ADPH Budget Submission: 2020 Spring Budget

This statement sets out our key priorities in advance of the 2020 Budget.

Read the full statement.

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)