Sally Gainsbury: just how much will public health have?

Of the “about £5.2bn” in ringfenced public health spending for next year, local authorities can expect around £2.2bn. Alongside that, councils will be asked to improve the health and wellbeing of their residents in impressively holistic ways – including reducing school truancy and child poverty.

Of course the government does not believe for a minute all of that and more can be done with a mere £42 per head; its aim is to use the promise of a health premium to induce councils to spend the £118bn they already spend in other, more healthy ways.

But will the potential pots be big enough to bring about change?

Directors of public health will ideally want to use their £42-a-head pot to entice council colleagues and clinical commissioning groups alike to reorganise their activities and spending to be more favourable to the public health cause.

As the council will already have the £42-a-head in the bag, the enticement will depend on the size of the health premium – the extra funding to be won for good behaviour.

But public health directors could find the prize insufficient to excite their new colleagues; even if the premium pot offers an incentive of an extra 10 per cent, that £220m is the equivalent of just 0.2 per cent of overall council spending.

That might be enough for cash-strapped councils to change their behaviour if it were cost free, but that seems a tad optimistic. And as the indicators that will be used to determine premium payments are largely based on outcomes, councils may have to wait some time before spending and organisational change in one year translates into outcomes and premiums in following years.

What then of the CCG? Assuming CCGs start off modestly, controlling say £30bn-£40bn of the NHS commissioning budget, council public health colleagues and their £2.2bn budget will appear supremely relevant in the first year. This will increase the likelihood that public health directors will be able to influence CCGs’ behavioural change through pooled arrangements and joint commissioning.

But will CCGs feel the same when they are up to speed? When their commissioning budget is nearer £60bn, for example? The risk is that even as the public health budget grows in real terms, gradual increases in CCG capacity will mean it will diminish each year in relative clout around the CCG table.

Countering this pessimism, however, there is much enthusiasm for local health boards and joint strategic needs assessments. Perhaps that is right. After all, size should not matter; it’s what you do with it that counts.

Sally Gainsbury is a news reporter for the Financial Times.