Written evidence submitted by Cancer Research UK [SRF 024]

About Cancer Research UK

Cancer Research UK is the world’s largest independent charity dedicated to saving lives through research. We support research into all aspects of cancer which is achieved through the work of over 4,000 scientists, doctors and nurses. In 2018/19, we committed £546 million to fund and facilitate research in institutes, hospitals and universities across the UK. Thanks to research, survival in the UK has doubled since the 1970s so, today, 2 in 4 people survive their cancer. Our ambition to accelerate progress and see 3 in 4 patients surviving their cancer by 2034 remains. However, it has been severely dented by Covid-19. In 2020, we have already had to make cuts of £44 million to our research and without government support, we will need to cut our spending even further.

Around 4 in 10 cancers in the UK are attributable to modifiable risk factors such as smoking, being an unhealthy weight, and drinking alcohol. Cancer Research UK believes it is vital that everyone has access to evidence-based stop smoking, weight management and alcohol treatment services which can help to reduce their risk of cancer. However, years of cuts to local public health budgets are severely compromising the delivery of these important treatment services across the country and continue to threaten the UK Government’s ambition for England to be smokefree by 2030 and the delivery of the new obesity strategy.

In response to the Committee’s 2019 Local Government Finance and Spending Review Inquiry Cancer Research UK, the Association of the Directors of Public Health, Mind and Terrence Higgins Trust submitted joint evidence outlining the devastating impact that years of funding cuts have had on local authorities’ ability to deliver public health functions and services. These organisations joined forces to call on the UK Government to increase investment in local public health at the 2019 Spending Review. Shortly after in May 2019, Cancer Research UK published a consensus statement,[1] supported by over 80 public health and local government interest groups, amplifying these calls for local investment in public health once more. At this year’s Spending Review, Cancer Research UK joined more than 50 other organisations to encourage the UK Government to provide an increased, long-term (multi-year) and sustainable public health funding settlement as a priority.[2]

Yet the small uplift in the public health grant last year, followed by a maintenance of the grant in 2021/22, is simply not enough to plug the funding gap. Going forward, Cancer Research UK implores the UK Government to outline and deliver an increased, multi-year settlement for local government in support of its health ambitions and to provide further clarity and assurance on how local public health funding will be delivered and distributed for the years ahead. We also ask the UK Government proceeds with a comprehensive review of both the resources available to local authorities, as well as how that funding is distributed according to local population health needs. This will ensure local authorities have the vital increased investment needed to deliver services that prevent ill-health, reduce health inequalities and support a sustainable health and social care system throughout and beyond their recovery from COVID-19.

The below submission focuses primarily on local government public health funding.

Summary

 

  1. Local authorities and the public health services they commission continue to face a funding crisis. The NHS Five Year Forward View argued that “the future health of millions of children, the sustainability of the NHS, and the economic prosperity of Britain all now depend on a radical upgrade in prevention and public health”.[3] Despite this, the UK Government has continued to cut the public health grant in real terms year-on-year from 2015 until 2019. Despite a small increase in funding for 2019/20, and the maintenance of the grant in 2020/21, local authorities are still severely under-resourced to deliver their public health responsibilities. This sustained programme of cuts inhibits the ability of local authorities in England to provide adequate public health functions and services for their residents that prevent ill-health and cancer, including effective stop smoking, weight management, and alcohol treatment services. The Health Foundation predicts that, to simply restore funding to 2015/16 levels, local authorities would require an additional £0.9 billion per year, and to adequately level up public health grant allocations based on local needs, would require an additional £2.5 billion a year to close the funding gap up to 2023/24.[4]

 

  1. Even before the COVID-19 pandemic hit the UK, local public health services were struggling to keep up with growing demand and health inequalities were widening.[5] With the continued focus on responding to and recovering from COVID-19, local authorities need further clarity on their short, medium and long-term funding futures so they can appropriately respond to the pandemic whilst also continuing to provide vital public health and preventative functions and services. For this reason, we have made three clear recommendations:

 

    1. In a joint submission to this year’s Spending Review, Cancer Research UK urged the UK Government to deliver an increased, long-term (multi-year) and sustainable funding settlement for local authorities in England, to ensure they can appropriately plan and deliver effective public health functions and services that meet the changing needs of their populations and support the evolving and increasingly important prevention agenda. With the disappointing news that this year’s Spending Review was reduced from a multi- to a one-year settlement, local authorities’ ability to provide vital prevention and health improvement functions for the long term is severely compromised. Additionally, the maintenance of the public health grant is inadequate to fill the funding gap and will further compromise local authorities’ ability to deliver public health and prevention services locally, which will have devastating knock-on effects for the health of the population, the NHS and local economies.

 

    1. Given another delay to 75% Business Rates Retention, and the unknown costs of recovery from COVID-19, it is critical that local government is provided with further clarity and assurance on how ringfenced public health funding will be delivered to them in the coming years, and by what mechanism.

 

    1. Indeed, following a continued delay to the Fair Funding Review, local authorities remain uncertain as to when their funding baselines, including public health funding, will be reviewed and updated based on local need and resource. For this reason, the UK Government must also provide local authorities reassurance that a needs-based assessment and review of funding baselines will take place in the near future to ensure adequate ringfenced public health funding is provided to local authorities.

 

  1. Our response sets out further information and evidence substantiating our three main asks. It seeks to respond to each of the inquiry’s four issues, focused primarily on the issue of public health funding.

 

1.      The approach the UK Government should take to local government funding as part of the 2020 Spending Review and what the key features of that settlement should be

 

1.1. Currently, public health funding for most local authorities in England is allocated through the public health grant from central government. This funding is based on an assessment of each local authority’s needs and resources. There are some exceptions to this rule, including areas which fall under the 100% business rates retention pilot scheme (Cornwall, Greater Manchester, Merseyside, the West of England and the West Midlands); in these areas, public health functions and services are funded primarily through the retention scheme.

 

1.2. The proposed move to fund public health from the centrally administered public health grant to universal 75% business rates retention in April 2020 has been postponed again in 2021/22. The UK Government has provided no further confirmation as to when this will be revisited. Given the full extent of the economic impact of the COVID-19 pandemic on local authorities is still unknown, local authorities need clarity on how public health budgets will be funded going forward, whether that be through business rates retention or otherwise.

 

1.3. Areas with higher deprivation tend to have weaker local economies and will therefore generate less revenue from business rates retention compared to more affluent areas; these areas also have poorer health outcomes.[6] As such, there is a risk that any future funding of public health through business rates retention could exacerbate health inequalities, unless a fair ‘top up’ mechanism is agreed.

 

1.4. Currently, a ringfence exists around the public health grant, whereby local authorities are required to spend this funding exclusively on the commissioning and delivery of public health functions. Without this ringfence and avoiding implementing more stringent, inflexible measures like mandating the delivery of all public health services, there is a risk that public health funding may be rerouted to aid the commissioning of other local services. We therefore recommend that any future mechanism which delivers public health funding to local authorities, whether that be through business rates retention or otherwise, ensures this ringfence is maintained so funding is used exclusively for public health functions and services locally.

 

1.5. There is a desire to reform the local government funding system and the funding baselines (which have been untouched for nearly a decade) and reassess the needs of all local authorities via the Fair Funding Review. This is welcome, but given this review has also been postponed, it is unclear when local authorities can expect the much-needed re-evaluation of needs and funding baselines. Local authorities need further clarity on how their public health allocations will be calculated and subsequently implemented. Public health funding must be allocated based on need, so that deprived areas with higher prevalence of avoidable risk factors receive more funding to commission important services to improve health and reduce inequalities.

 

1.6. It is unfortunate we have not seen the UK Government provide any additional investment to local public health budgets in this year’s Spending Review. The maintenance of the public health grant in 2021/22 is inadequate to fill the significant funding gap and will not provide any capacity to level up local authorities’ public health allocations. Next year, our key concern will be to ensure that local authorities are provided with increased, sustainable, multi-year funding, allocated according to need, so they can deliver vital public health and prevention services effectively and reduce health inequalities.

 

1.7. While not directly influencing local government public health funding, the UK Government’s decision to restructure England’s public health system provides an opportunity to prioritise and strengthen how the country delivers health protection and improvement regionally and nationally, and improve how these structures can best support local authorities in commissioning and delivering public health. Government must ensure that improving cancer outcomes by reducing cancer risk and improving cancer survival is at the heart of the new public health improvement system.

 

2.      The current financial situation for councils, how this affects their ability to deliver services and the demand for services

 

2.1. Even before the COVID-19 pandemic, local authorities had already dealt with a £15 billion reduction to core government funding between 2010 and 2020 equating to a cut of 60p in every £1.[7] These cuts to local authority funding have permeated the entire system. Since 2013, local authorities have been responsible for delivering local public health functions and services, yet despite their importance, they too have been subjected to significant funding cuts. The public health grant has been cut by more than a fifth (22%) since 2015/16[8] despite a growing and urgent need for investment in public health and prevention. In 2020/21 the public health grant was valued at £3.2 billion – around 2.6% (£80 million) higher than the previous year’s grant.[9] While this increase was some recognition of the need to fund local public health, it fell far short of the estimated £0.9 billion needed per year to simply restore cuts since 2015/16, and fails to provide a sustainable footing for long term investment in public health, prevention and health creation.[10]

 

2.2. This funding gap does not consider the impact of COVID-19 on local government public health budgets. The funding required will be even greater now local authorities have had to respond to the unprecedented challenge of the pandemic. As well as working hard to safely deliver normal public health functions, council-led public health teams have also had to respond by supporting national efforts to prevent the spread of COVID-19, protect vulnerable members of the community and support local businesses and communities.

 

2.3. Despite the sector’s pleas for urgent increased investment in local public health, this week’s Spending Review announcement - maintaining the public health grant - did nothing to change the equation. Years of disinvestment in the public health grant have threatened local authorities’ ability to deliver the important functions and services that prevent ill-health, despite them being among the most cost-effective interventions available. For example:

 

2.3.1.        Comprehensive tobacco control functions, which reduce smoking uptake and support existing smokers to quit, are essential to achieve the government’s ambitious ‘smokefree’ commitment by 2030. Despite political support for tobacco control remaining strong, local investment has decreased over recent years, even while in England alone smoking is estimated to cost society £12.5 billion a year.[11] Among the local authorities that still had a budget for stop smoking services, 35% had cut this budget between 2018/19 and 2019/20; the fifth successive year in which more than a third of local authorities had cut their stop smoking service budgets.[12] More than three quarters of local authorities report that the biggest threat to their tobacco control budgets were funding cuts.[13] In 2019, local smoking cessation services, which offer people the best chance of quitting for good, were only universally available in just over half of local authorities.[14]

 

2.3.2.        Overweight or obesity is a risk factor for a range of diseases including type 2 diabetes, cardiovascular diseases, and 13 types of cancer, and the most deprived areas have disproportionately higher rates of obesity compared with the least deprived.[15] Evidence also suggests that people who are obese are at a greater risk of infection and worse outcomes from COVID-19,[16],[17] making an even stronger case for action on prevention. Yet effective prevention and weight management services have seen damaging and inequitable cuts, with the ten most deprived local authorities in England seeing a 50% cut to their budget for obesity services between 2014/15 and 2019/20, compared to a 37% cut in the ten least deprived.[18] In addition, the National Audit Office found local authority spending on childhood obesity services fell by more than 13% in real terms between 2016/17 and 2018/19.[19] The government’s commitment to addressing obesity as a key priority in their recent obesity strategy was welcome and included a promise to expand weight management services available through the NHS. However, to be effective, local authorities will need to be provided with sustainable public health funding to ensure they can deliver these and other vital services at a local level.

 

2.3.3.        Alcohol can cause 7 different types of cancer; the less alcohol you drink, the lower your risk of cancer. Alcohol treatment is paramount in reducing alcohol harm: every £1 invested in alcohol treatment yields £3 in social return.[20] Despite this, Public Health England estimates that, even before the COVID-19 pandemic, only 1 in 5 alcohol dependent people in England were receiving treatment.[21] This is in part due to significant spending cuts: services in England have typically seen spending cuts of around 30% since 2012.[22] With a clear positive return on investment these cuts represent a false economy; especially when we have seen rising numbers of alcohol-related hospital admissions in England.[23]

 

2.4. To counteract disinvestment in tobacco control Cancer Research UK, alongside partner organisations, calls for a Smokefree 2030 Fund to be introduced as an additional source of funding for tobacco control. As outlined in last year’s green paper “Advancing our health: prevention in the 2020s”,[24] the government is exploring this option to raise funds from the tobacco industry via a ‘polluter pays’ principle. Fixing the fund to raise £270 million per year would help pay for evidence-based measures at a local and national level to help people quit smoking, with funding prioritising the groups who need it the most. Investing in prevention, through an increased and long-term public health funding settlement, coupled with the likes of a Smokefree 2030 fund, will help contribute to the long-term sustainability of the NHS by reducing the burden of preventable disease and will bolster the economy.

 

2.5. Public health and prevention services also play a vital role in tackling health inequalities and “levelling up” health and wellbeing experiences and outcomes across the population. This has come into even sharper focus since the COVID-19 pandemic, which has exposed the fault lines where public health and prevention services have fallen behind. Across England, death rates from COVID-19 have been higher among people of Black and Asian ethnicity than any other ethnic group, as well as those living in more deprived areas compared to those living in the least deprived areas.[25]

 

2.6. The levelling up ambition across the UK is hugely important for the health of the nation. The NHS England cancer plan of 2000 aimed to reduce inequalities in cancer survival between rich and poor,[26] but unfortunately, inequalities are still evident right across the cancer pathway. Cancer Research UK’s recent report into health inequalities shows that people from poorer areas have higher risk of cancer, worse experiences in the health service and poorer survival from cancer, meaning they are disadvantaged at every step of the cancer pathway.[27] In England, there are more than 27,000 extra cases of cancer each year, or around 76 extra cases per day.[28]

 

2.7. People experiencing higher deprivation are more likely to smoke or to be overweight, are less aware of symptoms of cancer and experience more barriers to seeking help than people from wealthier areas. It is therefore essential to focus energy and investment on tackling the root causes of health inequality through local prevention activities. The UK Government should provide increased sustainable investment for local public health functions and services at next year’s Spending Review to level up health inequalities and channel funding directly into the local communities that need it most.

 

2.8. The squeeze on the public health grant over recent years, while protecting NHS expenditure in the short term, is likely to negatively impact health outcomes.[29] Research suggests that public health expenditure is not only cost effective, but investment in these local functions and services will be more productive than funnelling money into the NHS. It is estimated that, using a measure of Quality Adjusted Life Years (QALY), public health spending is three to four times more productive than NHS spending.[30] Investing in local public health functions and services would help to reduce this pressure in the longer term by improving the overall health of the population and reducing the need for costly treatment services. This has never been more important. The NHS has been forced to respond to the unprecedented demands of the virus, despite already facing severe pressures due to workforce gaps and ageing infrastructure. To be most effective, any future uplift in NHS funding would need to be mirrored by funding for public health and prevention.

 

3.      What the financial challenges facing councils are as a result of the COVID-19 pandemic, including lost income and local tax losses

 

3.1. Local authorities are forecasting that they will collect £12 billion less in business rates and £1.5 billion less in council tax this year than they were initially forecast.[31] Significant loss of business rates, combined with; record numbers of people claiming council tax relief; emergency payments for those experiencing loss of income; and rising costs of adult social care and PPE provision means many local authorities are at breaking point as a result of the pandemic.

 

3.2. Research suggests that at least £2 billion is still needed for local authorities to meet the full financial impact of the pandemic in 2020/21.[32] We appreciate that the 2020 Spending Review prioritises the response to COVID-19, but increased, sustainable investment in local public health must play a vital part in our nation’s pandemic recovery. The UK Government still delivered multi-year settlements for other areas, such as priority infrastructure projects including for hospitals, tackling climate change and defence. Longer term investment in the NHS is sorely needed and welcome, particularly given Cancer Research UK’s desire to see the workforce ambitions of the NHS People Plan delivered effectively. A single-year funding package for local public health leaves local government seeking further clarity on the finance package they can expect to receive in the years ahead. This is despite the fact that local authorities are at the forefront of the COVID-19 response and recovery efforts and are responsible for delivering many of the vital services and functions that help to protect and improve health.

 

3.3. Public health teams have faced significant financial pressures in responding to the pandemic. With no change to public health funding allocations in 2021/22, this pressure will remain and grow as they continue to respond to the acute and lasting pressures of the pandemic. The emergency reallocation of staffing and resources has undoubtedly had an impact on frontline prevention services and residents’ ability to access support. The Spending Review must ensure public health teams within local government are able to access resources to deliver these vital frontline services, as well as adequate funding for responding to COVID-19.

 

4.      What the impact is of another one-year Spending Review and a further delay to a multi-year settlement and the Fair Funding Review

 

4.1. Local authorities are legally required to set a balanced budget every year by March 11th, as per the Local Government Finance Act 1988. But as local authorities enter their budget-setting cycles in late 2020, this is the third year in a row where they have only been able to plan for the year ahead. Another one-year Spending Review means, yet again, local authorities lack the information and certainty they need to make meaningful and sustainable long-term financial decisions across the board, including decisions on how best to commission vital public health and prevention services. It could also lead to local authorities making unnecessary cuts to vital life-saving services because they do not have the information they need to make the right decisions. In the case of public health functions and services, an increased multi-year settlement will help provide these on a longer-term basis, meaning better value for money, more local accountability and less variation in the quality of provision. The UK Government must commit to providing local government with increased multi-year public health funding settlements beyond 2021/22 to allow them to better plan and deliver public health functions and services.

