Why is the health of Public Health England not assessed?

You will have noted that the Secretary for Health and Social Care is promoting the notion that the NHS books can be balanced by keeping citizens fit, well and away from hospitals, doctors and nurses.  That would be a good idea if it worked but, if it does not, NHS costs will keep rising and the new budgets for Public Health England (PHE) will be wasted. Meanwhile public health activities at local authority level, where the real work is done, continue to be stripped of resources, leaving the NHS actually worse off.  The DHSC must be aware of the contradiction but this is their usual Management by Press Release.

PR and financial shuffling apart, the big question is whether spending more money on prevention, i.e. “health”, actually saves having to cure people, i.e. the NHS.  How effective is the generalized spending by PHE as distinct from their essential research and prevention of epidemics?

Since 2012, the “outcomes” from public health spending, at national and local levels, have been formally measured. We should therefore have good idea by now of where value for money lies. Needless to say, it is not that simple.  The measurements have, mostly, been taken but no one has added them up or drawn any conclusions. Every three years or so, the goalposts move: the consultation on the latest such exercise concludes (after a computer glitch) on 19th February: “Proposed changes to the Public Health Outcomes Framework from 2019/20: a consultation”. Join in and share the wonder.

“The PHOF [Public Health Outcomes Framework] consists of 66 high level indicator categories which include 159 individual indicators” (p.5).  It is immediately obvious that even if there was measurement consistency and expected or planned outcomes with which to compare them, the sheer number of probably contrary indicators would make overall performance impossible to judge.  It would appear that no thought has been given to defining what PHE is supposed to achieve.:

“The indicators are grouped into overarching indicators and 4 supporting domains:

• overarching indicators (high level outcomes of life expectancy)

• improving the wider determinants of health

• health improvement

• health protection

• healthcare public health and premature mortality.” (p.6)

This looks a bit more plausible; life expectancy and certainly healthy life expectancy (i.e. before one needs permanent health or social care) are valid ways to measure public health. But once one gets down to the details, it transpires that almost every aspect of life is being measured and included in PHOF, irrespective of whether improvements in those indicators can be attributed to PHE, for example, readiness of children for school, their performance in school, “Percentage of people aged 16-64 in employment”, crime, first time offenders, complaints about noise, children in low income families, road fatalities, re-offending rates, and homelessness.

Clearly quite a few, probably the minority of, metrics are relevant to PHE but the main thrust here is that no distinction is made between health and other social measures. Ironically, despite all the publicity given to the “Five a Day” promotion to restrain obesity, the listed metrics (2.11i) were not collected.

One major issue amongst the lists of outcomes is loneliness which “has been identified to be a serious public health concern, as harmful as smoking and obesity, At the beginning of 2018, the Prime Minister highlighted the issue of loneliness, announcing a Minister for [sic] Loneliness and committing to develop a national strategy to help tackle loneliness and a national measure for loneliness. The national strategy was published on 15 October 2018.” (p.18). The first Minister for Loneliness, who was also the Minister for Sport, quit after her first month and does not appear to have been replaced. The Strategy boils down to saying loneliness is a big social problem, too big for government so everyone must pitch in and sort it.  It’s hard to see how PHE can be accountable for it.

The metrics that most illustrate the division of PHE from reality are those for inequality in life expectancy (0.2ii,  iii and vi). It is well known that the more affluent tend to live longer. In the mind of PHE this is unfair and PHE should work to increase life expectancy for the less affluent.  No one would argue with that but the performance measures selected look only at reducing the gap, i.e. the level of inequality, which can be more easily achieved by reducing the affluence of the wealthy than by increasing the affluence of the poor as the study of any left-wing government shows.  In any case, that is a matter for the Chancellor of the Exchequer, not PHE.

The bottom line of all this is that, despite the much publicised collection of data to assess the productivity, i.e. health, six years ago of PHE, no one has attempted to add up the numbers or draw conclusions. Until the government does that, it will continue to chuck our money away.