Examination of Witnesses (Question Numbers
40-59)
RT HON
ANDREW LANSLEY
CBE MP
20 JULY 2010
Q40 David Tredinnick: That is very
helpful. One last question, if I may. Against that background
I understand that you are considering abolishing the FSA.
Mr Lansley: No, that is not true.
Q41 David Tredinnick: Earlier on
you were saying somebody was not responsible for dietary services
and I was not quite sure what organisation that was. Perhaps you
can clarify this for me.
Mr Lansley: Indeed, the Prime
Minister has made announcements this morning that make it clear
we regard the independence and the core function of the Food Standards
Agency in relation to the integrity of food safety and the food
supply chain as a continuing responsibility. The Food Standards
Agency will not be abolished, the Prime Minister has made that
clear. I made that clear previously if anybody cared to ask me.
It will continue to be a non-ministerial government department
accountable to Parliament through the Department of Health. What
he has also announced this morning, however, if anybody had cared
to ask me, was what I had said previously, which is I am determined
we create a Public Health Service which is capable of bringing
together government's responsibilities in relation to public health
in a more coherent and consistent fashion. To that end I am proposing
to transfer the diet and nutritional responsibilities of the Food
Standards Agency into the Public Health Service within the Department
of Health. I understand, and it is not for us here because we
do not look after Defra, that Defra have their own proposals in
relation to labelling and in relation to such matters as origin
of foods and so on. That does not mean the Food Standards Agency
ceases to exist, far from it, it has its core responsibility entirely
intact. Not only have I been clear about that but the Food Standards
Agency was clear about it before the election. I talked both to
Jeff Rooker and to Tim Smith, the Chief Executive, and had conversations
with the Chief Executive of the FSA, the purpose of which was
to be absolutely clear about precisely the boundary of the some
70 staff currently working in the Food Standards Agency who are
engaged in diet and nutrition in order that we could be clear
about the transitional mechanisms that need to be put in place
to make that happen.
Q42 Dr Wollaston: I just want to
suggest an area of very low hanging fruit when it comes to public
health and saving money, and that is the issue of alcohol. We
know that a third of casualty admissions are directly related
to alcohol, a third of ambulance costs, 1.2 million children's
lives affected by alcohol, unwanted pregnancies, homicides, accidental
deaths, the list goes on. It has been an absolute train wreck.
What we do have is very clear evidence from both NICE, from this
Select Committee and many, many others that it is around pricing
and availability. I think it would be very helpful to have a clear
statement about pricing. Of course, if we have minimum pricing
it is not going to help people who are established dependent drinkers
but there is very clear evidence that it will help to stop the
next generation of people who are dependent on alcohol and would
certainly save vast amounts of money from casualty costs and ambulance
costs. Would you be prepared to think again about minimum pricing
as it is so well evidence-based?
Mr Lansley: Can I say as far as
I am concerned the proposition that price has an impact on demand
is incontrovertible and the meta-analysis undertaken by the University
of Sheffield brought together evidence that demonstrated that
quite clearly. I do not disagree about that. You will have heard
in the Budget the Chancellor of the Exchequer made clear that
there will be a review of the relationship of alcohol pricing
to duties and we have made clear our wish to ban below cost selling
of alcohol. Collectively with my colleagues I will be saying more
about how we might be able to implement that in due course. I
will not go on about it at length here, Chairman, but it might
be helpful if I were to subsequently send you a note about minimum
unit pricing of alcohol.[1]
My argument is this: while price has an impact on demand the evidence
does not support minimum unit pricing as the mechanism to deliver
a price adjustment that best impacts on demand and does not as
a consequence have unwelcome regressive impacts in terms of low
income households. I will drop you a note about all that. I felt
quite strongly about this. People have picked up minimum unit
pricing and said, "It is evidence-based" when actually
the Sheffield study made it perfectly clear that there was no
evidence about the impact on low income households, so I am not
happy about simply endorsing minimum unit pricing. I agree that
we need to do something about price and that was why the Chancellor
said what he said. I agree we have to act on availability, which
is why we have got to be much better at enforcement. There are
examples, like the St Neots Community Alcohol Partnership, that
have demonstrated that within the existing legal framework we
can achieve far better results in terms of enforcement of the
law and the reduction of access particularly of young people to
alcohol. I think you left one thing out, which is demand. We have
got to impact on demand. If I were to describe what I regard as
one of the core differences in approach that I hope to bring about
in relation to public health, it is a recognition that many of
