Public Health - Health Committee Contents

Examination of Witnesses (Question Numbers 410-535)

Anne Milton MP and Professor David R Harper CBE

19 July 2011

Q410 Chair: Welcome to the Committee and thank you for coming. Welcome back to Professor Harper. This is becoming a habit. You are very welcome. I understand, Minister, that you would like to start off with a statement to the Committee, which we look forward to.

Anne Milton: I will not try the Committee's patience by saying very much, but I have just two things to say. First of all—whether I have to or not is not quite the point—I should mention that my husband is a public health physician, although not working as a director of public health. I feel it is important to have that on the record. Secondly, I would like to put in context what public health means for me in my ministerial role. I feel incredibly privileged to have responsibility for this. It is important to remember that successive Governments have tried to improve the public's health. Generally—overall—that has been the case, but the inequalities in health have widened. That is certainly not due to a lack of will on the part of successive Governments. The point is that they have all tried very hard and, in fact, the inequalities have got greater. That is because it is extremely difficult to do something about that and bring about the change that is needed. Thus, for me, this is a real one­off opportunity. We can be quite blasé about the figures surrounding health inequalities but they are truly shocking. If we really take them to heart and consider how they might affect our particular constituents, the fact you might live seven years less if you live in a particular area than another is dreadful. As I say, for me, this is a fantastic opportunity to try and make a dent. We will not turn round the fortunes of everybody in the lifetime of this Parliament, but I hope we set in train the structures and the philosophy needed to start to turn round what is like a great big tanker, and it is going to be slow. That is all I want to say at this stage.

Q411 Chair: Thank you for that. I do not think there will be any disagreement with the sentiment you express from any part of the Committee or indeed much broader than that.

That feeds quite nicely into the first question I was proposing to ask. What is the problem, essentially, that the changes in the structure of public health policy are designed to solve? Does it follow, from what you have said, that your prime motivation in this is to address health inequalities, or are there other issues in public health that you think also lie behind the Government's proposed changes in the delivery of public health policy?

Anne Milton: Health inequalities sit out there. We are and have continued to become healthier as a population, of course, which is due to diet and a number of other things. However, it is those inequalities we need to address first and foremost. What some of the changes in how we look at public health will achieve and what we have the opportunity of getting is a real understanding that intervention from the health services—in its broadest sense—is insufficient. If you want to improve the public's health, you have to bring about social and economic change and you need action from a wide variety of Government Departments and different local authorities—from parish level up to Government. There is not one single magic bullet for this. I am besieged by people who feel they have the answer. There is no one answer. One is always faced with a series of tools in the box. What is important is to employ the right tools.

Q412 Chair: It would also be said, would it not, that health inequalities are indeed an issue—and you have identified there are quite a lot of statistics that illustrate they are an issue—but you can solve inequality in any set of circumstances in two ways: one by raising the performance at the bottom of the heap and the other by restraining progress at the top of the heap? I wonder where the Government is. Should we be allowing the best to get better as quickly as possible and then narrow the gap with that, or should we be focusing specifically on inequalities rather than on the average?

Anne Milton: There has always been debate in the public health professions about that. In fact, they would argue that you have to shift the whole cohort to a better point. We want to put a focus on improving the health of the poorest fastest. It is not a matter of necessarily slowing down the improvements in health at the top—the people who are better off, if you like—it is also about speeding up the improvement of the health of the poorest. It is putting the foot on the accelerator for those people and trying to address some of the reasons why their health is poor.

Q413 Chair: Indeed. If that is the objective, to "put the foot on the accelerator", to use your phrase, for the people for whom health outcomes are poorest, what are the key elements in the changes being introduced that you think most empower that objective?

Anne Milton: It would be the move back into local authorities because, of course, public health has a proud tradition and history within local government. It is putting it there, for which—and I try to spend as much time as possible going around the country—there is widespread support. I do not think I have heard any dissent on that for that reason. That way you harness action at every single level and for every single—I hate the word "partner"—organisation that can join together to make the difference, because it is not an intervention from the health services alone.

Chair: Thank you.

Q414 Dr Wollaston: I appreciate the delivery and the objective. I think it is widely felt the issue is the independence of directors of public health; Public Health England. Public Health England will be an executive agency and, therefore, still a civil service body. How do you respond to the argument that it would be more independent if it were a special health authority?

Anne Milton: I am not the person to answer that question, Dr Wollaston, inasmuch as it is a technical one. The technicalities of special health authorities and executive agencies are something for officials. For me, what matters is the outcome. You are absolutely right that what we want is something independent and rigorous—whatever structure best achieves that. I understand that the executive agency will give that independence, which I think is very important, and that separation, if you like. It is extremely important, particularly in this area where we are treading on people's freedoms, sometimes, in the cases of health protection, and stepping into people's lives a little to improve their health as we do that, that the foundation for any intervention or action we take, or for any advice we give, has absolute public confidence. Therefore, it is important that it is independent and I understand an executive agency is the best way to achieve that.

Q415 Dr Wollaston: I understand those arguments, but the other issue is this: if public health doctors within Public Health England are directly critical of Government policy, how free will they be to make very direct open and public criticisms?

Anne Milton: Professionally, completely free. I do not doubt that they will.

Q416 Dr Wollaston: But will they within a public arena? For example, sometimes people are constrained, if they are working in the Department of Health, from being directly critical of Government policy. What the public want to see is directors of public health and Public Health England being able to directly criticise the Government if they feel policy is not going in the right direction.

Anne Milton: There will be people employed in Public Health England and people employed by the local authorities. Those will be the joint appointments. There are different pressures on both and I think your point is quite well made. If my history serves me correctly, this came up in the last century actually. Protecting medical officers of health—or whatever they were called at the time—from local business interests was the issue there, and indeed that would persist. A good example would be, maybe, a seaside town where local people derived some of their income from, say, slot machines, casinos or nightclubs, and the local director of public health being very worried about the impact those are having. So there is that conflict.

One of the reasons they will be joint appointments is to make sure we protect directors of public health. The Secretary of State would be involved in any dismissal or any appointment. Within the Department itself, the executive agency, I gather, is what will protect them. But, as you say, it is important. I do not have any doubt that they will be free to express their view.

