Public Health Funding: Enfield

I beg to move,

That this House has considered public health spending in Enfield.

It is a pleasure to serve under your chairmanship, Mr Betts.

I requested this debate to highlight some of the harsh realities stemming from the Government’s decision to slash the public health grant to our community, and to draw attention to the fact that the ongoing uncertainty around long-term funding is prompting a crisis in public health. Our council’s ability to deliver a range of public health services aimed at preventing disease, prolonging life and promoting good health is being seriously affected.

The Government’s national health service long-term plan may have put prevention at the heart of its policy but, to quote David Finch, senior fellow at the Health Foundation:

“The sustained cuts to the public health grant clearly run counter to these aims. The public health grant is not a nice-to-have. Without urgent reinvestment, we will continue to see a direct impact on people’s long-term health”.

Last month, the Health and Social Care Committee said that cuts to public health services were a “false economy”. Cancer Research UK and more than 80 other organisations have come together to call on the Government to provide a sustainable solution for public health. Ministers must take immediate and positive action to increase investment in public health, to reduce health inequalities and to support our health and social care system.

I will take this opportunity to pay tribute to the work of the Enfield Over 50s Forum and its president, Monty Meth, who is sitting in the Public Gallery today with many of the forum’s members. Their typically dogged campaign to highlight the cuts to Enfield’s public health grant and the disparity in per-person funding between our borough and other councils in London has forced this issue to the top of our community’s agenda.

The Minister should be well aware of the forum’s work on this matter, given the number of letters that its members have written to her and her Department in recent weeks and months—although, sadly, their letters have not received a considerate ministerial response. Instead, they have received a reply from the Department’s correspondence unit that, to put it mildly, leaves a lot to be desired.

One constituent with impeccable manners, who forwarded me a copy of the letter he received, described the response as “baloney.” Another resident labelled the reply “meaningless” and “full of Whitehall gobbledygook”, and it is hard to disagree with that analysis when they are treated to phrases such as:

“The formula is designed to generate target allocation shares of a funding envelope”.

Does my right hon. Friend agree that, because the baseline funding has been set from 2013, it takes no account of changes in the population of Enfield to do with age, poverty and other factors that might hugely affect the funding that Enfield actually deserves right now?

My hon. Friend is absolutely right; that is a key factor in this whole scenario.

On the kinds of responses that constituents are receiving, surely responses from Government Departments to citizens raising legitimate concerns on important issues should seek to clarify and not to cloud matters? I do not raise this point as an attack on civil servants, but to urge the Minister—and it is her responsibility—to provide some clear and full responses to the concerns I raise today on behalf of the Enfield Over 50s Forum and our whole community in Enfield.

Given that the population in London boroughs—including Enfield, as my hon. Friend has said—is growing twice as fast as in the rest of the country, the pressure on already strained public health resources is only set to intensify over the coming years. Enfield has some of the most poverty-stricken and deprived wards in the country, and we all know that poverty and poor health are inextricably linked.

According to a recent report by the Child Poverty Action Group, our borough is one of the 20 local authorities in the UK with the highest levels of child poverty after housing costs are taken into account. There are almost 40,000 children in poverty, or four in 10 children in the borough. Obesity rates for children in reception class are higher than the average in London and in England, and more than four in 10 year 6 children in Enfield are either overweight or obese, the eighth highest rate of all London boroughs.

However, it is not just children affected by serious public health issues in Enfield, but adults and the elderly too. Our rates of diabetes are higher than the London and England average. Cancer Research UK recently revealed that being overweight is a bigger cause of bowel, kidney, ovarian and liver cancer than smoking. More than six in 10 adults in Enfield are overweight or obese, a significantly higher rate than in London in general. Our bowel cancer screening rates for people aged 60 to 74—one of the best ways to diagnose bowel cancer earlier—are only just over 50%. That is lower than the average in England and far lower than the rate of 75% of eligible people taking part recommended by Cancer UK.

One of the most pressing issues facing our community and our country at the moment is the impact of serious violence and knife crime. I held a packed community meeting on Saturday on this issue, talking about how to keep our young people and our streets safe. Earlier this year, Enfield had the highest rate of serious youth violence in the capital. In 2018 alone, North Middlesex Hospital had to deal with the consequences of 1,457 assaults, including stabbings and gunshot wounds.

To protect staff and patients on site and reassure the local community of their continued safety whenever they visit the hospital, North Middlesex increased its security spend by an additional £149,000 and had to hire two additional overnight security guards in its busy accident and emergency department, at a cost of £3,000 per week. North Middlesex Hospital should not have to use its already stretched budget to address a situation that is not of its making. Every penny that is spent on these interventions is money that is diverted away from essential patient care.

Both the Government and the Mayor of London want to tackle the knife crime crisis with a public health response. That is an important and welcome initiative, but if the Home Secretary is going to implement a legal duty on the police, councils and the NHS to share information and intelligence, then those bodies will need the resources to make it effective.