these problems are so intractable because they are about behaviour
and underlying dependencies, sometimes just a simple lack of self-esteem
and self-confidence on the part of people that often from quite
an early age makes them dependent on alcohol, peer pressure, food,
drugs. They just cannot take, as it were, independent confident
decisions about their own lifestyle. I do not pretend, especially
when you are giving evidence to a select committee, because you
would say, "Well, where is your evidence?" I think it
is pretty clear that this is part of the problem. What we lack
in public health is sufficient evidence of what you do in order
to make a difference, the things that work. We need a public health
strategy that identifies all those things about supply and control
but goes way beyond that and begins to stop telling people what
they should be doing and starts to work in boosting self-esteem
and self-confidence so that make people much better decisions
from an early age and then we try to build on those social norms
and behaviour change concepts to arrive at a public health strategy
that is more effective. That is going to depend upon us working
collectively across government and society. In relation to what
the Prime Minister was saying in Liverpool yesterday about a big
society, the public health strategy can benefit enormously from
the stimulation of a community and voluntary-based response to
many of these issues, as you can see, for example, in how some
drug treatment and drug rehabilitation programmes work. Equally,
we have got to have an evaluative and evidence-based culture on
this, which is why I get myself into hot water occasionally when
I say, "Well, let's look at the evidence. Has it worked?"
Some things do work and some things do not work as well as they
should do considering the level of resources deployed, and let
us be clear about that.
Q43 Dr Wollaston: But you cannot get
away from the fact that because alcohol is 70% cheaper than it
was that is fuelling the problem for people who do lack self-esteem.
Mr Lansley: I am not disputing
that price has a relevant part to play, which is why in the Coalition
Programme we are quite clear that we are going to act on price
and the Chancellor was very clear in his Budget that he has initiated
a review with that purpose in mind.
Q44 Grahame M. Morris: Before we
move off this issue of the wider determinants of ill health, I
wanted to seek some clarification about your views on the uptake
of school meals and the influence that has. I know the whole thrust
of the White Paper is about outputs, but if we are going to go
to the heart of the issue about childhood obesity, which affects
particularly poorer areas like mine, and issues around Change4Life,
promoting activity, "move more, eat less, live longer",
it is an important area of work in tackling health inequalities.
I have read in the press that you have been quite critical about
the uptake and quality of school meals. It is an issue that has
been championed over the last few years by Jamie Oliver and has
had some public support. The Committee has had some figures from
about ten days ago from the School Food Trust showing that, in
fact, the uptake of meals has risen again this year. I wonder
what you see as the problem, Secretary of State? You were quoted
in one of the reports as saying that the new standards for meals
were too dogmatic. I read somewhere else that you said they were
inconsistent. As a final point, the Minister for Children and
Young Families was speaking in a Westminster Hall debate and he
said in his view the problems in poor uptake were down to poor
eating environments in school. I would appreciate it if you would
share your thoughts with us.
Mr Lansley: Tim and I have discussed
this often in the past and I think we entirely agree. The first
thing is what I said to the British Medical Association was that
I thought Jamie Oliver was quite right. He focused on the quality
of school meals and sought to improve the quality of school meals
and was absolutely right to do so. He was even more right, as
I said subsequently to the Faculty of Public Health, when he went
to Rotherham because what he saw was that the response to this—Do
you recall his programme in Rotherham?
Q45 Grahame M. Morris: Yes.
Mr Lansley: Why did he go to Rotherham?
Q46 Grahame M. Morris: He also went
to Peterlee in my constituency.
Mr Lansley: Very good, absolutely
right. The reason he went there was because he took an initiative
which was about the quality of school food and improving, in a
sense, people's relationship with food like I was saying a moment
ago about people's relationships with drugs, alcohol, food, sex,
relationships. We have got to give people greater confidence and
let them take more control, let them make better decisions and
from an early age make better decisions. Frankly, I do not think
the initiative that Jamie Oliver took, which I completely supported,
was turned into the right implementation because it should have
been something that changed young people's relationship with food
not just in school but beyond it. As happened in Rotherham, which
was why Jamie Oliver quite rightly went to Rotherham, one should
look outside the school gates because the position you ended up
with was parents trying to push burgers through school gates.
Why were they doing that? It was because at home and in that community
we had not arrived at the kind of social norms that said eating
better is something we want to achieve at school and outside it.
