness for managing future infectious diseases. Wider investment is also needed to address the critical shortages of public health specialist and strengthen the leadership pipeline. ADPH is therefore supporting calls for at least 30 additional specialist training posts per year.

On the establishment of ICSs, ADPH is clear that they must prioritise prevention, early intervention and tackling the causes of health inequalities. To support this, ADPH is calling for a commitment that ICSs will increase spend on prevention (eg by 1% a year up to an aspirational target of 10-20%). There is also scope for much greater devolution of funding, through place-based partnerships and Health and Wellbeing Boards (HWBs), to support place-based prevention activity.


  • Public health and environmental health capacity should be increased in every Upper Tier Local Authority to support the ongoing response to Covid-19 and build sustainable local health protection capacity.

  • There should be an increase in the number of public health specialists in training (ie at least 30 additional training posts per year).
  • A target should be set for the proportion of NHS funding that is spent on prevention, public health and health inequalities; this figure should increase over the course of the SR21 period.
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