The public health system is already at crisis point. We require a public health budget that addresses the desperate needs of our community in the immediate and long term. But where is the support from the Government? The Prime Minister has declared that austerity is over, so where are the resources to reverse the cuts suffered by our public health services?

When the NHS long-term plan was launched the Prime Minister said:

“We also know we need to…support prevention and public health, both for the benefits they bring in themselves and to relieve pressure on NHS care.”

In 2018, the then Health Secretary, the right hon. Member for South West Surrey (Mr Hunt), told the House that

“there cannot be a transformation of the NHS without a proper emphasis on public health.”—[Official Report, 18 June 2018; Vol. 643, c. 61.]

The current Health Secretary has said that prevention is one of the three pillars of his stated priorities. He also said:

“Each year, we are spending £97 billion of public money on treating disease and only £8 billion preventing it across the UK—that’s an imbalance in urgent need of correction.”

What urgency has he shown to fix this imbalance? That statement was made more than eight months ago.

While parts of it were leaked to the press over the weekend, we still await the formal publication of the Government’s Green Paper on public health and the future of funding. Analysis by the Health Foundation shows that the public health grant is now £850 million lower in real terms than the initial allocations in 2015-16. Last month, the Health Foundation and the King’s Fund stated:

“With the Spending Review likely to be delayed, key funding decisions will be postponed and as a result, the grant will face a further real-terms cut of £50 million in 2020/21 under provisional plans…With population growth factored in, £1 billion will be needed to restore funding to 2015/16 levels.”

Enfield is one of the communities to really bear the brunt of these savage cuts. Our borough’s grant is the 9th lowest in London, at £48 per head of population, compared with the London average of £71—a gap of £23—and we are getting £2 less per person this year than last year. In total, we are receiving £440,000 less from the public health grant this year than in 2018.

In addition, Enfield is one of five London boroughs that make up the NHS’ north central London sustainability and transformation partnership, which has pledged to reduce health inequalities for its 1.5 million residents. Haringey, Camden and Islington receive £70, £99 and £104 per head respectively for public health funding. I recognise that these boroughs also have considerable public health needs, but I do not understand how the disparity in public health funding between boroughs in the same area can be so large. There is then the Royal Borough of Kensington and Chelsea, which is allocated £130 per person for public health—almost three times more per head than Enfield. Where is the evidence that Kensington and Chelsea’s public health needs are almost three times worse than Enfield’s?

It is not as if Enfield Council can step in and plug some of the gaping holes in public health funding. Up to 2018-19, the core funding the council received from the Government to provide vital services was slashed by an average of £800 per household. Ongoing Government cuts and increased demand on services mean that the council has to find another £18 million of savings this year and then £12 million more the next. Austerity is clearly not over in Enfield. The cuts will continue to bite for the foreseeable future unless the Government do something about it.

What I find so frustrating is that the extent of these cuts to our public health system, and to local government, are so short-sighted; they have immediate and long-term adverse consequences. In April, when I asked the Minister for her assessment of the correlation between the levels of public health funding allocated to Enfield and the effectiveness of the provision of public health services in our borough, the response I received was:

“We have made no specific assessment of any relationship between funding…and the effectiveness of services in Enfield.”

Really? Maybe this type of assessment is required so that her Department can gain a better understanding of the public health situation in Enfield, as well as in other communities across the country. Will the Minister resolve to look again at this issue?

Given the pressing public health issues in Enfield I have outlined today, is the Minister willing to commit, at the very least, to reinstating the £440,000 cut in public health funding suffered by our borough this year? Does the Minister accept the need to increase the level of public health funding allocated to our borough to at least the London average each year? And does the Minister agree that Enfield urgently needs its public health system to be put on a sustainable footing? More widely, I want to hear from the Minister about the future of public health funding. Can she provide any indication of when the Green Paper will be released? Can we hold out any hope that the calls from the Health Foundation and the King’s Fund to reverse the £1 billion a year cut to public health funding will be acted upon?

There is a lack of clarity on the Government’s previously announced plans to phase out the public health grant to local authorities by 2021 and to instead fund public health through the proposed 75% business rates retention scheme. Cancer Research UK says that the continued uncertainty around the public health funding formula means it remains concerned about the potential negative implications of business rates on local service delivery. There is no point in Ministers extolling the virtues of a robust public health system if, in reality, all they do is weaken the prevention agenda by slashing funding for services. The success of the Government’s NHS long-term plan will be built on the foundations of improvements to public health, but these foundations will crumble, and the investment in the NHS’ long-term future will be undermined, if the Government fail to increase investment and make prevention a top priority.

Finally, I return to the work of the Enfield Over 50s Forum. Reading one of its recent newsletters, I was struck by this succinct but perfect encapsulation of why achieving fairer funding for public health in Enfield is so important:

“Improving public health is not just an over 50s issue. It concerns every single body and soul in the borough—toddlers, teenagers, every family with young children. This is one case when we are really all in this together.”

I look forward to the Minister’s response.