You did say about the School Food Trust and, you are absolutely
right, it has gone up over the last two years but it went down
and, strictly speaking, from 2008 there was a change in the data
collection so it is not strictly comparable. If you were not to
use that and were nonetheless to say what was the percentage take-up,
it went down and the increase in the last couple of years does
not even take you back to the position it was when Jamie Oliver's
programme first came out. I do not think that is any criticism
of Jamie Oliver. My problem is that it was not seen through to
its proper conclusion, which is that schools should be thinking
not just about what is in the food and trying to chase down the
saturated fats, with great respect to David about saturated fats,
or sugar or salt, it is about having a better relationship with
food otherwise where do you end up, you end up with the wrong
things in the lunchboxes and then you try to regulate the lunchboxes
and then you end up with them buying meals out of school and buying
sweets and stuff and not realising that actually they have got
to take responsibility for this.
Q47 Grahame M. Morris: It is part
of the solution, not part of the problem, is it not?
Mr Lansley: What is part of the
solution?
Q48 Grahame M. Morris: Quality school
meals.
Mr Lansley: Absolutely it is,
and the quality of the environment in which school meals are provided
is part of that. That is part of this message, is it not? If Jamie
Oliver is trying to do anything, he is trying to arrive at a point
where the enjoyment and pleasure that people derive from food
is considerably enhanced, not just because of the quality of the
cooking, not just because of the quality of the ingredients, but
also the quality of the environment where people eat it. That
is absolutely right. I do not think simply prescribing that you
must only have chips twice a week on the menu while at the same
moment you can have roast potatoes cooked in oil as often as you
like actually gets to the point of this. The point of it is changing
people's relationship with food.
Q49 Chair: Can I move this on. You
have published today the terms of reference of the Commission
to look at the funding of long-term care, care for the elderly,
a very important carrying forward of a commitment made at the
time the Government was formed. Looking at those terms of reference
I would be interested to know what you envisage as being the objective,
the level of care that their recommendations are anticipated to
fund. When Wanless looked at this for the King's Fund, and earlier,
he said that merely in order to maintain the current inadequate
level of care would cost an addition 24 billion. He then went
on to say that to achieve a level of care that would be regarded
by most people as a minimum acceptable level of care would cost
probably another five or six billion in addition to that. In setting
out the terms of reference for this Commission, is it the Government's
intention that the resulting policy should fund the current inadequate
level of care or are you looking to address the level of care
as well as the funding formula?
Mr Lansley: I think it is a very
fair and, indeed, very perceptive question. The purpose of establishing
a Commission in this form, I have to tell you, is not to prejudge
that because that would be in large measure to prejudge some of
the ways in which they approach their task. We are not seeking
to fetter the way in which they go about this. We are looking
for a partnership between the individual and the state and it
is perfectly clear in the terms of reference that we are looking
for that. To that extent, the extent to which there is, as it
were, publicly funded support for the care services will have
to be sustainable in the long run and consistent with the fiscal
framework. We have made that clear in the terms of reference.
I think, as you know, with the calibre of membership that we have
they are perfectly capable of judging what is sustainable in terms
of publicly financed care and support. Of course, that does not
of itself determine in advance what level of support they think
is achievable in a system that includes a partnership and insurance
models of the kind that have been discussed in previous Green
Papers and in the King's Fund and elsewhere. They are going to
have the opportunity to look at that. They will be able to say,
"Right, what is the public contribution? Where are those
coming from? What do they look like? Where are the family and
individual contributions and what do they look like? What standard
will that enable us to meet and under what circumstances?"
However, the one thing I would say might help is we have asked
them to come back to us within two months with the criteria against
which they are going to assess the proposals, the solutions that
they come up with. I think it is perfectly reasonable—I
am sure they will read this—for them to look at that question
that you ask in the context of how they are to set their own criteria
for judging the proposals that they bring forward.
Q50 Chair: That is a helpful answer
because this is a hugely important movement of the development
of policy in this whole area of funding public services. What
the Government is establishing, it seems to me, is a Commission
to look at future co-payment models to apply to the social care
arena. They have to take account of the public funds available
but they also have to look at the resulting level of service and
the achievable level of private funding in a way that is compatible
with the principles of equity.
Mr Lansley: And the other principles
set out in the terms of reference, yes.
Q51 Chris Skidmore: You just stated
that in the terms of reference it will be constrained by the June
2010 Budget and the forthcoming Spending Review. Also, in your
response to the previous Select Committee's report on social care
you note the Office for Budget Responsibility include in their
pre-Budget Forecast of June 2010 that public expenditure on long-term
care is going to have to rise from about 1.2% of GDP to around
2.1% by around 2015.
Mr Lansley: To be fair to the
Office for Budget Responsibility that was on unchanged policies.
Q52 Chris Skidmore: Even on unchanged
policies, and certainly we will see what happens with the review
in the forthcoming year, at the same time we do know that spending
on social care has not been ring-fenced, unlike NHS spending.
What additional costs do you envisage falling on the NHS as a
result of that imbalance taking place?
Mr Lansley: It is not recent but
there have been estimates derived in the past about the extent
to which people who are not supported through the care and support
system are likely to increase their demand for health care services.
This brings me back to the point I made earlier about the desirability
of acting now and using the opportunities that are available already
through care trusts and the like. It is better to integrate health
and social care services and the commissioning of those services
will help us do that. We are driving those things in any case.
You will recall in the revision to the operating framework I published
on 21 June, one of the proposals I put there was starting on a
locally determined pilot basis this year but from April 2011 that
we will be asking the Health Service to take responsibility, hospitals
essentially, not just for the initial treatment of patients who
have procedures but for the subsequent rehabilitation and reablement,
so effectively taking responsibility for 30 days post-discharge.
This is for two reasons. One is about outcomes. It focuses the
hospital on the outcomes and removes what might otherwise be a
perverse incentive for being paid for emergency readmissions.
That is important in itself, and hopefully will lead to savings
and improvements in health care services, but it actually has
a significant benefit from the social care system point of view.
We did not have the resources to proceed with the Personal Care
at Home Bill, there was no money for it, but the evidence was
clear that reablement is effective, so using these processes and
health care support we are going to seek to increase the quality
and extent of reablement, reducing subsequent hospital admissions
and lowering costs on social care. There will be other areas where
the relationship between health and social care can be improved
in ways that both meet health needs and support the social care
service.
Q53 Andrew George: There seems to
me to be pretty much cross-party consensus that the integration
of health and social care that you described earlier—Torbay,
Hammersmith & Fulham, and elsewhere—is desirable and
clearly should result, at least theoretically, in a more efficient
use of resources as the discharge conundrums from hospitals would
hopefully be ironed out as a result of those types of integration.
Within the White Paper do you envisage the kinds of arrangements
that you see in place in Torbay and elsewhere to become the norm?
How do you intend that to be rolled out? What incentives are likely
to be in place in order to facilitate that type of move towards
greater integration nationwide?
Mr Lansley: If you will forgive
me, there is a tendency in the way the service tends to work at
the moment where if the Secretary of State says something should
be the norm everybody thinks they have to go and do it tomorrow.
Sometimes it may be absolutely fine, but that has a tendency to
distort what would otherwise be perfectly sensible decisions made
locally about how this works. I do think there is absolutely nothing
to stop primary care trusts, GP practice-based commissioning consortia
and local authorities sitting down now making what I would regard
as rational local decisions about establishing the right relationships
and the commissioning structures to support them. There are good
examples across the country, I just hope people will look at them.
It does not follow that I want to mandate what those look like,
it is just that it is perfectly clear there are good examples,
and the Audit Commission made it clear that those examples were
not being pursued anything like as much as people imagined and
hoped. I do want to see more integration between health and social
care, I just do not want to turn it into some top down structure
rather than it being devised locally.
Q54 Andrew George: Within the White
Paper itself do you think that the configuration of new structures
and commissioning arrangements that are being put in place would
facilitate that as an option to a greater extent?
Mr Lansley: Yes, I think it would,
partly because in the past there has been a tendency for primary
care trusts to think, "Our responsibility is to commission
and we'll hold on to it". I think general practice consortia
will approach it with a whole different mindset. Their mindset
is, "Our job is to look after our patients, to get the right
services for our patients and deliver the right results for our
patients". They will be focused on that clinical need. From
their point of view, therefore, I do not think the general practice
consortia will have the same kind of institutional ownership of
commissioning, they will be much more willing to contemplate that
they can exercise their commissioning responsibilities through
a range of support structures. Local authorities in relation to
some services are very well placed to enable that to happen.
Q55 Rosie Cooper: Following on from
what you have just said, there are good examples, great, but there
are also bad examples. As somebody who has been a local councillor,
who has a long career in the Health Service and chaired hospitals,
I can tell you that local government perceives the NHS to be very
much more resourced than the local authority. I am trying to imagine
this consortia world where local authorities are cash strapped,
social care is not ring-fenced, yet your local authorities, your
accountable people in this design, are actually part of the problem.
How would that be resolved?
Mr Lansley: Forgive me, part of
the problem in what sense?
Q56 Rosie Cooper: If the local authority
has pulled money out of social care, it is not meeting its social
care responsibilities, then that will go down the chain and years
ago that ended in bed blocking, which was the biggest manifestation
of that. If the local authority does not actually meet its obligations,
which it is struggling to do now—
Mr Lansley: I see the point you
are making but I think it is very harsh on local authorities to
characterise—
Q57 Rosie Cooper: It is not harsh
if you are a patient who misses those services.
Mr Lansley: To describe them as
part of the problem because they have limited cash, let us face
it, we were left with a deficit and we are having to deal with
the deficit. There are consequences that flow from that. In the
same way as I described thinking wholly new creative thoughts
about how we deliver our public health strategy, in each locality
they are going to be given the opportunity to think about how
they can structure their public health responsibilities and, indeed,
their health and social care integration in order to deliver overall
a much more efficient and effective response. There are local
authorities, and I hope there will be increasing numbers, who
recognise that this is a necessity, that they have to change the
way in which health and social care works together in order to
deliver a better result for both. The fact that social care resources
are heavily constrained, to that extent it is not them arriving
with a problem, it is them arriving with, "Here is a necessity,
how are we going to deal with it?"
Q58 Rosie Cooper: Secretary of State,
I absolutely understand that but the problem about this new model
as you have described—it is inherent in the current model—is
if we have got a local authority, let us call it a really maverick
local authority, one who is not putting a great deal of money
into social care or whatever, a lot of people can talk about services
that are given to constituents being six months or many months
late and real difficulties there. In the current financial climate
that is going to be even tighter, and I accept that, but how is
a local authority that is part of the consortia that is going
to be charged with delivering this going o do this that hands
up cannot do it? The Health Service has an obligation to the patient.
How are you going to deal with that problem? It is not about blaming
people, it is about resolving it for the better.
Mr Lansley: I think what the White
Paper sets out is a substantial advance on the current situation
because what you describe is exactly what tends to happen too
often now, a local authority has a problem and the primary care
trust might have the solution but it has no responsibility, "We're
looking after our budget. We do our job". The recognition
of the interconnectedness of health and social care, particularly
from the point of view of patients, is not being followed through.
I think the White Paper is clear about two major ways in which
we will enable that to be better. The first is through personalisation.
I do remember in January 2006 when my predecessor as Secretary
of State published Our Health, Our Care, Our Say. She then
said personal budgets in social care but no personal budgets in
health care. Just before the election the Labour Government changed
their view on that. I argued that we should enable aspects of
health care services to be incorporated into personal budgets
and the White Paper is clear about pursuing further the ability
for care users themselves to have the opportunity to integrate
with services that are provided to them. Secondly, the strategy
that we have been talking about, putting the local authority together
with the health commissioners with its new public health responsibility,
has not only a new strategic mechanism through which those relationships
must be resolved but also, particularly where the public health
budget is concerned, a funding mechanism that is able to address
some of those issues. That is not to replace budgets that are
being cut somewhere else but to look creatively at how, for example,
through prevention we can deliver an improvement. In the same
way as I was describing reablement, which is a sort of follow-up
to treatment, look at something like earlier intervention with
older people through things like home adaptations. You could say
that is entirely a local authority's responsibility, sometimes
it is done by the Health Service, but there is an opportunity
through the Health and Wellbeing Partnership for them to sit down
and say, "What is the Health Service going to do? What can
we do? What can the public health budget do? Where are the benefits
that flow in terms of overall outcomes in each of our respective
responsibilities by focusing on the speed and effectiveness of
earlier interventions to try and support people at home more independently?"
Rosie Cooper: I look forward to revisiting
that in a year's time or so.
Q59 Chair: We have eight minutes
left until our appointed deadline and Mr Sharma has been waiting
patiently to ask some questions about the public expenditure round
and I understand you have just submitted your first stab at that.
Mr Lansley: We are going to do
that in eight minutes!
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