Having started my career as a trainee accountant at South Tyneside Council nearly 25 years ago and returned after a time elsewhere in the public sector to have a stint as Head of Finance, local government still feels like my spiritual home. It was somewhat serendipitous, then, that I took up the role of Finance and Commercial Director at Public Health England (PHE) as public health returned home to local government.
Since taking up post, I’ve remained concerned at the low and variable level of investment in public health that local authorities and NHS commissioners inherited. Since 1 April 2013, responsibility for improving the health of the people in their communities rests with local government, working in statutory partnership with clinical commissioning groups with both focused on addressing inequalities. This involved the transfer of funding of about £2.7 billion from the NHS to local authorities, 3% of the health budget. In reality, much of this was the transition of what the NHS spent on drugs, alcohol and sexual health services and it may take some time for further measures to reduce A&E admissions and shift the focus to prevention to take effect.
We must safeguard the money we have, making sure the best use of the resources in the system is made to protect and improve the public’s health. The funding flow for public health to local government is via a ring-fenced grant from Public Health England, with the Chief Executive of PHE as the Accounting Officer for the whole amount.
There’s been some recent, often uninformed, debate about whether local government is using the grant on public health appropriately. Our experience of supporting local authorities with their public health responsibilities is that they are passionately and genuinely committed to the health of their communities. In fact, the biggest concern they have is how they can leverage public health benefits from the whole of their spending power and not just the ring-fenced grant.
PHE is responsible for assuring itself and for providing assurance to Parliament that the public health grant has been appropriately used, so it’s important that we do more than take this at face value, though we do of course recognise local authorities’ prime accountability is to their electorate. Local government faces severe financial constraints, so it would be all too easy to use the public health grant to ease the pressures on their general fund. Therefore, we remain vigilant.
I regularly speak to local government finance professionals and without exception they understand their statutory responsibilities with regard to public health. Their focus on economic prosperity and jobs, good neighbourhoods and providing the best start in life is synonymous with the factors that we know lead to good health and wellbeing. Colleagues I speak to acknowledge that commissioning patterns are beginning to change and will continue to do so as contracts are renegotiated with providers, best value is driven out and spending is matched to local priorities identified by Health and Wellbeing Boards through their Joint Strategic Needs Assessment. There may be a re-profiling of spend but it’s from one aspect of public health to another.
I do expect that local authorities will have different priorities and spending plans from the pattern that they inherited they will want to combine the ring-fence with other funding streams and focus on the wider determinants of health. Given the scale of the change needed, it is surprising that there have only been a really small number of instances during the year where we have become aware that some councils may have taken, in our view, too liberal a view of the definition of public health. Where that’s happened, it’s been through the strength of our local relationships, and where necessary through engagement at a senior level, that we have worked together to agree a mutually acceptable approach.
This use of ‘soft intelligence’ is just one aspect of an assurance framework which we have put in place to assure ourselves about the regularity of the use of the grant. The assurance framework we have developed involved the production of an assurance map following the three lines of assurance model recommended by HM Treasury. It sets out the various mechanisms and assurance sources that are in place across the system which help to ensure that the public health grant is used appropriately including:
- the conditions governing the use of the public health grant
- the financial reporting arrangements agreed with the Department for Communities and Local Government, requiring an annual budget and outturn to be reported across 18 defined categories of public health spend
- summary quarterly financial returns from each local authority to PHE
- local authority member-led scrutiny processes
- sector-led improvement arrangements
- public accountability, transparency and local freedom of information responses
- local authority internal and external audit arrangements
- Joint Strategic Needs Assessments (JSNAs) and Joint Health and Wellbeing Strategies (JHWSs) providing clarity on priorities
- the statutory role and responsibilities of each Director of Public Health
- soft intelligence from regular PHE/Director of Public Health dialogue
- an annual assurance statement signed by local authority Chief Executives.
As a key element of this PHE has written to each local authority setting out what is needed by way of assurance and the requirements for the annual assurance statement, which will involve each Chief Executive certifying that their public health grant has been used in line with the grant conditions.
It is inevitable that there may be some, limited, blurring at the edges in some areas. We do all the same remain confident in not just the integrity of the use of the public health grant, but also the commitment, enthusiasm and imagination of local government in delivering their public health duties and investing in new innovative approaches to improving the public’s health.
Local accountability is now very real. Was there ever such a degree of transparency of both inputs and outcomes prior to the transition?
Featured image via NHS Photo Library. Used under Crown Copyright.