Q417 Dr Wollaston: For example, if they were critical of Government policy, perhaps in having partnership arrangements with, say, Diageo or drinks companies, would they be free to make those public criticisms?

Anne Milton: Yes, they would be, unless they are part of the civil service and, with the civil service, I am really straying into areas I do not know.

Q418 Dr Wollaston: But that is the point—

Anne Milton: They would not be civil servants, I understand.

Q419 Dr Wollaston: —if they are part of the civil service. They are not going to be, directly, civil servants, but it is not going to be as much independence as they would have if they were a special health authority.

Anne Milton: No. I understand. I don't know—

Q420 Dr Wollaston: We saw this in the last Government when Professor Nutt was directly critical of Government policy because he was an adviser and sacked. There is a precedent for people being dismissed if they criticise Government policy, but what the public want to see is Public Health England being able to be independent and able to directly criticise the Government's policy if they feel strongly.

Anne Milton: There are several issues that have now come up. As to whether a special health authority gives more independence than an executive agency, my understanding is that, as an executive agency, they would be free to voice their views. They are not civil servants in the purest sense, and civil servants are restricted in what they can do. The Professor Nutt thing was completely separate. They were an advisory committee and free to say, think and feel what they wanted. I could not comment on what happened in the previous Government's time, but I go back to the fact that, from my point of view, and as far as policy is concerned, what is absolutely critical is that independence. What the public has to have is confidence, and the public are, rightly, always very suspicious of what Governments say and vested interests. It could not be more topical at the moment than at any other time. Thus, it is very important that the public have confidence. It is not only the case that there is independence but that it is seen to be independent.

Q421 Dr Wollaston: You are confident that they would be able to be critical if they felt strongly about it.

Anne Milton: I can certainly ask officials to send you a specific note on the precise differences between executive agencies and special health authorities.[1]

Q422 Chair: Given what you have said—and Professor Harper is sat alongside you—and that you have stressed the importance of independence, it would not be unfair to say it flows from that that the choice between executive agency and special health authority would at least be influenced by which gives greater assurance of independence.

Anne Milton: Yes.

Q423 Chair: Against that test, how is it that executive agency status gives more independence than special health authority?

Professor Harper: Good morning. There are a number of different points I would like to make very briefly, if I could, to supplement what the Minister has said. First of all, on the different parts of the new system, if we take directors of public health in local authorities, they will have a right and a requirement to publish, on a statutory basis, an annual report on the health of their population. They will be expressing their view without fear or favour. That is the intention and, subject to the successful passage of the Bill through Parliament, that will be the case. They will be producing their statutory report and will be held to account for doing that. So there is independence there.

With Public Health England, which we have announced will be set up as an executive agency, one of the helpful comparisons is the Medicines and Healthcare products Regulatory Agency. That is an executive agency, staffed, largely, by civil servants as an executive agency, but the vast majority of people would see the MHRA as independent regulators. That perception is vitally important. The governance structure that is set up and the mandate given to them ensures, alongside professional requirements and professional stewardship, that the MHRA is able to act in that independent way as a regulator of those products. The comparison I would draw for the executive agency that will become Public Health England is exactly with the MHRA.

Q424 Chair: Can I push you on that? I have heard the Government say they prefer executive agency. I have heard others say they prefer special health authority. I have not, in truth, heard an argument from either side that justifies their preference. The Minister was saying that she was looking for the greatest possible level of security of the independence. If that is the test, why does that test lead to one conclusion rather than the other, apart from an instinctive preference?

Professor Harper: I might have a very quick go at that and then I am sure the Minister will want to say something more. With a special health authority—this is an NHS organisation—the way special health authorities have worked in the past is that some of them have been very long standing. The intention in the future is that they are time-limited. That is an important distinction. Also, Ministers are very much of the view that this is an opportunity to open up public health to everybody. It is not being driven from the National Health Service. That is a very important feature of the proposals that you are familiar with from the policy statement.

Q425 Chair: Did you want to come in, Minister?

Anne Milton: No. I think Professor Harper has picked up on the point that I made, that it has to be independent and be seen to be independent. That is extremely important.

Q426 Rosie Cooper: Could you describe to me the structure of Public Health England? Who will be on it? I just want a rough idea. Frankly, I understand the distinctions that we are making in here, and I understand the idea of independence, but if you were to go to the general public, they wouldn't give a tinker's about any of these detailed bits. They would look at what name appears. With a special health authority, at least half the people on it would be lay people with a lay chair. Would you envisage this being set up in such a way?

Professor Harper: No, Chair, if that question is directed to me. The intention is not to have a non­executive board. It is absolutely that the Chief Executive will be accountable to the Permanent Secretary of the Department and then to the Secretary of State.

Q427 Rosie Cooper: People out there will not see that as independent. How can that be?

Professor Harper: If you said who was in the new Public Health England—the organisations or the functions of the organisations being brought together—if we take the Health Protection Agency, there are of the order of 4,000 staff in the Health Protection Agency. Many of them are laboratory scientists working in a very specialist area, and it is very important to protect—

Q428 Rosie Cooper: Can you describe the structure of the executive agency? What do you see making it up?

Professor Harper: The constituent parts, or the functions, coming from the Health Protection Agency, the National Treatment Agency and from those parts of primary care dealing with public health that will not, in the final structure, be in local authorities—so perhaps some of the public health specialists. What is being worked through at the moment is exactly what you are asking about, which is the operating model and the detail of the structure for Public Health England. What we have said, very clearly, is that the chief executive should be in post from the beginning of the next financial year. During that key transition year, the chief executive will be helping to shape the new organisation.

Anne Milton: Could I come in, Chairman? The crucial thing—and you are absolutely right to talk about how the general public couldn't care but they want it to be independent—is that public health for the general public is going to be about the local authorities, be that unitary authorities or two­tier authorities. That is where public health is going to happen. For them, it is about their health and well-being. What matters to the general public is the outcome of it all.

Q429 Rosie Cooper: Absolutely. When things are going well, I can see that that model and solution is absolutely fine. The minute you have a real crisis and a difference of opinion, this model may not have the confidence of the public because, in their eyes, it would not be seen to be independent. Everybody who is feeding into it is part of the NHS structure somewhere, however loosely you would describe that, and eventually reporting straight through to the Secretary of State. If you are basing this on independence, this model is not necessarily going to be perceived as giving you the qualities you want.

