Public Health - Health Committee Contents

Examination of Witnesses (Question Numbers 289-355

Professor Dame Sally C Davies DBE, Chief Medical Officer, Department of Health, Anita Marsland MBE, Transition Managing Director, Public Health England, Department of Health, Professor David R Harper CBE, Director General, Health Improvement and Protection, Department of Health, and Professor John Newton

12 July 2011

Q289 Chair: Good morning. Thank you very much for coming along this morning. Welcome in particular to Dame Sally Davies, the new CMO, on your first appearance before the Committee in your new role. I apologise for keeping you waiting. We have a bit of a backlog of reports building up that we are trying to get out and we have been discussing those as well as preparing ourselves for this session. Could I begin by asking you to introduce yourselves and the particular areas of departmental responsibility that you come from?

Professor Davies: As you know, I am Sally Davies, the new Chief Medical Officer. I am also the Chief Scientific Adviser to the Department and I hold the R&D portfolio, which I had previously managed as Director General. As Chief Medical Officer—I have actually brought the job description in case you wanted to get right into the details—I am the principal medical adviser to the Government to advise on health and the population's health. I am both independent as well as part of the Government. In that role I attend the Cabinet Sub­Committee on Public Health—the only official who does—and I am clearly the advocate for the public's health cross­Government and generally.

In the job description I have been given a new role, as professional head of the public health profession, and as we develop our plans, I have to make sure they are all right. While I am no longer the professional head of the whole medical profession, we take the view that the leaders of the medical profession are collective and multiple and that it does not rest with one person. I will be writing an annual report, which is independent, and continuing in that way. I will stop at that point and pass over to Professor John Newton.

Professor Newton: Good morning. My name is John Newton. I am the Regional Director of Public Health for South Central and I chair the Working Group on Information and Intelligence, which I believe is of interest to the Committee. Thank you.

Anita Marsland: I am Anita Marsland. I am Transition Managing Director for Public Health England.

Professor Harper: I am David Harper. I am the Director General for Health Improvement and Protection within the Department of Health. I am also the Department's Chief Scientist and Head of Profession for scientists.

Q290 Chair: Thank you very much. Could I begin by asking Dame Sally a question about the role of the CMO as a result of the changes the Government proposes in the structure of public health in England. How do you see the role of the CMO changing in the context of the proposals as they have developed over the last twelve months compared with the historic role of the CMO in public health issues?

Professor Davies: Historically, the CMO straddled health care and public health, whereas now I see the NHS Medical Director as playing the lead role for the health care part. As CMO, I will play very much the lead role and be the senior doctor for public health. That plays out in a number of ways. I am going to set up—I have not yet because it is unclear to me the best way to do it—a public health advisory committee that will advise me, and through me, Ministers. It will have the function, relating to Public Health England, of keeping an eye on it, challenging it and doing deep dives, if necessary. Therefore, it will be looking at public health and advising. As Public Health England will not have a non­executive board, this CMO advisory committee becomes particularly important in its challenge and monitoring functions.

As to the important role of the annual report, I see it as being in two parts: one, a quite old­fashioned one about the state of the public's health and the data that need to be out there for transparency and for everyone to use, and another doing an in­depth review of an area that matters. I am considering doing infection as the first and getting experts to contribute to that in a way that antique CMOs did—but not the last one. I think they would be antique now anyway, if they are still alive.

Then there is the role of leadership: externally showing that this matters to me, to the Government, to everyone and trying to make the linkages; and inside the Department and Government advising, chivvying and pulling—doing what we all do.

Q291 Chair: In your introduction you drew out the fact that you were the head of the public health profession rather than the medical profession more generally. Do you, therefore, see the role of the CMO now as almost a director of Public Health England?

Professor Davies: No. It is not an executive role. There will be a chief executive reporting to the Permanent Secretary. It is a serious advisory and challenge role. It is written down as advisory and I have put in the "challenge" as well.

Q292 Chair: The classic three domains of public health include health care public health and the question is how far you interpret the role of the CMO, as you have defined it, allowing you to get into health care questions as opposed to prevention and health protection?

Professor Davies: Being me, I am reserving my right to range widely, but there is a limit to what one person can do. My role is to make sure the public health profession play that out. In the Government's response to the Future Forum they accepted that the public health third pillar would be delivered by Public Health England and out of local authorities, and we are working on how to do that. If there were concerns that came to my attention, or to your attention and you remitted them to me, clearly I would pick them up. Infection is an example. We have infection in the NHS, we have infection broadly in the community and we have infectious threats. That is why I thought I would try using infection as the first expert report to show that I am going to reach into every area on certain issues if I need to.

Q293 Chair: Infection is a classic health domain—prevention—arguably. Suppose, for example, there were concerns about—an issue very rarely out of the headlines—cancer outcomes and the delivery of cancer outcomes in different parts of the health care delivery system. Would that be something, as CMO, you would follow up as part of health care public health, or would you say that is now defined elsewhere in the system?

Professor Davies: The executive role would sit with the National Commissioning Board and the medical director there. Clearly, if I was concerned, I would be asking questions, throwing a light on it and advising about the science and what might be considered, but the executive role is in the Commissioning Board.

Q294 Chair: Thank you. Can I move the spotlight to Anita Marsland to understand what is proposed now in terms of the structures for Public Health England? We have moved from it being a core function of the Department to it being an Executive agency. The question in many people's minds is what that means in practice. What is the degree of independence implied by an Executive agency? Some people have said that it ought to be a special health authority. It becomes a bit of an anorak issue, if you are not careful, about "Why an Executive agency rather than a special health authority?" and "What are the implications of the choice?"

Anita Marsland: I will take the Committee through the development of thinking on this. Ministers have been very clear about the importance of a clear line of sight between them and the front line when it comes to health protection issues. This is akin to the defence of the realm. We look to central Government to defend us against threats which we, as individuals or communities, are not well placed to tackle. That is why Ministers have taken the view that a non­departmental public body like the HPA, however responsive—we would agree with the proposition that the Health Protection Agency is very responsive—is less fit for purpose than an organisation that is part of the Department.

However, we have heard a consistent message and concern that that was going too far. We believe that locating Public Health England completely within the Department would risk compromising the attributes of scientific excellence and independence that we depend upon. Executive agency, therefore, in the Ministers' view, is a sensible compromise. Executive agencies are part of the home Department but have an operational distinctiveness. Such status would allow Public Health England to build and maintain a distinctive identity but within the Department. Also, it will support the ability of scientists in Public Health England to give expert independent scientific advice and make it easier for PHE to continue earning significant sums from external sources, as the HPA does at present, as I am sure the Committee is aware.