It is a pleasure to serve under your chairmanship, Mr Betts. I thank the right hon. Member for Enfield North (Joan Ryan) for raising this issue. She is a great champion for her constituency, as is the hon. Member for Enfield, Southgate (Bambos Charalambous) for his.

I reassure the right hon. Lady that the Government are fully committed to improving public health. We want to place prevention at the heart of our health and social care system, because that is the only way to make the NHS sustainable in the long term. That is challenging, as we all know. We need to tackle the root causes of poor health, not only the symptoms. The population of our country is growing. As both the right hon. Lady and the hon. Gentleman pointed out, growth in London boroughs is particularly acute and has been rapid over the six years since the formula was put in place, and we recognise the demand on the NHS, social care and other public services. My right hon. Friend the Secretary of State for Health and Social Care and the Prime Minister are aware of the great gaps in life expectancy in London boroughs and across the country. We also know that lots of diseases that people die from nowadays are preventable, which is why we want to put prevention at the heart of what we do. The Prime Minister’s ambition is to extend healthy life expectancy by five years by 2035 and to reduce the gap between the richest and the poorest. We have made great strides in many areas.

Childhood obesity is an international problem, but we are being ambitious on it, as well as on air quality and tobacco. All these measures have the potential to make a real difference to people’s health and wellbeing. We have reduced sugar in fizzy drinks by 11%, we have cut average calories per portion by 6% through the soft drinks levy, and by 2020 the NHS diabetes prevention programme will support 100,000 people at risk of diabetes across England each year. On screening, the right hon. Lady will be aware that Professor Sir Mike Richards is undertaking a screening review at the moment, so issues such as those she raises about bowel screening will be brought up. That review will report later in the year.

The Green Paper is coming up and I hope that that will take us even further. We need action across local government, central Government and the NHS. Of course, the over-50s group to which the right hon. Lady has referred is an important part of that, because only through everybody working together will we be able to tackle the determinants of health and be far more successful at improving and protecting health outcomes.

To move specifically to public health and where it sits now, we gave back to councils responsibility for public health in 2013. That was important. They recognise what is relevant for their communities and are uniquely placed to use the full range of their activity—levers such as planning, transport, housing and the local economy—to promote better health.

I realise that there is not a great deal of time today, but the Minister says that the funding given to Enfield Council is relevant to its needs. Is she saying that the funding that it has been given is adequate to cover the public health requirements in Enfield?

I will move on to the specific issue of the funding formula, how it came into being and how it might change. Of course public health is a question of the investment that national Government put in and how local authorities spend it, but there is a lot of innovation. I applaud Enfield Council and all local authorities for what they have done, because different authorities have used it in different ways. They are adopting innovative approaches. They are renegotiating contracts that perhaps had been untouched for years before the 2013 transfer. I will address funding later in my remarks. Councils are adopting new service models that have the potential to reach communities that have often been left out by traditional service delivery models.

I recognise that in the last spending review, there were difficult decisions to be made to ensure the sustainability of public finances, but over the five-year period, £16 billion has been available to local government for use on public health, including £3 billion for the current financial year.

The right hon. Lady raised a very important issue about the distribution of funding for local authority public health activity. I recognise the pressures that she has referred to specifically in relation to Enfield. When responsibility for local health functions moved from the NHS to local government in 2013, funding for relevant services was transferred to individual local authorities. That was based on historical local spend for the NHS, and the process revealed huge variation across the country. The funding for Enfield is based on what the NHS had been spending there up until 2013.

The Government are now carefully considering how to allocate public health funding in a more needs-based way, rather than continuing to allocate funding based on NHS historical spend. We recognise that Enfield’s per capita funding breakdown is different from that of other London boroughs, but a per capita basis is not actually a meaningful way of comparing allocations or the best way of determining funding. That is precisely because it takes no account of different levels of need and it disregards significant variables that have a major influence on the need for public health interventions. An example is the age profile of a local authority’s population. We will look carefully during the next spending review at future funding arrangements and the best way to allocate funding to each local authority.

On the letters from the Enfield Borough Over 50s Forum, if the right hon. Lady would like to distil those messages into a letter to me, I will happily respond to her and she can make that response available to her constituents.

A future funding formula needs to take account of need. There should not be the current differentiation. Kensington and Chelsea receives £82 per person more in funding than Enfield. It cannot be right that two boroughs that are about 8 miles apart have such a variance in funding. Will a future funding formula take more account of local needs?

As I have said, the Department is looking at the funding formula. The hon. Gentleman says that the boroughs are only 8 miles apart, but we know that in areas that are very close together, life expectancy and, importantly, the length of time a person lives in good health can vary hugely. That is why we need to look very carefully at all the factors before the new formula is created. That will be assessed in the next spending review in the light of all the available evidence.

I am committed to working closely with local government, and with other partners and colleagues, to build on the achievements of the last six years. We need to act on a local, national and global level to meet the public health needs of the present and to rise to the public health challenges of the future.