Anne Milton: Things are not going well. That is a point. One of the reasons for these changes is that things have not gone well. I hesitate to point the finger—and I wouldn't because it is very difficult—but things are not going well. Despite the fact that the overall health of the population has got better, inequalities have got worse. We have problems with alcohol, persistent problems with smoking­related disease and problems with people not exercising enough. Things are not going well. We do not need to set up structures. We need to change that and we need to make sure we have the form to produce the functions we want, which is about improving the health of the local population.

As far as the public is concerned, in the case of public protection—E.coli outbreaks or a terrorist attack or something like that—the public have to have confidence that Government can act. The direct line of sight that the Secretary of State has talked about, and we have talked about, is going to be very important—accountabilities and who is responsible for whatever. In terms of improving public health, much of it is going to happen on a local level, and rightly so.

Q430 Dr Poulter: I wanted to pick up on a couple of issues. First of all, as to Public Health England, there is going to be a role here, you say, in regulation. There is also going to be a role, I presume, in setting leadership on some sort of national level in terms of dealing with the interrelationship with these sub­national hubs in the regions and setting some sort of focus for those local authorities in what their agenda should be. Are you envisaging there is going to be that leadership role for Public Health England in actually working to direct policy in some ways for those sub­national regional hubs?

Anne Milton: The leadership role of public health professionals is going to be absolutely critical. As a director of public health said to me when we first started out on this, "It feels like Christmas came early," because public health has tended to be a little bit in the cupboard. Most directors of public health would produce an annual report and it would collect dust on all the stakeholders' shelves for the next year, when they would write another one. Everybody would maybe read it once. If you had an imaginative council, particularly in two­tiered authorities, they might have one debate on it or a presentation, but that would be it. The leadership role and the facilitative role of public health are going to be critical. We will look both to regional hubs and local areas to do that.

Q431 Dr Poulter: To clarify this, we have established that there is a leadership role for Public Health England to set a focus—an agenda—which will be delivered through local hubs and local authorities.

Anne Milton: Yes.

Q432 Dr Poulter: Obviously, that will be with some local nuancing. Is that correct?

Anne Milton: Yes, and quite a lot of local nuancing. As Members of Parliament, we only need to think of our local areas to see how different they are to the one next door to realise how much there should be.

Q433 Dr Poulter: Absolutely. It is very clear that the public health agenda in Eastbourne, with an ageing population, would be very different from Bradford, for example, with issues, maybe, with cardiovascular disease. Nevertheless, there is an issue on that and there has been a problem in the public sector sometimes around mechanisms of failure. Let us say, for example, we have identified and acknowledged there are big problems with health care inequalities, but there is a feeling that some of the criteria or problems we have identified with health care inequalities have not been addressed. What mechanisms will there be in place to create change or to improve delivery of public health policy in terms of Public Health England if we continue to fail to meet these challenges we have identified in the public health agenda, particularly around health care inequalities?

Anne Milton: I am not sure I am entirely clear what you are asking.

Q434 Dr Poulter: For example, there is an issue about dealing with failure in the public sector, and sometimes public sector bodies when there has been a failure, say, on a local council or elsewhere, but I am talking now particularly about replacing the people who have not been delivering what they should be delivering. How are we going to do that in terms of Public Health England if you are having an arm's length body, which I am not saying is necessarily is a bad idea?

Anne Milton: I am going to hand over to Professor Harper to talk about the centre bit. Certainly, locally, you have an elected body so you can vote them in and vote them out, and there are going to be outcomes frameworks against which the local council will be judged. In my dreams, I imagine local councillors in the council chamber fighting about the fact that Councillor A's residents live less long than Councillor B's instead of whether Mrs Smith has a porch on her house. You have that democratic accountability, which is, in many ways, a failure mechanism and, as many ex­local councillors will tell you, can actually be quite effective.

Professor Harper can maybe talk about failure at the centre. I don't think we deal with it very well, do we?

Q435 Dr Poulter: This is what I am trying to get at.

Anne Milton: It is across Government. I think it is wider than the Department of Health.

Dr Poulter: It is wider than the Department of Health.

Anne Milton: Very much so.

Q436 Dr Poulter: Let us say we have accepted that a key issue for health care is tackling the public health agenda, smoking, alcohol and the health care inequalities you have identified, but we decided that Public Health England is not necessarily helping to deliver some of those objectives. What mechanisms does the Secretary of State have in place, if we do set up an arm's length body, to intervene and act?

Professor Harper: The key points are about the differences in this context between the health improvement side of public health and the health protection side of public health. What we have done with Public Health England—or the intention of Ministers—is to set up, with a clear line of sight on health protection, delivery through Public Health England. With health improvement, the delivery is through the front line, through local authorities, and there are the local authority mechanisms to deal with failure. That is not a central Government issue. If you take health protection and Public Health England, the main role of Public Health England in health improvement will be to provide, along with organisations such as NICE, that authoritative source of evidence, advice and evidence­based interventions to inform how the local authorities and the DsPH in local authorities deliver what is required to meet the outcomes that are set, centrally, by the Secretary of State.

The Secretary of State will be setting the outcomes framework. There will be a number of outcomes, I have no doubt, that local authorities will want to set for their own purposes, and Public Health England will be providing information and intelligence, through the Public Health Observatories and so on, to help local authorities in the health improvement area deliver what they need to deliver. It is different on the health protection side, and sometimes it is helpful to make that distinction, where Public Health England will be responsible for leading public health emergencies. We can say more, later, about the NHS side of the business if that is of interest to the Committee, but it is quite an important distinction to make.

