Commissioners ordered to redo public health accounts amid 'gaming' concerns

The NHS chief executive wrote in a letter last Friday that the Department of Health needed a good understanding of current local spending to help set indicative allocations for local authorities, which will take over public health budgets under the NHS reforms.

However, 2010-11 audited accounts for primary care trusts and strategic health authorities showed “considerable variability” on public health spending, and “in some cases” unexpected “values and omissions,” he said.

SHAs and PCTs have until 16 September to repeat their public health returns, and 23 September to submit overall expenditure returns.

“[This] time all PCTs must ensure that the 2010-11 public health expenditure is reported in full,” Sir David wrote.

“I would suggest you check your final returns for reasonableness.

“Where a zero value is included the chief executive signing off the return should be confident that the service is not commissioned by the PCT.”

Commissioners must have the new returns signed off by the local authority chief executives taking over their public health budgets.

Sir David admitted the deadlines allowed commissioners “only a short time” to finish the exercise.

Association of Directors of Public Health chief executive Nicola Close said: “The previous collection showed enormous variation which implied different things were being counted in different places. The new sheets [for the new returns] are more detailed as to what to count to try to unpack some of the embedded public health spend.”

She added: “There was also a fear that in some places there was some ‘gaming’ going on to reduce the amount going to public health.”

“We have been saying for some time that public health resources have been squeezed to improve PCT finances.”

King’s Fund senior fellow in public health and inequalities David Buck said he was surprised the Department of Health had reacted so late over the issue. He said: “Public health funding data has always been very, very poor.”

He said this was partly down to “definitional questions” over what should be recorded in accounts as public health, which he warned would also be a problem for local authorities trying to ringfence public health spending in future.

He said: “I’m surprised for this [letter] to go out so late, as the DH would have been aware of this as a problem. It represents the sense of rising panic about the allocation process for public health.”

Faculty of public health vice president and NHS Sandwell director of public health John Middleton said the repeat audit was a significant move.

He said the second audit exercise – which HSJ understands is based on documents developed by NHS North West and the former government advisory body Health England – was much better than the original done from usual accounts in April.

Dr Middleton said “some clear issues with definition” in the first exercise had been clarified, for example around recording the public health share of overheads such as human resources and IT.

“It’s questionable if it will ever be completely right. It’s probably as clear as it’s going to get now,” he said.

Sir David also demanded that PCTs completed the return on their overall expenditure broken down to the level of individual GP practice populations. The returns are intended to help the department and the NHS commissioning board to set shadow allocations for the clinical commissioning groups that will replace PCTs.

A DH spokesman said: “This is the first time we have collected these data at practice level; there are no other returns that would provide spend disaggregated in this way. The emerging membership of CCGs may change before they are authorised, but these data will allow us to develop a flexible approach to allocations.”

One PCT commissioning professional told HSJ that providing practice level figures would be “relatively straightforward” for secondary care spend, but “almost impossible to do meaningfully” for services paid for on block contracts, such as mental health or community services.