Is underinvestment in public health setting up ICSs to fail?

One of the much-lauded elements of the NHS long-term plan has been its emphasis on prevention, and it is not hard to understand why this is a focal theme. The NHS spends hundreds of millions of pounds each year on treating conditions that are preventable.

In diabetes, for instance, a staggering 10 per cent of the NHS budget is spent on drugs and treatment relating to the condition, the vast majority of which is for avoidable type-2 diagnoses. Today around one in four adults in the UK is obese, a statistic that puts the country among the very worst in Europe.

It is welcome, then, that the long-term plan includes measures relating to public health, including new smoking cessation programmes in hospitals and digital tools for diabetes prevention. However the plan is a strategy for the NHS, not the health system as a whole.

There is only so much that NHS services can do to promote healthy living as local authorities are primarily responsible for public health (with good reason, given the significance of the wider determinants of health).

All eyes were therefore on the Spending Review last month to see whether there would be any much-needed increase in the public health grant. As both the Health Foundation and the King’s Fund argued prior to the Review, the grant has been subject to a sustained real-terms squeeze in recent years and over £1bn was needed to restore it to 2015-16 levels.

Would the government match its rhetoric on the shift to a more preventive health system with the investment needed to deliver it?

If the prevention agenda is to be taken seriously then whoever is the chancellor of the exchequer next year must be prepared to properly fund the public health grant

The Spending Review committed the government to an undefined “real-terms increase to the public health grant budget’, with the Public Health England chief executive subsequently confirming this increase to be 1 per cent for 2019-20. While any increase is to be welcomed, this will only take the public health grant back to 2018-19 levels, recovering the £85m cut in the current financial year.

Local authorities hardly, therefore, have much reason to celebrate, and indeed new burdens on authorities relating to pay and PrEP costs may “wipe out” the increase anyway.

This is, of course, an issue of real concern for sustainability and transformation partnerships, and integrated care systems.

As the NHS Confederation has discovered through engagement with system leads (whether commissioners or providers), programme directors and independent chairs, there is a worry that while better integration of services may help to mitigate growing pressures on acute and secondary care, integrated care models cannot be expected to single-handedly improve population wellbeing.

A sustainable solution to growing demand will rely heavily on promoting good physical and mental health early, avoiding the need for secondary care later. To that end, there is a feeling among STPs and ICSs that they can help to manage demand but they cannot stem the tide.

This is not, however, simply an issue of demand management; there is a more fundamental political and structural concern, too. STP and ICS leads are aware of the need to involve local authorities in strategic discussions about the future of integrated care, however their role as an equal partner must be predicated on their ability to engage in partnership working.

One system representative recently told the Confederation that with local authorities so stretched they have had to say with regret that they have neither the time nor money at the moment to engage in conversations about integrated care.

Put simply, we currently have a long-term strategy for the NHS that puts prevention at its heart, yet without the funding or resources to improve prevention measures. With an election looming, any future government will have a long list of challenges to address – not least on social care.

However, if the prevention agenda is to be taken seriously then whoever is the chancellor of the exchequer next year must be prepared to properly fund the public health grant.