Q437 David Tredinnick: Following on from the points that have been made, I would like to ask you a little about the status of the chief officers—the new directors of public health. Concerns have been expressed by public health bodies that the directors of public health should be appropriately trained and qualified; they must be of an appropriately senior level; and they should be free to speak out independently. Are you confident that these chief officers will have that status? I am mindful of the fact the Command Paper says that the Government "would expect the DPH to be of Chief Officer status with direct accountability to the Chief Executive for the delivery of local authority public health functions." What happens if a council says, "We don't agree with that"? Your Command Paper says the Government "would expect". It does not say "we intend to require" that the director of public health will be of chief officer status. What are you going to do if a council says, "We don't agree with that. We don't think he should have that status"? If they do not agree to it, then you are going to have somebody, I would suggest to you, who does not have the clout to get the job done.

Anne Milton: There are two issues. Public health professionals, both medical and non­medical, have been right to raise the issue of status because it is quite important and local authorities are quite smart organisations. Officers in local government organisations, particularly the unitary authorities, are quite sharp. I am very aware of the fact—and I have talked to the Faculty about this—that we are going to need to do quite a lot of skills development of directors of public health to ensure that they can take on that challenge. Therefore, status matters and we would expect them to report to the chief officer—I will come to the point you make—but that in itself, of course, is not enough. We are continuing to look at this and whether we mandate it or not. I think we still have a window on that. In fairness, the more important point is whether they have the skills, because whether they report to the Chief Executive, as I say—although that status is important—in itself is not enough. That is for sure.

Q438 David Tredinnick: Thank you. On that point, we have had a debate in previous sessions about the proper qualifications: should they be medical qualifications or other qualifications? The balance of feeling was that they should not just be exclusively medically qualified. My recollection is that we were told there was an increasing number of those not medically qualified. Professor Harper is nodding his head, so my recollection appears to be correct. Another issue is about what happens if everything goes wrong. At the moment a local authority only has to consult the Secretary of State before sacking its director of public health and social care. Why will the Secretary of State not have a power of veto, which was the case—I think I am right in saying—with medical officers of health before the 1974 reforms? Why are you not taking those powers as a safeguard?

Anne Milton: If you think that there is power in localism, then localism must prevail. There are going to be a number of safeguards out there to ensure that directors of public health are protected. One is that there is going to be an outcomes framework. If a director of public health is not performing the job for which they were employed, the local authority would want to take action. If we feel they are being treated unfairly because they have given advice the local council does not want, the proof of the pudding will be on how the local authority is performing against an outcomes framework. There is an annual report in the outcomes framework and I think they are going to be two very powerful tools. You also have a body of elected councillors.

I accept the fact, Chairman, that I am an eternal optimist, but local authorities are going to want to improve the public's health and there is going to be the support, in terms of evidence and rigour, from Public Health England. As I say, we want to make sure that directors of public health feel they are free to give the advice they want and take the action they need, but the Secretary of State will have to be consulted if they are dismissed, which is the protection in there.

Q439 David Tredinnick: Chair, I do not propose to proceed on this line any further. I will move on to funding unless any colleague wishes to come in. The Command Paper confirms that the Government intends to ring-fence the public health funding allocation for local authorities. We heard from Professor Harper last week that public health was subject to management and administration cuts but that "front­line services, as far as possible, are protected." Can you tell the Committee, please, exactly which aspects of public health are being defined as "front­line services"? Could you elaborate on where you see the division between front-line and, shall we say, second­line services?

Anne Milton: I would see it in very simple terms. Front­line services are actions that deliver improvements in public health, or certainly attempt to. Some of the time scales on public health improvements are very long. The money will be ring-fenced—you are quite right—for the first time. Whereas, previously, we have seen money filched away for other things—not necessarily unworthy things, but always public health has been the poor relative and it has been very easy money to take away—now there will be that fence around it.

Q440 David Tredinnick: What I am getting at is this. If you say you are going to ring-fence front­line services but that management will be subject to cuts, somewhere in the middle there is a very vulnerable area of health care provision, if reductions have to be made.

Anne Milton: Health care services and provision is not really in my remit. That is straying. Maybe I am misunderstanding, Chairman. You are looking as if I am misunderstanding.

Q441 Chair: There is quite a simple issue at the heart of this. On the one hand, we have a proposition that the funding will be ring-fenced and, on the other hand, a lack of clarity about what services are required to be delivered. Ring-fencing funding for an indeterminate service seems quite difficult.

Professor Harper: I was going to give an example, Chairman, but having heard the comment, it might not be as useful. To me, it is a very clear example of what I would classify as a front­line service. A consultant in communicable disease control currently employed by the Health Protection Agency will, in the future, one would expect, become part of Public Health England. Up until the creation of the Health Protection Agency, they were providing a front­line NHS service. They have moved into the Health Protection Agency and continue to provide the same service and a proper officer role for local authorities and so on. They are very clearly, to me, front line. There will be, at the other end—if you consider this to be a spectrum perhaps—people involved in the management of public health. Those are the people it is considered, along with all the other management cuts being made, should be subject to those cuts across the National Health Service and the public sector more widely. There will also be a group in the middle providing essential support to front­line services, and it could be laboratory diagnostic work. As the operating model for Public Health England and for the system is developed over the next few months, some of that will become much clearer. However, there will inevitably, on this spectrum, be the bit in the middle that I think you indicated.

Q442 David Tredinnick: Thank you very much. Minister?

Anne Milton: I apologise for not entirely understanding it. As Professor Harper says, the bit in the middle and providing support to front­line services is the more tricky area.

Q443 David Tredinnick: I have a last line of questioning about proportions—how the money will be divided up. What proportions of the public health budget do you envisage will be allocated to, (a) local authorities, (b) Public Health England, and (c) the NHS Commissioning Board? How is the cake going to be chopped up, please—or cut up, perhaps I should say?

Anne Milton: "Chopped" and "cut" are the same. We are working on that at the moment and, of course, it has not been an easy task to extrapolate exactly how much is currently being spent on public health. One of the difficulties is that it has been a moving feast because it has not been ring-fenced before. What we are very determined to achieve, in line with everything else we are doing within health, is to make sure, as Professor Harper said and you highlighted, that the maximum is getting to the front line to get the improvement in public health that we want. We need sufficient in Public Health England to ensure that it is adequately resourced to provide the leadership from the centre and the rigour and the evidence base that is needed to assist directors of public health and all those employed in public health locally. But this is a work in progress at the moment.

Q444 David Tredinnick: In a phrase, it is work in progress.

Anne Milton: Yes.