Shall I go on to "Why not a special health authority?"

Chair: Go on, yes.

Anita Marsland: I would refer you to my previous answer in part, that Ministers have of course been very clear about the importance of the clear line of sight. It is also important to recognise, though, that Ministers have taken the view across the system that the freedom to set up special health authorities has been overused and that the lifespan of any such body should be strictly time limited and subject to review.

Q295 Chair: I am less interested, personally, in the precise structure than I am in the principle that Public Health England is seen to be, and wins public confidence as, an independent voice that speaks truth unto power.

Professor Davies: That is terribly important, and is why I am happy we are going to have an agency rather than incorporate it into the Department. If you think about the MHRA, it is seen internationally as a model and functioning independently. Most people do not even know that it is an Executive agency. We will have to work hard with the scientists, but as Chief Scientific Adviser, it is one of my roles to guarantee the independence and to get them talking about what they are doing to power and to mediate where necessary.

Q296 Chair: Not necessarily speaking truth in private.

Professor Davies: I hope they will speak truth in private.

Chair: That is not what I meant.

Professor Davies: That is important. When it is needed, we will have to speak truth publicly if it is not heard, yes. I would prefer to have the uncomfortable stuff discussed.

Q297 Valerie Vaz: Do you see Public Health England, in this new structure, as part of the NHS? For instance, will there be joint appointments or will it be jointly appointed?

Professor Davies: It is going to be separate from the NHS but will work very closely with the NHS.

Q298 Valerie Vaz: Is it still part of the NHS?

Professor Davies: It is funded by the same vote that funds the NHS, so it is part of the health bit, but what we are trying to do is give a much bigger emphasis to public health and prevention than we have ever given it before.

Do you want to pick up on the links across?

Anita Marsland: You have said what I would have said, Sally. I think that is clear.

Q299 Valerie Vaz: Is it joint appointments or jointly appointed?

Anita Marsland: Do you mean of the director of public health?

Valerie Vaz: Yes.

Anita Marsland: It is jointly appointed.

Professor Davies: That is between Public Health England and the local authorities.

Q300 Valerie Vaz: That is not what the Secretary of State said last week.

Professor Davies: Directors of public health in local authorities will be jointly appointed between Public Health England and local authorities so the NHS will work through the local Health and Wellbeing Boards at the local level. At the national level there will be working between PHE and the National Commissioning Board and we are looking at our sub­national hubs to try to make sure they not only match with the DCLG resilience stuff but that the Commissioning Board and Public Health England are, ideally, co­located and work very closely together. We are working to make them very close to each other. We cannot let the NHS walk away from public health. They are a key part of it.

Q301 Chair: When you say "co­located with the Commissioning Board," that raises another question in our minds about the nature of the structure that Public Health England intends to have below the national level. The Commissioning Board is itself developing its ideas about offices outside Richmond House. Is that a conversation that is going on in parallel with PHE and is it the implication that wherever the Commissioning Board had an office PHE would have a presence?

Professor Davies: I will let Anita give you the detail, but yes, of course it is a conversation we are having together. Not every office will be co­located, but where significant amounts of activity are going on, if we can, we will. However, that does not mean that at the end, it will be like that.

Anita Marsland: Thank you. We are not proposing a regional structure but we will align the hubs that we create for Public Health England with the DCLG resilience hubs and with the NHS Commissioning Board. As far as possible, we will look to the same geography. That may not always be necessary or appropriate, but it will be our starting point. We are not able to say anything definitively today about that as we are still working on it, but we feel very strongly that alignment is important.

Professor Newton: As an existing regional director of public health, of course I have a view on this. The important thing is that Public Health England can interact with a variety of bodies. No single arrangement is likely to dovetail perfectly with all of them, so we need flexible national coverage that allows us to work effectively with all the other organisations we need to work with.

Q302 Rosie Cooper: Can I jump in and ask a question? All these reorganisations are supposed to make life easier. Is this better or worse than where you have been? Is this simpler or more complex than where you have been? What are the real upfront advantages of yet another mess?

Professor Davies: I believe, for public health, that when we get to the end of this it will be better.

Q303 Rosie Cooper: When will we get to the end of it?

Professor Davies: We expect to have Public Health England up and running from 2013. We are looking to appoint a chief executive for it this autumn.[1] They will be able to do shadow running so it should start at a run. At the moment there are lots of very good bits, but they are rather separate. By creating Public Health England in the way we envisage, we are bringing it together. We will get efficiency savings, which we need, and we should get a much better information, intelligence and surveillance system. John is leading on that and can talk to you about it. I do believe it will be better.

Q304 Rosie Cooper: You are involved in it. You are all professing independence and yet you are all part of it. I hear you, but I do not know whether the public out there will actually buy this "I am part of the health department, but I am independent" line that everyone keeps saying.

Professor Davies: I think I am the only person who sits here with an independent role, as it happens. My colleagues are civil servants. If I thought it was wrong, I would say so. I think we will end up with a better system. I believe that or I would not be doing this.

Q305 Chair: Could you elaborate for the Committee what you think are the three or four key improvements that come from this process?

Professor Davies: The efficiencies in the delivery of services by bringing them together, the increased focus on health improvement and behaviour by bringing it together, the wins from putting local public health into local authorities, back where it came from, and—

Q306 Rosie Cooper: With no money.

Chair: We will come to that, Rosie. Let us do it one by one.

Professor Davies: They are going to have a budget.

Oh, dear, you kind of interrupted me.

Rosie Cooper: I am sorry.

Chair: Savings, integration, local government. 

Professor Davies: Yes. As I had a heavy winter with flu, I also saw how having the disparate bits made for complications and slowness. It worked fine, but if we get a really nasty E.coli or something, I would like it to work better. I believe—I am trying to make sure—we are designing a system that will work better.

Q307 Valerie Vaz: This is an opportune time to talk about what is happening now. You are talking about your hopes for the future and where it is going to go. We are all quite confused because we don't know either, even though we have had various people in front of us. Could you elaborate on or give us a snapshot of what is happening on the ground now? Where do you see the transition? How is it going to get to this wonderful new structure that you are hoping will work terribly well?

Professor Davies: I am determined it will work well. I will start with Anita and then hand over to John.

Anita Marsland: Obviously we are working on all the dimensions of this reform, which is complex. Starting with the local system, the regional directors of public health have the lead for putting together transition plans in their areas, working with directors of public health and the wider public health community and local government to ensure that there is a smooth transition into local government. Progress is variable thus far around the country, but what we are seeing is a real appetite for that transition. That is working well. The other aspect, of course, is establishing the new national organisation with its hub structure. We are working with key stakeholders to design that organisation. There is lots of activity at the moment.

It is really important that we involve people who are part of the system in designing it, but also the public, and we are engaging with as many people from as far and wide as possible in that discussion. I am going around the country with some of my colleagues talking to as many local authorities as possible because it is equally important to them what Public Health England is like for the local system because they are so interrelated. There is a lot happening. There is a lot of discussion and debate and a lot of energy and enthusiasm. I believe we have the right people involved in those discussions.

Professor Davies: Can you talk about the pathfinders?

Q308 Valerie Vaz: I am still not clear what the transition is and what is happening. You are talking to lots of people, but where is it? It has only recently been announced that we are going to have Public Health England so the structure can't be clear in your minds. What is the morale like out there? Do we have a work force? What is happening to all the data in terms of health inequalities? What is happening to all of that? Are they doing no work or are they just talking?

Anita Marsland: I will invite John to comment. It is variable, as I have said, but I think morale is improving. It has been a difficult period for colleagues.

Professor Newton: If I could answer one of your earlier questions, there is a huge potential benefit in having a national integrated public health service. There is no doubt about that. There is huge benefit in the transfer of health leadership to local authorities, but like any change, there is good and bad. Some people are seeing more of the good and some people are seeing less of the good. We are seeing a mixed picture in terms of morale.

What are we doing? There are two jobs. Whether you are talking about Public Health England or the local system, there is a continuity job to be done. We are trying to find out exactly what we are doing at the moment. It is not easy working out what everyone is doing in the primary care trusts and in other areas. So there is a continuity job. What are we doing? How do we make sure that the good things carry on? That is the point you made about the inequalities data and so on.

  Then there is the opportunity job. We are doing all this for a purpose. We must make sure we realise the opportunity in having local councillors involved in health strategy and so on and, at national level, realise the opportunity in bringing together disparate organisations whose mission is determined by which ICD chapter they are responsible for. I am talking about the classification of diseases. You have the Health Protection Agency doing infections, Cancer Registries doing cancers and Public Health Observatories doing some of the other things. In some areas, like childhood accidents, we have very little activity. Here is the opportunity to bring that together and take a rational view of what the public health priorities are for the population, how we use our resources most effectively to address those and then follow that through in a properly founded structure. That is my quick summary of the task. If you wanted to know more about any of those elements, I am sure we could elaborate.

Chair: Mr Tredinnick wants to follow up on some of the local stuff.

Q309 David Tredinnick: We may well be getting into some of these points, Chair, through you, later on. I am sure you will have a chance to elaborate. I want to focus on local government and the directors of public health—the new arrangements—because, of course, up until 1974, as we are all aware, public health was the responsibility of local government. Now the proposals are for Public Health England to share that with the higher echelons of local government, including unitary authorities.

I would like to ask, first, a question about the Department's memorandum which says that Directors of Public Health "will be qualified in the specialty of public health (which includes those from both medical and non­medical backgrounds." Does this mean that there will now be a statutory requirement for them to be appropriately qualified?

Professor Davies: I had better answer that. The Government has not yet decided. It is still under debate. The profession feel very strongly that there should be statutory regulation. The debate centres on the cost­effectiveness of that, and I know you are addressing it in your next session.

What we are clear about is that the director of public health in local authorities will be appointed jointly by the local authority and Public Health England and will, therefore, be an appropriately qualified and certified person—a professional.

Q310 David Tredinnick: What if there is a disagreement between the local authority and Public Health England about the appointment? How will that be dealt with?

Professor Davies: Do you mean at the appointments committee?

Q311 David Tredinnick: Yes. Are you going to have guidelines for that?

Professor Davies: I have seen many appointments committees where there have been disagreements and we have always resolved them.

Q312 David Tredinnick: Fine. Fair enough.

Professor Davies: Often the third party walks through the middle.

David Tredinnick: Thank you.

Professor Davies: But it will be an appropriately qualified person.

Q313 Chair: It is a dual key.

Professor Davies: Yes.

Q314 David Tredinnick: The memorandum says that the Government is "working with local government to ensure that there is maximum flexibility" to ensure directors of public health continue to be independent advocates for population health. What form exactly will that flexibility take and will councils be free to decide how flexible they are?

Anita Marsland: The democratic accountability of local authorities is a strength of the new system, not a weakness. We would expect directors of public health to be senior officers and to have the same corporate responsibilities as any other senior officer. The Bill gives them clear duties that they would be expected to undertake in a professional, impartial and objective way. The Bill also gives the director of public health a duty to produce an annual report on the health of the local population and, importantly, the local authority to publish that report. Finally, before dismissing a director of public health, local authorities would have to consult the Secretary of State. All together, that gives quite a bit of independence in terms of their voice.

Q315 David Tredinnick: I put it to you that the key issue is the seniority of the public health officer and whether they report directly to the chief executive or whether they are going to be an underling somewhere, buried in the infrastructure. Can you explain to us how directors of public health are accountable to you as the Chief Medical Officer? How will that fit in with their accountability to local authorities and to Public Health England in the new system?

Professor Davies: People are formally accountable to their employers. DPHs will be accountable in the local authority to the chief executive. We expect them to have chief officer status with a direct line of accountability to the chief executive. Thus, their accountability to me is a professional accountability that will be exercised through Public Health England in general, but, clearly, if there are issues, I may have to step in.

Q316 David Tredinnick: We have a dual reporting system here, reporting to you and reporting to the council.

Professor Davies: It is not unusual in health that doctors are part of a formal structure for accountability, and so we should be, but also have professional responsible lines.

Q317 David Tredinnick: Thank you. I have one other question. What work is the Department undertaking to ensure continuity of the public health work force in the transition to local government's new public health role, please?

Anita Marsland: As David Nicholson made clear in his most recent letters to NHS colleagues, there is a clear expectation that sufficient resources are retained within the system to enable critical public health functions to be delivered. The NHS is itself in the process of completing a people and function migration map to make local decisions about the nature and shape of their work force. The regional directors of public health, as I mentioned earlier, are actively supporting those local transition plans and charged with managing the transition process locally.

Q318 David Tredinnick: You have been looking at these, obviously, with great care. Is there anything that particularly worries you in your portfolio at the moment?

Anita Marsland: It is complex, and we certainly have to be careful that our colleagues in public health continue to feel valued and are supported through the process. It is our responsibility to ensure that clear processes are put in place so that they can continue with their roles, their professional development and their ambition, for the very reasons that brought them into the jobs that they do. To that end, we are in the process of producing a concordat with local government to guide some of that transition so that they feel more secure in their profession and roles going into the future. We are producing an HR transition framework as well to further support the whole of the public health system. While those things are clearly very high on my agenda, we have processes in place to manage them and I am confident that we can. I am sure we will be successful.