 

4.2. Local authorities prove time and again they are well-placed to provide vital services for their communities, but this needs to be backed up by further financial commitments from central government. After yet another delay of the Fair Funding Review, local authorities face great uncertainty on how their funding, including public health funding, will be distributed as the needs formula and funding baselines will remain unchanged. With the added impact of the COVID-19 pandemic on local authorities and their local economies, a reassessment of needs must be carried out regardless of whether funding is delivered via a ringfenced grant, business rates retention or any other mechanism going forward.

 

4.3. Local authorities must be given enough time to plan their medium and long-term budgets in the lead up to and following the transition to a business rates retention scheme, should that still be the government’s preferred mechanism to fund public health beyond April 2022. As local authorities will become heavily reliant on the rates generated by businesses in their area, we are concerned that the scheme will make long-term financial planning extremely difficult for local authorities. This is due to uncertainty in the income they generate year-on-year; particularly given the added impact of dealing with and recovering from COVID-19.

 

 

November 2020

 

 

References:

 


[1] Consensus Statement on Sustainable Public Health Funding. May 2020.

[2] Joint representation on local public health funding to HM Treasury. September 2020.

[3] NHS England. Five Year Forward View.

[4] The Health Foundation. Spending Review 2020. Priorities for the NHS, social care and the nation’s health. November 2020

[5] Marmot M. et al. Health Equity in England: The Marmot Review 10 Years On. February 2020.

[6] Marmot, Michael G., et al. `Fair society, healthy lives: Strategic review of health inequalities in England post-2010'. February 2010.

[7] LGA. Local government funding: Moving the conversation on. June 2018.

[8] The Health Foundation. Today’s public health grant announcement provides some certainty, but more investment is needed over the longer-term. March 2020.

[9] The Health Foundation. Today’s public health grant announcement provides some certainty, but more investment is needed over the longer-term. March 2020.

[10] The Health Foundation. Today’s public health grant announcement provides some certainty, but more investment is needed over the longer-term. March 2020.

[11] Action on Smoking and Health. The Local Costs of Tobacco: ASH Ready Reckoner: 2019 Edition. Published 10 October 2019, accessed 21 September 2020.

[12] Action on Smoking and Health and Cancer Research UK. Many ways forward: stop smoking services and tobacco control work in English local authorities, 2019. 14 January 2020.

[13] Ibid

[14] Ibid

[15] NHS Digital. Health Survey for England 2018, Overweight and obesity in adults and children. December 2019

[16] Docherty Annemarie B, Harrison Ewen M, Green Christopher A, Hardwick Hayley E, Pius Riinu, Norman Lisa et al. Features of 20 133 UK patients in hospital with covid-19 using the ISARIC WHO Clinical Characterisation Protocol: prospective observational cohort study BMJ 2020; 369:1985

[17] Public Health England. COVID-19: review of disparities in risks and outcomes. 2020.

[18] IPPR. Hitting the poorest worst? How public health cuts have been experienced in England’s most deprived communities. 2019.

[19] National Audit Office. Report by the Comptroller and Auditor General: Childhood obesity. 9 September 2020.

[20] Public Health England. Alcohol and drug prevention, treatment and recovery: why invest?. 2018.

[21] Public Health England. Public health dashboard. 2017, accessed Nov. 2019.

[22] Drummond, C. Cuts in addiction services are a false economy. BMJ: 2017.

[23] NHS Digital. Statistics on alcohol, England 2020. 2020.

[24] UK Government. Advancing our health: prevention in the 2020s – consultation document. London: UK Government; 2019. Available at: https://www.gov.uk/government/consultations/advancing-our-health-prevention-in-the2020s/advancing-our-health-prevention-in-the-2020s-consultation-document

[25] Public Health England. Disparities in the risk and outcomes of COVID-19. August 2020.

[26] NHS Cancer Plan, England  https://webarchive.nationalarchives.gov.uk/20130222181549/http:/www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4014513.pdf

[27] Cancer Research UK. Cancer in the UK 2020: Socio-economic deprivation. September 2020.

[28] Ibid

[29] Martin S, Lomas J, Claxton K from the University of York. 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 166. July 2019. 

[30] Martin S, Lomas J, Claxton, K. Is an ounce of Prevention worth a pound of cure? Estimates of the impact of the English public health grant on mortality and morbidity, p22. Centre of Health Economics, University of York. 2019.

[31] Ogden K, Phillips D, Spiliotis JC. COVID-19 and English council funding: what is the medium-term outlook? September 2020.

[32] Ogden K, Phillips D, Spiliotis JC. COVID-19 and English council funding: what is the medium-term outlook? September 2020.