The Government has always maintained that there will be no cuts to frontline services – money must be saved through efficiency savings, and the NHS budget is ring-fenced, it says. In reality the healthcare budget has been cut and frontline services are being axed.
Public health budget cut
Some of deepest cuts to frontline services are taking place in the area of public health, where the Government has made severe cuts to the budget. Public health services are funded by local authorities using a budget from the Department of Health. In November 2015, the government separated the budgets for public health, education and training, capital and national bodies, from the budget for NHS England. By doing so the government removed the budget for public health from any ring-fencing and it could be cut, but the government could still claim that the budget for NHS England was not being cut.
But public health is still NHS healthcare and of vital importance to the health of the nation. It includes a range of services that focus on education, prevention and treatment in the community, such as sexual health services, alcohol and drug addiction, obesity prevention and treatment, smoking cessation, health visitors and school nurses; all these services are frontline and cuts will have a significant effect on the future health of the population.
The first cuts to public health spending of £200 million were announced in May 2015 and as a result the £2.8 billion that councils were to receive to spend on public health in 2015/2016 was cut by 6.2%. This cut was imposed across the board with no tailoring to the needs of a particular area: areas of high need received the same cut to funds as those with a lower need. This was an in-year cut, later in November 2015 the Government announced that public health spending will be cut by 4% a year in real terms, as part of the spending review. As a result public health spending will fall by at least £600 million in real terms by 2020/21, on top of £200 million already cut from this year’s budget.
Frontline public health services cut
The Treasury said at the time that the figure for the first cut of £200 million was based on projected local authority underspends and that the cuts would not affect frontline services. What has actually happened is that cash-strapped councils have cut many frontline services and reduced others and this trend is likely to accelerate as the cuts to the budget continue. The services targeted include smoking cessation, contraception, sexual-health clinics, weight management services, NHS health checks and support services to HIV patients.
One of the major targets for cuts has been sexual health services and contraceptive services. In February 2016, a Pulse investigation found that more than 20 local councils were planning on taking away contraceptive services from GP practices. In York, the GP-run sexual health and contraceptive service has been closed completely. In 19 London Boroughs the services are being put out to tender, whilst funding cuts in Devon means that many GP practices have been forced to drop contraceptive services.
Smoking cessation services have also been a major target for cuts. By February 2016 six major metropolitan and county councils reporting cuts to smoking cessation budgets, including: Leeds City Council which has cut £127,000 from its budget with more cuts likely; Manchester City Council closed its smoking cessation service in October 2015; in York only those with chronic diseases will be able to use its service; and services in Lincolnshire and Salford are both being cut by 50%.
In January 2016, the BMJ reported on the results from Freedom of Information requests sent to local authorities; nearly a third (30%) of local authorities that replied had already made cuts to frontline services in 2015-16. An investigation by the HSJ published in July 2016 found that among the 77 councils that provided information there were more than 50 services that had been or were being decommissioned entirely in 2015-16 and 2016-17 as a result of financial constraints.
Other examples of council cuts are:
- Lincolnshire County Council has completely cut GP referral services for weight management and exercise;
- Leeds council has cut the only support service for vulnerable people with HIV;
- Camden council has cut £1 million from weight management services, including £400,000 from a programme to manage child obesity;
- a £100,000 cut to programmes to reduce levels of infant mortality and low birth weight in Calderdale, West Yorkshire;
- a £50,000 cut to falls prevention services in Cambridgeshire;
- and Harrow council has announced plans to cut public health services including health visiting, drug and alcohol, and sexual health over the next three years by up to 60%;
- North Somerset has cut a family nurse partnership service;
- Southampton has cut a population chlamydia screening;
- Hartlepool has cut its bereavement care service.
Children and young people hardest hit
The July 2016 investigation by the HSJ found that the groups hardest hit by the cuts in public health were children and young people’s services. Overall, the analysis found planned spending reductions worth £50.5m in 2016-17, across 77 local authorities which provided information; the biggest area for cuts was services for children and young people. The figure could be much higher as not all budgets had been finalised. The HSJ investigation found that the biggest single area was a £7m reduction to services directly aimed at improving the health of children and young people, such as health visiting, school nursing and childhood obesity programmes.
The cuts to the public health budget were condemned by many organisations: in October 2016 the UK’s Faculty of Public Health, the Academy of Medical Royal Colleges (AoMRC) and seven other leading organisations, including the Royal College of Nursing, the Local Government Association and the British Dental Association, called upon the Chancellor to reverse the decision to cut £200 million from the local authority public health budget. The cut was not reversed and as a result frontline services in public health are being cut across the country.
Critics of the cuts emphasised that in the long-term, cutting spending on public health leads to a much greater costs for the NHS. According to the Family Planning Association cuts in the area of sexual health services could end up costing the NHS around £3.5 billion due to the increase in unintended pregnancies and sexually transmitted infections. In February 2016 academics and organisations representing health visiting, paediatrics, midwifery and family services wrote an open letter to Government ministers raising concerns that recent statistics show UK breastfeeding rates at 12 months after birth are the lowest in the world: they attribute this to cuts in public health spending that have led to cuts in support for new mothers.
Mental health services cut
For some time now, mental health services have seen cuts to budgets and as a result cuts to services. A YoungMinds investigation in 2014 found more than half the councils in England had cut or frozen budgets for child and adolescent mental health between 2010-11 and 2014-15. A health select committee report in 2014 warned that “in many areas early intervention services are being cut or are suffering from insecure or short-term funding”. In January 2015 Government figures showed that spending on children’s mental health services had been cut by 6% from 2010. More recently, the King’s Fund reported in January 2016 that around 40% of mental health trusts experienced reductions in income in 2013/14 and 2014/15.
In February 2016 a survey by Pulse of GPs found that the majority of GPs say they have to diagnose child and adolescent mental health disorders ‘above their level of competence’ due to a marked deterioration in access to specialist services. The Pulse survey of over 900 GPs found 47% believed access to child and adolescent mental health services (CAMHS) had worsened in the past year, compared with only 5% who believed they had got better. Some 58% of respondents said they are expected to diagnose child and adolescent mental health disorders due to a lack of access to services.
Budgets continue to fall despite promises
The Government promised money for improving mental health services in January 2016, however in reality cuts are still taking place: in April 2016 Manchester Mental Health and Social Care Trust cut seven frontline community-based services to save £1 million. Greater Manchester was given complete control over its £6 billion budget in 2015 and according to the Trust the cuts are designed to “protect essential services.” The cuts to the seven frontline services were not supported by the three CCGs affected.
In May 2016 research undertaken by NHS Providers and the Healthcare Financial Management Association, found that only half of the 32 mental health trusts they spoke to had received a real-terms increase in their budgets in 2015-16 and only 25% said they expected clinical commissioning groups (CCGs) to increase the value of their contracts for 2016-17. The Cavendish Square Group, which represents the chief executives of London’s 10 mental health providers, said that the proportion of CCGs’ budgets that went to their trusts went down from 12% in 2014-15 to 11% in 2015-16.
In July 2016 an investigation by Pulse highlighted the consequences of these budget cuts; information from 15 mental health trusts revealed that 60% of GP referrals to child and adolescent mental health services (CAMHS) lead to no treatment and a third are not even assessed. Despite the government promises on action on mental health, the situation for young people is worsening, with the numbers of referrals that progress to treatment decreasing from 44% in 2013 to 39% in 2015. Several GPs told Pulse that CAMHS were refusing to treat patients unless they had attempted suicide or self-harmed.