Professor Davies: Perhaps it would be helpful to tell you that I addressed the Faculty of Public Health last week—500 public health practitioners—and I expected low morale. Actually, people were really up for it, but the concern they had—it was a general concern and they made me well aware of it—was whether there would be jobs for the public health specialists that we are training at the moment. I was not aware that there was this concern and I went back to the Department about it. There is quite a bit of work going on about that and I believe that by the end of the week I will have a report on how we are going to handle it. Clearly we cannot be training doctors or other public health professionals and not finding jobs for them. We need them. The fact I did not know does not mean the team did not know and work had not been ongoing, but that was the biggest concern the profession gave me in Birmingham at the Faculty.

Q319 Valerie Vaz: Will there be jobs for them?

Professor Davies: I am assured that we should have jobs for them. David Nicholson, in one of his letters, has specifically alluded to this—trainees should have jobs. I am waiting for the report. Having been apprised of the issue, I am now looking into it.

Q320 Rosie Cooper: Can I pursue that a little more? The whole health service is in a complete state of flux or disarray. As to PCTs, doctors and nurses, nobody knows if they have a job. But you are able to say here today that if you are a public health professional doctor David Nicholson is going to guarantee your job. Is that what you are saying?

Professor Davies: No, I did not say that. I was talking about the trainees who are coming through.

Rosie Cooper: I can be a trainee doctor or nurse and not be sure I am getting a job, but if I am a trainee public health doctor, I am going to get a job.

Professor Davies: I would see what you have said as an exaggeration, speaking as a medical practitioner. I come from the hospital sector, which is not changing its structures significantly. We are training doctors and nurses and we have jobs for the vast majority of them, if not all of them. I can only talk to you about public health—

Q321 Rosie Cooper: Can I tell you that there are loads of people out there listening to you—in your independent status—telling us that as far as you are concerned, we do not have a problem; that people are not going to be losing their jobs all over the place and that you do not know there are nurses and doctors out there who are going to lose their jobs? As the leading medical doctor, are you really saying that to me?

Professor Davies: You are over­interpreting what I am saying. We are in a time of austerity; there is a reduction of 30% on management costs and that will mean losses of jobs, and as we change the structures of care across the whole of the NHS to more integrated pathways and things, people's jobs and opportunities will change. I do not think that the NHS has bottomed out what that means for all the staff. I definitely do not know what it means for all the staff.

Q322 Rosie Cooper: But you do know what it means for public health doctors.

Professor Davies: I am responsible for public health.

Q323 Rosie Cooper: They are assured of jobs.

Professor Davies: I am apprised of a concern that we have a number of trainees coming through who think there may not be jobs. I am told that we should be able to look after this. I have not promised it yet. We are looking into it and I hope it will be all right. If we train any professional for public health or health they are a precious resource for this country.

Q324 Chair: Before we leave it, I would like to come back to one of the answers Anita Marsland gave David Tredinnick, which I think was that it was the Government's policy that every director of public health should be a chief officer of the local authority, should be accountable to the chief executive and should not be accountable to any other senior officer of a local authority. Given the concerns that have been expressed about this among public health professionals, if that is what you said, it is a very important announcement. Have I heard you correctly or am I over­interpreting? I am not seeking to do so.

Anita Marsland: Maybe a slight—

Professor Davies: I think you are over­interpreting. We expect this, but we cannot mandate it, as I understand it, into local authorities. By being strong about the expectation, we would hope that this will happen across—

Q325 Chair: I am going to push you further, in that case. I accept that you, as an independent CMO or as departmental officials, cannot mandate it, but the House of Commons can and the Government has to be clear whether it thinks this should happen and it should be part of the structure or whether it is simply left as a matter for local discretion. There is a clear policy choice to be made. Which choice is the Government going to make?

Professor Davies: The policy paper that will be published later this week should make that clear.

Chair: Thank you.

Q326 Mr Sharma: You talked earlier about trainees who would possibly have jobs. How many trainees are there?

Professor Davies: I do not have those figures. That is the report I expect to have at the end of the week.

Chair: Rosie, you wanted to ask about funding, if I can remind you.

Q327 Rosie Cooper: I do. The public health White Paper said the total annual public health budget is likely to be over £4 million. I wonder whether people on the panel might shed some light on where that figure was magicked from? Also, what areas of spending is it intended should be funded from the ring­fenced public health budget, at local and national level? I would like to come back on that as well.

Professor Harper: It is £4 billion. I am not sure if I heard you correctly. Did you say £4 million or £4 billion? It is £4 billion.

Rosie Cooper: I meant £4 billion if I said £4 million.

Professor Harper: I understand. We said in the White Paper published at the end of November that estimates at that stage would suggest it would be £4 billion, or over £4 billion. The figure was taken from a number of sources, not least from money that is currently spent in national programmes and budgets from those arm's length bodies that would be coming together—or the functions of those bodies that would be coming together—to form Public Health England. The part that we have found most difficult is to tease out the local spend on public health because, of course, different parts of the system currently classify spend in different ways. That is a part of what we are still working on. Those three elements, essentially, went together to form the over £4 billion.

You have mentioned ring fencing, and it is probably helpful to clarify the different types of ring fencing. Within the total spend for health, there is an element of ring fencing along the lines of £4 billion plus. There is also a ring fencing that is referred to, which I think is the one you are alluding to, that goes out to local authorities essentially to be spent on those health improvement activities—the commissioning activities—laid out fairly clearly in one of the papers that we consulted upon alongside the White Paper on public health. All of this is work in progress.

Some of the work will be mandated from the Secretary of State. Much of it will be framed around the outcomes framework that we are currently working on. There will be outcomes that are considered so important at national level that local authorities will deliver them through their own means. We are not saying how things should be delivered, but we are saying what, at national level, we consider important, in the context, say, of inequalities. How do we get this reduction in health inequalities that we are all agreed we should be looking for and that Michael Marmot has been closely involved with for many years now? Those are the sorts of activities that will be included within the local authority ring­fenced part of the budget. Thus, there will be the local authority-determined activities, there will be the activities related to the outcomes framework and there will be a number of mandated services that the Secretary of State feels have to be delivered because of that national importance.

Q328 Rosie Cooper: Do you believe local authorities will have sufficient resources to be able to comply with all those signals and signposts they are supposed to?

Professor Harper: That is absolutely the objective. The objective at this stage is to determine what is currently spent and to match that with the priorities that I have alluded to. We are not completely there yet because the elements that I have not mentioned—we might want to discuss them later—are of course around health protection. I have focused on health improvement. Without overcomplicating a very complex landscape, other areas would be expected to be funded out of this ring­fenced budget. However, much of the interest—what we have gleaned through the consultation process, through the listening exercise—is around health improvement activities where there will be a commissioning role, particularly for local authorities.

Q329 Rosie Cooper: Most people would find this all very, very nebulous, but can I ask you a question about the concerns that I and a number of people have, that local authorities might redesignate some of their existing activities as public health activities? In fact, we have had people give evidence who suggested that making roads 20 miles per hour zones around schools is a public health activity.

Professor Harper: That is a risk that we have been made aware of over recent time. It is something that we need to take into account. The very fact that this is being described as "ring fenced" signals the intention. What we need to do over the next few months is work very closely with our key partners to make sure that the sort of risk that you have just alluded to—

Q330 Rosie Cooper: Forgive me. It is down to you to make sure it does not happen. It would be an outrage if public health finances could be moved in that way. I would really like to ask Anita—because, Anita, you know from your previous life how easy this would be—how do you see it? Not that, "We hope we would make sure it did not happen," but that we—

Professor Harper: I am sorry, at the risk of interrupting, I did not say "hope". I said "our intention" was, and that is what we are working on. We will be working and already have worked extensively with local authorities and others. Part of the challenge is to identify areas within local authority remits that are legitimately public health. There will be areas of transport—not the one that you identified, which is, I think, a very clear example—where we would not expect the ring­fenced budget to be paid. However, you might well find that there are areas on housing, on redevelopment and on other areas of transport, such as cycling and walking, that could legitimately be funded using some of that ring­fenced money.

Professor Davies: Could John come in?

Professor Newton: From my experience of working at the moment with local authorities in the transition, most of the ring­fenced budget that will come across to local authorities is currently spent on quite specific items, if you break it down—things like drug treatment services and smoking cessation—and it would be quite difficult to take that money and use it for some of these more general projects. In fact, the NHS spends relatively little on the sort of infrastructure projects that we think local authorities will really want to address. The real win is the strategic and advocacy role of public health embedded in local authorities. That is what we think will make the big difference, not the spend of the specific budgets.

Q331 Rosie Cooper: I absolutely understand the strategic part, but that will go into things like the ideas and the evaluation. The evolution of this will be associated with Health and Wellbeing Boards, but they are powerless. The question I have not yet asked you, is this. I have, as will most people, a problem with the fact that the strategic idea is extremely good but local authorities—councils—are under huge pressure to deliver services to the elderly that they have to deliver and, where they are not required, they are reducing the entitlement of people with moderate needs. They are only dealing with people with severe and critical needs.

Professor Newton: My experience of going round speaking to local authorities—I was talking to the leader of Southampton last week—is that they really welcome the presence of the director of public health on their management boards and they are using that opportunity to look again. Absolutely. Southampton is a good example of where they are making substantial cuts. However, they see public health as something different they can do strategically. In fact, all the arguments around public health getting upstream are that unless you invest in public health they will not be able to make their books balance.

Q332 Rosie Cooper: I understand that. That is where the strategic point is good, but the reality is that we are here today. We have to get to 2013 and beyond and I think there are serious hiccups on that journey. I do not see any real signposts from the Department of Health that they are dealing with the "now". Without going into much detail—I can give you an example today—Liverpool City Council, when a person goes from a residential home to a nursing home, is, in essence, making a family pay an extra £100­odd for nursing care that is free. They are making the family pay. If they are doing that now, and that is totally outwith the rules, what fun they are going to have with this lot.

Professor Davies: We are designing an outcomes framework—we have consulted on it—which will be used to judge the outcomes, because we are trying not to tell local authorities how they should do their business, and, of course, there will be the health premium, particularly aimed at health inequalities. Would one of you pick up on that?

Anita Marsland: If I may I will go back to your point that I should know from my previous experience. My previous experience was working in Knowsley where we did join up the system. We did that over nine years ago. We found that we were able to reduce health inequalities and that there was much more ownership about some of those very difficult decisions. They are always very difficult decisions and, arguably, even more difficult now than previously. In that authority there was the real strength of working together. We did have a Health and Wellbeing Board all those years ago and we gave it teeth locally. The benefit of this reform is that the Health and Wellbeing Boards will be given teeth.

Q333 Rosie Cooper: What teeth are they? Can we see any? Can you tell me what those teeth are?

Anita Marsland: Now their powers are strengthened in terms of being able to challenge the clinical commissioning groups—

Chair: If we are going all through Health and Wellbeing Boards, we will never finish by lunch-time.

Q334 Rosie Cooper: No, absolutely. I cannot see any teeth that are worth their bite coming out of those powers. They can recommend, talk and do this and that, but they do not have a vote, a power or a veto. What use is all that?

Anita Marsland: They can challenge the clinical commissioning groups in terms of their plans, which will be very helpful. Having experience of working in the system where people genuinely did come together—they did not always agree about things but they came together—the Health and Wellbeing Boards certainly provide opportunity for that debate in some areas where it has not been the case thus far.

Q335 Rosie Cooper: I totally agree that it is an area where debate will take place, but not very much more. Can I very quickly finish by coming back and talking about how local authorities may circumvent your intention? You said you were intending to stop it. My question to you would be: how would you actually prevent them doing it? Also, I have a general question about the extent to which public health is subject to cuts in NHS management and administration. We now know that public health doctors or trainees will not be threatened, but everybody else is. What effect is that having on public health today?

Professor Harper: As to the first part about how we can stop it happening, a number of points have been made already, such as having the director of public health in the right place within the senior structure in the local authority. That will be critical because the director of public health will be the person whose responsibility it is to ensure delivery of those sorts of outcomes that I referred to earlier, but also to produce, on a statutory basis, a report on the health of their population. These are, together, the sorts of things that should help reduce that risk. Over the next two to three months, working towards the autumn, we will be continuing to do this work and in a number of other areas as well around outcomes, around the commissioning lines, the budgetary lines and the health premium that the CMO mentioned earlier. Working with local authorities and with our key partners, we would expect to be able to manage that risk. Of course, that is in the future. That is our intent. That is where we are now and we have quite a lot of work to do to be able to deliver that.

Q336 Rosie Cooper: Okay. What about cuts in NHS management and administration and how that affects public health today?

Professor Harper: The general principle that I know you will be very familiar with is that front-line services, as far as possible, are protected. As far as the rest of the administration is concerned, the whole system is subject, over the next three-year period, 2014­15, to a cut of the order of a third. That will apply equally—

Q337 Rosie Cooper: Except to trainees.

Professor Davies: I will have to come back on this.

Professor Harper: That will apply to the administration of Public Health England and the public health system as well.

Professor Davies: I will know, by the end of the week, the size of the problem. I will do my very best for those trainees because it is my responsibility and it is a waste of public money not to use them. I cannot guarantee people a job. Some of them might not be up to it, of course. I sincerely hope, if they are trained, that they are.

Chair: These are the joys of debate in the House of Commons. We have been going 700 years and we have not got to the conclusion yet. We go on to public health outcomes.

Q338 Mr Sharma: The Department is still working on the details of the public health outcomes framework, but are you able to indicate how the Department is working to refine the framework in response to the various concerns that have been expressed about it?

Professor Harper: Yes, certainly. There are a number of responses that you are alluding to through the consultation on the document that was published alongside or just after the public health White Paper. There was a great deal of support for the general approach. One of the key responses—a number have responded—said that they would like to see an alignment of the three outcomes frameworks: public health, the NHS and social care. That is something we are very mindful of and we are working towards getting as much alignment as is appropriate but recognising that they are there to do different things.

The other strong element of the response was the need to focus on health inequalities. These run right through four of the domains that were consulted upon. The fifth domain is health protection and resilience, and we can talk about that separately. Much of what was said was about choosing the right indicators. We included, therefore, in our consultation document, a number of indicators, but they were only ever there to act illustratively and to prompt discussion. As you rightly said, over the next few months, as with the funding and commissioning issues, we are going to be working and engaging with a range of key partners to develop our thinking on the right indicators. We are not there yet.

Q339 David Tredinnick: I would like to mention the domains. My understanding is that there was a consultation document published in December last year which proposed this outcomes framework and the divisions into domains. I would like to focus on what I have down as domain 3, health improvement—helping people to live healthy lifestyles, making healthy choices and reducing health inequalities, for example, by reducing smoking rates and increasing physical activity rates. Over the years I have chaired the Complementary and Alternative Medicine Group here, and have been an officer of it for about 20 years, and I have been part of the Food and Health Forum, but I am not going down that route today, Chairman. I would suggest to you that the key issue here is diet and food consumption. If you really want to improve people's general well-being you need them to cut back on fat consumption, probably meat consumption and to eat more vegetables. This is something that you need to put up there right at the top of the agenda. I would like you all to comment on that, please.

Professor Davies: You are absolutely right. The science is quite clear; the major cause of obesity and the consequential diseases relating to it is our diet. Physical activity plays a role in our health outcomes but a much smaller role in our overall size. Because it does play a role in our health outcomes, on Monday I launched the four UK CMO's physical activity guidelines. We do believe that diet is important and the Change4Life campaign and the Responsibility Deal have addressed that quite a bit. It is, again, one of the ways that local authorities can play a role: how they look at the provision of fruit and vegetables in their localities and their shops and how the whole system works locally. We would agree with you that it is very important.

Professor Newton: Yes, that is absolutely right. We know that diet is probably the second biggest cause of health inequalities. There was a recent study published showing that in people who do not smoke, obesity is the next biggest cause of health inequalities, so it is very important. It emphasises, again, the importance of an approach to public health that crosses all sectors of society. If you want to influence people's diet, the most effective way is through education. I would point to the work of the School Food Trust, for example, in trying to change children's food culture. There is evidence about how that could be done and there are a number of projects that have illustrated that.

If you are going to tackle something as fundamental as what we eat, you have to take a root­and­branch approach. That is the sort of thing that is easier to do if you are in a larger organisation that can, frankly, punch a heavier weight with all the big partners that you have to deal with, which is an argument for Public Health England. You will see where I am going with this. The other argument is for local authorities who, of course, have such a big role in education.

Coming back to your original point about the outcomes framework, if it does not cover diet and the consequences of diet, it will not be a public health outcomes framework.

Q340 David Tredinnick: From listening to professors of nutrition over a period of time, it seems pretty clear that those who change their diet then get improvements in the functioning of the body; their arteries clean themselves out gradually over time and their metabolism speeds up. That is why I think this is so important.

Chair: Good advice at the beginning of the summer recess.

Professor Harper: I have a very quick comment to follow up the points that have been made. The outcomes framework is a very important part of the new public health system. It is, though, only one part and I think you have already mentioned the Responsibility Deal. Within that there are specific pledges, as you will well know, about reducing salt, reducing trans-fats and increasing physical activity. With the outcomes framework itself, there are, under this particular domain, indicators—for the moment—for further discussion about increasing the number of people of healthy weight. Thus, it is absolutely embedded in the total approach that we are taking, but well recognised.

Q341 Valerie Vaz: You mentioned an advisory group. Who will you have on this advisory group? Are you going to have food manufacturers or alcohol producers on it? Who are you having on your advisory board?

Professor Davies: The reason I have not set it up, as I said earlier, was because we have not finally decided that between all of us. That is a new idea to me. I had not thought of having food manufacturers and everything on it. I wonder whether you would advise me to.

Q342 Valerie Vaz: I am sorry, do you want me to do your job? I am very happy to do that. Shall we swap?

Professor Davies: No. I am just interested in the provenance of your question.

Q343 Valerie Vaz: I am asking you a simple question: who are you going to have as your advisory group? We have heard that there are some people who have influence at the Department of Health who should not be part of it. I am wondering who you have on it. It is a simple, straightforward question. Please do not be defensive about what we say.

Professor Davies: No, I wasn't. I was interested in your advice.

Q344 Valerie Vaz: This is about public money. You referred to the fact that we are in austerity measures, but nobody asked for this reorganisation and there was a way to evolve all this restructuring very simply. The morale of people in the NHS is at rock bottom, I feel, given the evidence. We have heard from all four of you and it is extraordinary that nobody knows what is going on. It is quite scary because it is a third of the budget and all four of you sit here and say, "I don't know what is happening," and, "We don't know what is happening next week." It is no offence to you.

Chair: Let us get back to the membership of the advisory group.

Q345 Valerie Vaz: Professor Davies threw the question back at me. You are here to answer our questions. It was just a simple, straightforward question: who are you going to have on your advisory group? You have taken the decision to pick on infection when there are a huge number of other issues you could have picked on and it seems simple and straightforward for someone at the top of public health to pick something like that.

Professor Davies: Clearly there will be both academics, who bring one sort of expertise, and practitioners there. I am sorry if it was not proper protocol to ask your advice. Further than that, we have not decided. I want to make it work, which is why I am open to advice.

Valerie Vaz: I am very happy to advise you then.

Q346 Rosie Cooper: We have heard concerns about the risk in the proposed health premium, that it could act in a regressive way by rewarding wealthier areas, which have the least tractable health problems, and penalising poorer areas. I am an MP for West Lancashire where if you live in one area, you will die 10 years before people living in another area, around three miles away. What policy options is the Department looking at to obviate or mitigate that risk? If you are doing that, what are they? I am not only talking about the grand scale but actually down to, for example, my constituency where I have huge differences in health outcomes.

Professor Davies: It is complex and I agree that we have to do our best to get it right. David.

Professor Harper: I can give you the answer that I think you are not looking for, which is where we currently are. It is reiterating what I said earlier about the bigger funding issues. When we consulted on the health premium we had a number of responses, not least those in the area that you have indicated. Our intention is, as I think you are very well aware, to incentivise local authorities to tackle those areas where we can have a reduction in health inequalities. Of course, this is a huge issue and one we have not managed to tackle successfully so far, in spite of the best intentions of a vast array of very capable people. The health inequalities gap is still increasing, and that is not a surprise, given that the health of the more disadvantaged is improving but the rate at which the health status of the better-off groups is improving even more quickly. Thus, the gap is increasing.

This is something that is at the heart of the current Government's strategy for tackling health inequalities. Michael Marmot himself said, at a recent meeting I attended with him, that he was extremely pleased to see how the Government has responded through the public health White Paper, in a strategic sense, to address some of the key issues that he has been talking about for a very long time. How the health premium can be made to work is exactly what we are working on over the next one, two, three or four months. We will publish the shadow allocations, including the health premium, as intended and as reported in the various documents that you have had before you for shadow running of those health budgets from April next year.

Q347 Rosie Cooper: Forgive me, but what I have heard since I have been here this morning is a lot of change, intent, hope and whatever, but very little evidence­based change. All these changes are taking place. You don't have the evidence to back it up. You are trying to make this work based on a strategic objective that nobody could disagree with; we have never had any disagreement even before this reorganisation. Wouldn't the amount of money and effort that has gone into all this reorganisation have been better directed at issues such as this?

Professor Harper: No. I think on public health we have a clear position, and my apologies if it has not come across like that. In the funding and outcomes area, we have consulted. The consultations closed at the end of March. We have been assimilating all the responses, through the listening exercise as well, and we are developing policy. One of the very strong messages is, "Don't come to us with the answers." In the responses that we have had the people want to be able to play into the co­production—how these systems will work. That is what we are doing. We have said very clearly that we will be doing that over the next two to three months.

Q348 Rosie Cooper: If I come back to you in three months' time, you are going to tell me how this policy will affect the differing parts of my constituency.

Professor Harper: Specifically with the health premium. There is a timetable for various pieces of information that we are working on over the next two to three months. With the funding, we will be in a position, we expect, to be able to issue shadow allocations for the start of the next financial year. That is the timetable that we have talked about and that people are working to.

Rosie Cooper: Thank you.

Q349 Mr Sharma: There seems to be some confusion about the extent to which funding for Public Health Observatories has been cut in 2011­12. In an Adjournment debate on 17 May 2011, the Public Health Minister referred to "The Government's contribution of £12 million to the observatories". Can you explain to us what changes have been made to the observatories budget this year and exactly how that £12 million figure was arrived at?

Professor Newton: I will come in there, Chairman, if I may. I should say, by the way, that I spoke to the secretariat and it might be helpful if I give you a written comment as well, since there are figures involved, but I can briefly explain now as well. If I take the overall approach to the funding first, in recent years the Public Health Observatories have received two types of funding from the Department of Health. The first is a core grant to support reasonable health intelligence infrastructure and the second is funding to support specific programmes of work—specific projects, such as the health profiles or the specialist observatories, and many of the other things that you will be familiar with. In 2010­11 these were, respectively, £5.1 million for the infrastructure and £7 million for the specific projects, the specialist observatories. That totals £12 million. That was for last year. I can give you the list of what made up the £7 million. In this year, 2011­12, the budget committed by the Department to health intelligence infrastructure is the same—£6.5 million—as it was last year. As last year, that budget will be used to support the Public Health Observatories but also to deliver some other public health intelligence functions, such as congenital anomaly registers and health impact assessment gateway projects. It is not only for the Public Health Observatories, but it is there for the Public Health Observatories and it is the same as last year. This year, however, we have asked the Public Health Observatories to work more in an integrated national approach. In fact, in different roles, I have been having that conversation with them for the last two to three years and there was widespread acceptance that the Public Health Observatories should be moving to a national structure. This recognises the change or move away from regions themselves, but particularly regional public health programmes that are not now funded. The requirement, and in fact the experience, is that the observatories have worked extremely well when they have taken national leader roles, things like the specialist observatories. What we have asked them to do is develop a single integrated work plan and Professor Brian Ferguson, when he was here, indicated that he was working on that. He has been working on it for a year. We asked him for it, in fact, in March this year because we wanted to base this year's funding on it. He has told me that it will be ready by the end of July. While we are waiting for that programme, we have allocated £4 million to the observatories for this year for the infrastructure function. It is an unspecified amount upfront to the observatories which they have—guaranteed—for the whole year. If, when we have received it, the plan requires more than that for the observatories to deliver it, the budget is available to fund the plan. We think the move to a national integrated approach will be efficient. For example, each observatory currently supports their own website. In addition, there is APHO's website. That is 10 websites pointing people to largely similar resources, so we think there are efficiencies from this single integrated work plan. However, I stress that the budget remains the same and it is available to support the observatories if they need it. We are obviously reluctant to support a model that is going to be left slightly out of date by all the other changes happening across the public health system. In terms of the rest of the money, in other words, the specific projects, the specialist observatories and so on, that is business as usual as far as the Department is concerned. The figure, so far, is that £5.2 million has been confirmed for this year. I should say, by the way, that the £4 million confirmed for this year already would represent a reduction of 23% in the core budget if they receive no more money for the rest of the year. Obviously, if they do receive more money as the year goes down, that reduction would be less than 23%. In terms of the special projects, the reduction is, as it happens, also equivalent to 23% compared to last year. Some of that is because programmes have come to an end; they were three­year programmes that have reached their end. Some projects have moved; for example, the National Library for Public Health has moved to NICE. The same work is being done but not through the Public Health Observatories, so there is a reduction in the money going to the observatories. Going back to the original figures, the money that I have mentioned is the money the observatories get from the Department of Health. In addition, in 2010­11, the observatories received £3.7 million from other Government Departments and from other sources such as the NHS Information Centre, making up their total budget.

Q350 Mr Sharma: Can you tell us what the role is of the Working Group on Information and Intelligence for Public Health, which you chair, and can you summarise what it has achieved so far?

Professor Newton: Following the White Paper and the recognition of the significant change to the public health delivery system, there has been widespread recognition—the policy papers published have clearly said this—that information, intelligence and evidence have to be at the heart of public health. We have been asked to set up a group representing all the different interested parties, including, for example, Cancer Registries, Public Health Observatories, the NHS Information Centre, the Health Protection Agency and the National Treatment Agency, to consider three things: what should the information and intelligence function of Public Health England do—what should be the products; how we work from what we have now to what we need in the future; and ensuring that essential products are protected in the transition. Thus, there are three distinct functions: designing the future, designing the transition and ensuring that nothing gets dropped on the way.

In terms of what we have achieved, we thought the right way to do this was to start with the products—to decide what the new system needs rather than starting with the structures. We have come up with a draft list of products that we have put out for consultation—I think we have had three weeks of consultation so far—and we have had, broadly, a very positive response. We set ourselves a target of, by September, having agreement from all the parties involved that this is the plan, these are the products and then we will start working on implementation from September. We already have nine draft projects.

Chair: Thank you very much. We have two short questions that I would like to cover and then we need to move on. Rosie wants to ask a question about NICE.

Q351 Rosie Cooper: Absolutely. In your evidence to my colleague you indicated that some of the work of the observatories was being done by NICE. I understand that NICE is supposed to have a continuing role in evaluating public health interventions, but we have recently heard from a member of NICE's Public Health Interventions Advisory Committee that its workload has reduced dramatically and that, in fact, it has not met since December last year and usually they meet monthly. Everybody is a bit mystified. Can you tell me what is going on? If you are saying some of the work is going to NICE and NICE has not met since last December, here we are, six months later, and there is a bit of a gap.

Professor Newton: I can tell you about the areas in which I am involved, but I will pass over to my colleagues for the more general picture. The work I am talking about is the National Library for Public Health. NICE currently provides the National Library for Health, which covers all the other areas, so it makes sense. In fact, the National Library for Public Health started with NICE, has moved through various places and is now back with NICE. It makes sense.

Q352 Rosie Cooper: Why has this advisory board not met since last December?

Professor Newton: I am a member of the NICE public health reference group, which meets monthly, and is a very active group, but I will hand over to David who may know more, or indeed—

Professor Davies: I do not know anything about their internal workings. I don't know whether you do.

Professor Harper: No. I can say that we are meeting regularly with the head of public health in NICE. Some of the work they have done recently we discussed with them and decided that it is better to take a different approach for some of the guidelines. It could be that that is one of the reasons why the advisory board has not met, but I am not sure of the advisory board itself. What we have said consistently throughout is that NICE will play this key role but we need to redefine what that role is for public health because we want to have the whole system, information and intelligence, properly integrated. I do not know why the advisory board has not met.

Rosie Cooper: It sounds like a Polo mint intervention: there's a great big hole through the middle. Thank you.

Chair: David Tredinnick wants to ask a question about emergency preparedness and resilience.

Q353 David Tredinnick: The whole structure for dealing with emergencies seems to be going through a period or process of considerable change. The Department's memorandum of evidence says that "Arrangements for emergency preparedness and response are to be strengthened and made less fragmented" in the new system. How is that going to work and how will the roles of the Secretary of State and the Chief Medical Officer change?

Professor Harper: We have spent a considerable amount of time already working with the key parts of the system. One of the big challenges has been having the current roles and responsibilities properly defined. In the past, we have had difficulties because of a lack of clarity. One of the huge advantages of the new system will be the clarity that has not been there to date. The Secretary of State, ultimately, will be responsible for emergency preparedness, resilience and response and the new system, we expect, subject to some final agreement—not least by Ministers—will have that clarity of parallel lines from the NHS Commissioning Board side and from Public Health England. Each of those two parts of the system will be responsible, in public health terms, for their own preparedness and for assuring that they have plans in place and are able to respond. Wherever NHS resources are used, the NHS Commissioning Board will be responsible and wherever public health is in the lead, then Public Health England will be responsible. That key element of the role at the front line of the director of public health will also be properly defined with the clarity that we have not had.

Part of what is going to happen in terms of the infrastructure—as people move around the system, and the changes that have been referred to several times this morning—is that it has already been agreed that those people responsible for emergency response and planning will be identified, where they have not already been, at the earliest opportunity during this transition period. Special attention will be paid to protect those posts so that as new organisations are coming along, the people that are moving through the system will be a part of the new system through transition, recognising those risks, so that we get to April 2013 and the new system will be ready to go with the right people in the right places.

Q354 David Tredinnick: Soldiers often talk about "the fog of war". It is almost as if you are talking about the fog of emergencies. It is the second time today we have heard that at the Department you are having to investigate what different areas in the Department's purview comprise and how they work. I wonder if you are not dealing with a very difficult situation where it has been very unclear who is doing what out there and a lot of this has been hanging together in a rather haphazard way. Do you think that is fair?

Professor Harper: No, I do not think it is fair, if I may say so, and I am sure Sally Davies will want to comment as well. The system has been tried and tested and has been shown to work extremely effectively in an emergency. By "emergency" we have to be slightly careful. There is a huge spectrum of different emergencies. People consider it everything from a local food­borne disease outbreak as an incident that requires the sort of processes around it that we are very familiar with all the way through to the national emergency where the Department of State, the Secretary of State himself, will hold the ring and bring together the different parts of the system.

What has happened to date has been effective. What will happen in the future, I think, will be even more effective and the risk will be reduced. This is about having the right powers and links between the different organisations and very clear concepts of operations—very clearly knowing what the relationships are at all levels between the different parts of the system—right through to that critical front­line piece, which is, as somebody already mentioned today, the alignment not just at the sub­national level but at the very local level for emergency preparedness. The Secretary of State has already said very clearly that he would like that alignment between the Commissioning Board, Public Health England and, very importantly, between the local resilience fora on the DCLG side of the business.

Q355 David Tredinnick: Thank you very much for that detailed explanation. What plans, if any, are there for the designation of bodies as Category 1 responders under the Civil Contingencies Act 2004?

Professor Harper: The bodies that are currently designated as Category 1 responders, such as the Health Protection Agency, would suggest very strongly, and we work on that basis, therefore, that Public Health England will be a Category 1 responder. The blue­light services, local authorities in their own right, are Category 1 responders in some instances. We are working through Category 2 responders as we speak. The constituent parts will not change. Ambulance services will be Category 1 responders in the new system in just the way that they are currently.

Chair: At that point, we have overrun, significantly, where we were aiming. Thank you very much for coming this morning. We have enjoyed meeting you and we have enjoyed the debates. We will reflect on what you had to say. Thank you very much indeed.

1   Witness correction: The appointments process for a Chief Executive starts this autumn, and a Chief Executive will be appointed by early 2012. Back

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