David Tredinnick: Thank you very much.

Professor Harper: May I make one small additional comment, to reiterate some of what I said last time. Over the next few months, particularly as far as the allocations to local authorities are concerned, including details of how the health premium will work, that will be developed so that shadow allocations can be made for the start of the next financial year for local authorities. Alongside that, there is work going on to see how much is necessary for Public Health England and, indeed, how much will need to be channelled through the NHS Commissioning Board to deliver the likes of immunisation programmes and so on.

Q445 Dr Wollaston: Going back to the issue of ring-fencing, because the definition of public health can be very wide if you look at the Marmot report, what if an authority decided that their top priority was housing? Could they make a decision to divert public health money into housing or other projects?

Anne Milton: What they are going to be judged on is the outcomes framework. Fundamentally, that is the lever. I have been quite impressed with some of the innovative ways of working that I have seen local authorities doing already without a public health budget. If we accept the fact that public health is everybody's business—and you are right to bring up housing because the association between housing and health is a very long and established one—the outcomes framework is what will drive it. Sadly, we do not have that in front of you at the moment. Within those five domains, that is going to be very important.

Q446 Dr Wollaston: They will be very much constrained within the outcomes framework by your definition of "front line".

Anne Milton: Yes. The flexibility of local authorities is going to be quite important and I can see differences between unitary authorities, but I can also see unitary and two­tier authorities doing this completely differently. Although responsibility will lie with upper­tier authorities, I can see some devolution of that budget down to the second tier, without a doubt. To improve the public's health, you have to have a very nuanced system and the idea is that it will be driven locally.

Q447 Rosie Cooper: Can we get to the nub of this, which is that, given a time of constrained financial resources, it is going to be very difficult for local authorities in the next few years. We have had public health academics and people working with unitary authorities who have described 20 mile­an­hour zones outside schools as a public health measure and there is a fear that we will get to the point at which filling in potholes will become a public health exercise because it saves lives. In reality, there will be some measure of local authorities using the public health ring­fenced budget to fulfil their core function.

Anne Milton: Absolutely. I know there is nervousness, but there are two sides to this. There is nervousness but there is also seeing an opportunity to be more imaginative about how you improve the public's health. The fact is that public health funding is not currently ring-fenced at all and lots of different organisations can try and get at it from the PCTs. In fact some of the PCTs will give money to improve, say, cycle lanes and you could argue that improving the potholes encourages more cycling. The point is that there will be an outcomes framework. That is going to be critical. That, if you like, is central Government's lever on it and, in many ways, is the protection. At the end of the day, the council will be judged, as councils are judged, through the ballot box if they have not improved the public's health. Also, there will be a health premium, which will incentivise local authorities—

Q448 Rosie Cooper: Minister, you are not really telling me that public health will be become number 1 on the agenda for local authority elections, that people are going to understand and be into the public health framework, especially as they have Health and Well-being Boards which have no power. Are you going to tell me that is going to be upfront and centre? Could this not be yet another layer upon which the local electorate is theoretically going to make a decision but is so low down on the list of whatever is happening at that particular time it is almost an excuse, in a way? It is a fog.

Anne Milton: Maybe I am more optimistic about the great British public than you are. I think it will and once local authorities have public health in their remit—let me finish—there will be enthusiasm. There is enthusiasm from the local authorities themselves, and it is not only because they can get their hands on some money that they did not previously have. Most people genuinely want to improve the public's health. This comes at just the right time because there is a change in public mood. There is an understanding that we have to do something to improve the public's health. To some extent, the drivers of this are going to be local councillors and they will be very powerful in this argument. If I think of my own constituency—an affluent area with small but significant pockets of deprivation—it is already out there rumbling away as an issue. As I say, once local authorities have the power to do something about it, I have no doubt they will. I think it does bother people that more than is reasonable of the population—

Q449 Rosie Cooper: Minister, you genuinely misunderstand my concentration on that.

Anne Milton: I am sorry.

Q450 Rosie Cooper: I am not saying public health is not important. It is very important, and very important for the fact that we are all breathing. The problem is that this is complex, it is layered and when people get to elections, as you introduced, the state of the Health Service—and we may disagree about where we are going to end up with the Government's current policies and Bill—will be more on their mind than the detail of the Public Health Outcomes Framework. That is what I am saying.

Anne Milton: The Public Health Outcomes Framework will not necessarily bother the public. How the councillors perform will do, and the director of public health will produce an annual report which will say how the council is doing. In fact, local authorities take a great deal of notice of the number of services done and their performance, so it will affect the public. What the public want to see is populations given opportunities to become healthier. They do not care—rightly so—about the mechanisms by which we do it. What matters to them are the outcomes. I know you think it is important. I also think that is a vision shared by the local authorities.

Q451 Rosie Cooper: The resources are being reduced.

Anne Milton: They are going to be ring-fenced for the first time. They have never been ring-fenced before. It is a start.

Q452 Rosie Cooper: But we do not know what is going to be inside the ring fence.

Anne Milton: As I say, you will do. It is tedious in the extreme, I know, for many committees to have to sit there and be patient while we say that this is a work in progress, but we need to get it right. In fact, I have been impressed—and I am not always impressed by everything that "government" does—with the time and trouble that is being taken to try and get this right first off, because it does matter.

Q453 Dr Poulter: Picking up on some of the issues around outcomes and the outcomes framework, there are domains that have been identified around health protection and resilience, tackling of the wider determinants of health, health improvement, prevention of ill health, healthy life expectancy and preventable mortality. I understand Professor Harper told the Committee last week that you were "going to be working and engaging with a range of key partners to develop our thinking on the right indicators" for the Public Health Outcomes Framework. What criteria are you using to determine which indicators are appropriate? Professor Harper can go first with that question.

Professor Harper: You are absolutely right that, over the next few months, we will be working with a whole range of key people, including people from academia, practitioners and the people involved absolutely in delivery on the front line. Of course, we have the benefit of the organisations that will be coming into Public Health England to help us develop those indicators. The criteria are very basic and are laid out in a number of different documents. It will be about having something which is meaningful and something which is measurable. It is all very well having an aspirational indicator, if you like, or an aspirational outcome that we are trying to pick an indicator for, but it has to be a measurable—a meaningful—indicator, something that is quantifiable and can demonstrate progress towards reaching the outcome that is being considered.

Q454 Dr Poulter: Clearly, these outcomes are going to be applicable on a local basis, as we have heard, in different local authorities and there is going to be a framework established. Let us say, for example, a local authority were to prioritise clearly one, two or three of those framework criteria but were to ignore, effectively, one or two others. Would that be something you think would be acceptable, in terms of the outcomes framework? Let us say you are a local authority putting in place your outcomes framework—which will be applied locally, but nuanced—and you had your five domains around which you are focused but you effectively ignore some of that outcomes framework and focus on only some aspects of it. What would your view be of that?

Professor Harper: The point I would make is that the nationally-set outcomes framework are outcomes considered to be of the utmost importance for the country—for population health across England. If we take the first domain, as currently indicated in the document you are referring to, I must say that, over the next few months, there could be substantial changes on the back of comments received through the consultation and listening exercise. We will be working further even on the domains, not just outcomes within those domains, and indicators of progress against those particular outcomes.

If we took health protection and resilience, there would be things such as having plans in place to deal with an emergency, which are vitally important, and being able to reduce numbers of cases of tuberculosis. I am picking—there is a risk in picking—particular outcomes to illustrate the point, and I hope people will understand where I am coming from. If these are considered, when we publish the outcomes framework later in the year, to be of such national importance they need to be part of the national outcomes framework, then the strongest indication is that those will need to feature in the delivery plans of any of the constituent parts of the system. Of course, there will be local outcomes frameworks as well and there will be things that are absolutely the responsibility of the local authority, for example, and other delivery organisations within the public health system. Those will be developed and they should be complementary to the nationally­set outcomes framework, which, in public health, should be, as far as possible, aligned with the NHS Outcomes Framework and the Social Care Outcomes Framework.

Q455 Dr Poulter: Do you have any concerns on that basis? I accept what you have said, but there would be money, obviously, going to local authorities directly. Although the money going to local authorities will, effectively, be ring-fenced and you have your national outcomes framework and your local outcomes framework, a local authority could potentially divert funding into areas with a funding shortfall rather than those necessarily compatible with the national outcomes framework. That is, a funding shortfall for that local authority, for example, housing or other issues or duties that may be connected with the local authority.

Anne Milton: This is the issue which was raised earlier and alluded to. It does cause some concern. It would be naive for us to sit here and deny that that is a possibility because public bodies have become awfully good at what is commonly referred to as "gaming the system"—dressing something up as something else in order to get their hands on the money, or to achieve targets or whatever. The meaningfulness and measurableness of these outcomes is going to be very important and this money is being given to local authorities on the back of compliance with the local outcomes framework. That is a very important message and one that has been heard by local authorities loud and clear. There are wonderfully imaginative schemes out there already which local authorities are using to improve the public's health. On first appearances, they stray into all sorts of areas you would not normally associate with improving the health and well-being of the local population, but they have actually been incredibly effective.

Q456 Dr Poulter: I hope I am not being disingenuous to local authorities—I do not mean to be because we have to assume that public servants are, generally speaking, publicly spirited—but there is a certain amount, and we have seen this, to some extent, with, say, the QOF payments to GPs, of game playing that can occur in order to attract—

Anne Milton: Surely not.

Q457 Dr Poulter: It can happen. If we saw that, for example, a local outcomes framework were to be structured in such a way as to pick up areas of other shortfalls in funding that the local authority felt it may have, what mechanisms are going to be put in place centrally to make sure that sort of game playing cannot occur?

Anne Milton: We need to be mature enough, if we do not get it right first time, to adjust it. It is almost impossible in Government to exclude entirely the possibility of unintended consequences of legislation and unintended consequences of something like this. I would not suggest, Chairman, the Committee is being disingenuous to be appropriately sceptical about local authorities, but that is where we have to get this right. That is why we are trying the patience of not just this Committee but others in saying, "I am afraid you will have to wait for the absolute results," because it is an important work in progress. As you say, public bodies at all levels and in all fields have become very good at gaming systems. From my point of view—this is very personal and, in a way, I feel is an important part of my role—working through DCLG, the Local Government Association, and up-skilling councillors into this very big and new area of work they will have influence and power over is going to be essential because they are quite a significant balance in this as well.

Chair: Talking about gaming the system, Rosie would like to come in.

Q458 Rosie Cooper: My constituency has pockets of great wealth and great deprivation. At some points, if you were to compare them, for the person living in the poor area, the gap in life expectancy is 10 years, which is a very scary fact. I would like to address the health premium question. Minister, last week we asked Professor Harper what the Department were considering doing to reduce the risk that a proposed health premium may in fact operate in a regressive way. He was not able to give us any details. I am looking to you for assurances. What assurance can you give us in this regard?

Anne Milton: What I can give you is political assurance. I have to repeat—not because I do not think you have not heard it but it is important to say it again—that to reduce inequalities in health we have to improve the health of the poorest fastest. The health premium is a way of doing that but there are several issues we have to consider really carefully. We were talking about gaming on outcomes and councils spending money on inappropriate things. With the health premium, it is going to be even more important to get it right. There are several issues. One is in local authority areas where there is a very mobile population. Although they get the health of the local population better, they move out and another lot, with poor health, come in. Thus, the area appears to have done nothing but it has possibly achieved quite a lot.

The other issue you have raised is about it being regressive. Again, it is a work in progress and I know the King's Fund have offered to give us some help and support on this. To get this right and to work—and it could be a very powerful tool, as you rightly say, in areas like yours where you have very big discrepancies—it is very important that we seek every piece of advice we can from a wide variety of experts to make sure we get the gearing on this right to produce the outcome we want. I can give you my political assurance. I do not have the expert knowledge to say how that is best done, but I am very clear, and the Secretary of State is very clear, about the outcome he wants to achieve.

Q459 Rosie Cooper: When are we likely to get those?

Anne Milton: I think in the autumn. Professor Harper will now come in and correct me if I am wrong on that fact.

Professor Harper: On the health premium itself we would expect to have details of how it will work later this year, but, of course, it will be dependent upon having the outcomes framework agreed. We will have shadow allocations agreed for the start of the next financial year, but the first year of introducing the health premium will be at the end of that first year. Therefore, there will be a year for local authorities to perform against the outcomes framework and then the health premium will be introduced, for the first time, for the second year of the new arrangements.

Q460 Rosie Cooper: In that first year, will you, obviously, be using that to make changes?

Professor Harper: Yes, to improve.

Anne Milton: That will be quite an important year. It will be when we start to see where we can tick a box if it has worked well. I think any gaming that might be in the system will bubble to the surface at that point. It is going to be important and critical to inform so that we get it absolutely right when we kick off with the real allocations.

Q461 Chair: There is a core issue here, isn't there? It is not really about gaming or the technicalities of the system. The concept of the health premium is to channel money to those areas that have already demonstrated a capacity to outperform other areas. Therefore, I do not fully understand how it can be that the health premium is not regressive. It is a means of channelling resources towards those areas that have already demonstrated a better performance than other areas, is it not?

Anne Milton: It is about progress.

Professor Harper: Yes. The intention is to pay a greater premium for more disadvantaged areas that make that progress.

Q462 Chair: You have bands of areas where there are relative Jarman-style disadvantages, presumably. However, it is still true, is it not, that, as between two areas in the same group, one area demonstrates greater progress than another—presumably by raising the health standards of the most disadvantaged in that area—and wins a health premium and another area does not make such good progress with the disadvantaged and does not get the resources for the future? I do not understand how that does not deliver a perverse outcome.

Anne Milton: That is why it is extremely important. If you measure progress alone—progress as against the absolute improvement that you achieve—it should not mitigate against authorities, as you say, who still have the same problems but have not made the progress that they should. That is why you have to be very careful with it and why talking to organisations like the King's Fund, who I know have done quite a lot of work on this, is going to be quite important. As I say, there are other issues about transient populations. They have not been raised but I know they are also an issue.

Chair: Thank you.

Anne Milton: Then there is the measuring of it which, in itself—

Q463 Chris Skidmore: I was coming on to the measurement because, obviously, with public health interventions you simply cannot measure them. It has to be a five-year period at the very least, I would have thought. On issues such as sexual health, for instance—where improved screening will probably increase the rates of STI infection and you will have a perverse system where the number of cases would rise—would you penalise areas doing a good job in detecting rates of STIs, or coronary heart disease or whatever incidences are currently hidden? How would the premium work then, because the results over the first two to three years would probably be perverse?

Anne Milton: Absolutely. You are quite right. If you were going to measure the incidence of smoking­related disease, for example, chronic obstructive airways disease, you would have to wait a very long time. There has been quite a lot of research into this because previous Governments have also wanted to demonstrate improvement. As you rightly say, with STIs—and it was a good one to choose—if you start diagnosing them, the rate appears to go up. You would need to look at proxy measures. On things like smoking, you could look at quit attempts, you could survey populations to see how much they are drinking and you could weigh people to see how fat they are. You cannot, however, go to the ultimate outcome which is to reduce the incidence of coronary heart disease, which are much longer timelines. There is quite a good evidence base. As somebody said to me only this week, one of the mistaken things sometimes about public health is that, almost as an excuse, people say there is not a good evidence base when there is some quite good stuff on measuring those proxy things that demonstrate whether things have improved.

Chair: Thank you.

Q464 Dr Wollaston: I am going to change the subject now to Public Health Observatories. We have heard some serious concern within Public Health Observatories about their funding and also about their future role. Could you give us some undertakings on both those issues?

Anne Milton: Yes, I can. I answered an Adjournment debate—I think possibly from a member of this Committee—on this.

Dr Wollaston: Yes. It was Mr Morris.

Anne Milton: I do not have the details of the current allocations, but I can certainly let you have that. Without a doubt, Public Health Observatories have led the way on a lot of the research and absorbing them into Public Health England is going to be very important. That is where a lot of the rigour, expertise and research have lain. We cannot do this without the evidence. Again, I suppose what I am giving you is a political commitment to their importance. Without doubt, there is an overlap, and certainly, as a new Minister, bright-eyed and bushy-tailed, I am slightly appalled at how many people appear to be doing not the same thing but similar and related things and not having a conversation with each other. From my point of view—and I am a neat­minded person and like everything in order—bringing in those Public Health Observatories and harnessing that expertise so that we use it and do not replicate it is going to be very important.

Q465 Dr Wollaston: To some extent they do that already, do they not? They have regional specialists as well.

Anne Milton: Here they do, yes.

Q466 Dr Wollaston: The north-east would, say, focus on alcohol policy. They are not all reinventing the wheel and doing the same things.

Anne Milton: No, they are not. There are other organisations that are doing it.

Q467 Dr Wollaston: But you can give us your commitment to the value that they play and make sure that their role will not be diminished.

Anne Milton: Absolutely, without a doubt. In fact, I would argue that their role will be enhanced. What will arise out of the changes in public health, notwithstanding concerns about the detail and the process, most importantly, is that the sort of work the Public Health Observatories do will now be spread out into the wider world because they are a source of quite a lot of information for a lot of organisations beyond the realms of health.

Q468 Dr Wollaston: You are not intending to concentrate them all within one organisation at the Department of Health in London. They will still have a regional presence.

Anne Milton: Where they will be physically based, I do not know.

Q469 Dr Wollaston: You mentioned that they are going to be spread out.

Anne Milton: What they know and what they say will be spread out. What matters to me is not where somebody is physically. As we all know in this day and age, where you are physically is not desperately important. It is how far and wide your message goes that matters.

Q470 Dr Wollaston: Although you could argue that, for public health, the information gathering does need to be, to a certain extent, regionally placed. You are better able to—

Anne Milton: I do not think there is any right or wrong answer. As I say, where people are physically is not any longer the point. If we have important messages we need to spread out, it does not matter from where they start. What matters is that they get out. The trouble is that a lot of work done in public health has not got out. It has been a little bit of a Cinderella service.

Q471 Dr Wollaston: Is it still a work in progress in terms of the structure of how Public Health Observatories—

Anne Milton: Yes, the structure and where everybody sits at a desk—where personnel sit and all the rest of it—is all ongoing.

Q472 Dr Wollaston: That is all ongoing but you are absolutely committed to their role.

Anne Milton: Yes, very much so, and mindful of the fact that we are dealing with people's lives—travelling arrangements, family arrangements and all the rest of it. We can be very theoretical when we talk about things like this and devise good models but we are dealing with people's lives.

Q473 Rosie Cooper: I would like to ask a question on NICE. They are supposed to have a continuing role in evaluating public health interventions, yet have not met once this year. One question is what that indicates about NICE's future involvement. However, I would also like, just before that, to ask you a quick question about Public Health Observatories and their funding. My understanding is that they get two sources of funding, core funding and that for commissioned work. In all the assurances we have had about protecting the front line and protecting the outcomes, it appears that both those budgets have been reduced by a fifth—23%. How does all that fit in?

Anne Milton: I am going to ask Professor Harper to come in and help me. My understanding is that bit of the budget—I can send you the reference for that because I know I covered this in my Adjournment debate, although I do not recall the detail—is being replaced from somebody else. I will look to you, Professor Harper, to see if you have the figures.

Professor Harper: There are two parts of the funding. As far as the core funding is concerned, some of that funding has been held back centrally this year but is available, should it become necessary, for use in the most appropriate way. The figure quoted as having already gone out as core funding is part of the total funding available, of the order of £5 million. The non­core funding is funding for a range, if you like, of specialised services. That has gone down by the same order, coincidentally. That is partly, at least, because some of their contracts that were let have, themselves, terminated. There are a number of reasons why the non­core funding has gone down, but there is a portion of the core funding that is retained taking it up to the order of £5 million.

Q474 Rosie Cooper: Why?

Professor Harper: It is because we are going through the transition and the groups that have been set up—not least the group chaired by Professor Newton as you heard last week—are looking at the best arrangement to deliver the functions which are critical to Public Health England and the public health system in the most efficient way.

Q475 Rosie Cooper: Are we saying that some of the core funding was spent in previous years in the wrong way or unnecessarily?

Professor Harper: Not necessarily. We are saying that now is a good opportunity, with the transition, to take stock, look at the priorities and look at how best to deliver the outcomes we are looking for in terms of information and intelligence. There is a huge amount of consideration of the best way of dealing with this. Retaining part of the core funding at the centre until such time as it is needed or it is recognised where it can be best spent gives the flexibility we have not had in previous years.

Q476 Rosie Cooper: Who will decide that? How will that get fed out?

Professor Harper: It will be decided through the group and the infrastructure that has been set up—the governance arrangements—where Professor Newton is playing a key role.

Q477 Rosie Cooper: It will not be the Department of Health that decides whether they are getting it or not. The budget is there for them to use.

Professor Harper: If it is necessary.

Q478 Rosie Cooper: So it is not really there for them to use.

Professor Harper: If it is considered to be necessary, through all the governance processes I have alluded to, then the money will be made available.

Q479 Rosie Cooper: I see. In a previous life I used to work in a retail organisation where the directors' and associate directors' bonus payments were referred to as "the Goodwin Stakes" because there were that many hurdles you never got there. Is this going to be anything like that?

Anne Milton: We would hope not.

Q480 Rosie Cooper: Shall we go back to NICE and their involvement in the future public health agenda?

Anne Milton: Yes. They are going to be very important. I understand—my little note tells me—that the Health and Social Care Bill re­establishes NICE in primary legislation. They are going to be an important source. I gather that we asked NICE to review the public health interventions programme in the light of the new priorities. NICE has a critical role to play, particularly if we consider that, although there is quite a lot of evidence on public health and public health interventions, we have not always collated and collected all that evidence together under one roof and come out with some good guidance. It is going to be absolutely vital.

Q481 Rosie Cooper: But if it has not met so far this year—

Anne Milton: As I say, we are reviewing how we do public health. NICE needs to consider how it is going to do this in the light of our priorities. There is nothing sinister in it not meeting. NICE continues to play a terribly important part. Its reputation is world wide, so we are obviously going to use it. What we need to make sure we do with NICE is to use it in the most effective way. There would be a danger of scatter­gunning requests to NICE and commissioning work. We need to make sure that Public Health England and NICE are well aligned.

Q482 Rosie Cooper: When do you think that will happen?

Anne Milton: I gather the Secretary of State has already commissioned some work.

Professor Harper: Yes. I know this question came up last week, particularly about the Public Health Advisory Board, which has not met. Of course, the executive part of NICE is there, it is working and we have close contact with the staff. They are doing the work. What has not happened is the Advisory Board has not met. Part of the reason for that, having gone back and checked this from last week, is because we have asked NICE, as we indicated, to reconsider how they play into the new public health arrangements. Ministers have already asked NICE to consider some additional topics. It would be surprising, but not my call, if the Advisory Board did not meet in the relatively near future.

Q483 Rosie Cooper: Thank you. Minister, how has the Government's response to the Future Forum specifically changed plans for the involvement of public health expertise in commissioning in the new system? Also, why are seats on clinical commissioning groups not reserved for public health specialists to ensure that the very input you have been talking about takes place?

Anne Milton: I know this is an issue that came up a lot when the Future Forum was wandering around—moving around, not wandering. It sounds like a rather slack attitude.

Q484 Chair: That was an interesting choice of verb.

Anne Milton: Yes. If you talk to any member of the Future Forum, they talk about a frog-march around the country at an enormous rate.

Something that has come up with me is the concern that public health advice will be lost to commissioning intentions and decisions. The directors of public health will provide public health advice. Whether this is laid down in statute is something that forever gets argued and I always get slightly frustrated because whether it is laid down in statute does not necessarily make it effective. The commissioning groups will have to have due regard to public health advice.

Q485 Rosie Cooper: Why? They do not have a veto. The Health and Well-being Boards have no powers to veto it. They can make recommendations. They can talk to that wall, and many people do quite often, but they do not have to.

Anne Milton: Who talks to walls, if I may ask you a question? Chairman, if I may indulge the Committee Member by asking a question back: which walls and who is talking to them?

Q486 Chair: Can we regard it as a rhetorical question?

Anne Milton: Yes. