Exploring local government public health grant spending by health indicators, time and deprivation strata: an ecological study in England

BackgroundThe public health grant is used by upper-tier and unitary local authorities in England to fund public health services. Public health grant allocations have declined by 26% per person since 2015/16, with cuts being made without any adjustment based on population needs, resulting in absolute cuts often being greater for more deprived local authorities. This study seeks to investigate how these cuts have affected spending decisions across different areas of public health and how changes in spend relate to population health needs. MethodsIn this longitudinal ecological study, data on local government revenue expenditure and financing to 146 upper-tier local authorities in England were extracted from the Ministry of Housing, Communities, and Local Government for the years 2017/18, 2018/19 2019/20 and 2022/23. Demand for each function of the public health grant was proxied using a publicly available indicator of need. Descriptive analyses explored changes to grant expenditure over time by function and IMD quintile. A compositional regression model was developed to account for the relatedness of spend data. The significance of associations between indicators of need and spend on functions of the grant was tested using MANOVA, producing Pillais Trace statistics as an indication of the effect size of each explanatory variable relative to others. FindingsPublic health grant spending reductions were widespread. More deprived local authorities often experienced deeper absolute cuts against a backdrop of greater need, with spend being protected across all IMD quintiles in only three areas: childrens 0 to 5 non-prescribed functions, health protection, and public mental health. In the multivariate regression, there was limited relationship between indicators of health need and patterns of grant spend between public health categories. InterpretationThere is no clear relationship between potential indicators of need and expenditure of the public health grant in different reporting categories. Instead, spending decisions are being driven by other factors that may include historic spend, wider local priorities and financial pressures. These findings suggest a review of the public health grant formula to support local authority public health teams to more strategically apportion spend based on population health need. O_LIWhat is already known on this topic O_LILocal authority public health teams in England receive a ring-fenced grant from central government which was originally based on an allocation formula that has not been updated since 2012/13. C_LIO_LIThe grant has been cut substantially over the past decade, often with larger absolute cuts for more deprived local authorities. C_LIO_LINo previous study has investigated how public health teams allocate a diminishing grant across competing areas of public health need and how this may vary by deprivation. C_LI C_LIO_LIWhat this study adds O_LIThis study found limited evidence that indicators of health need have driven public health grant allocation in related spend categories, nor any differences by deprivation. Our analysis is the first to explore multiple indicators of need and to employ compositional regression to account for corelations between categories of grant spend. C_LI C_LIO_LIHow this study might affect research, practice and policy O_LIThis study supports a review of the public health grant funding formula to better distribute the public health grant according to local population health need. C_LI C_LI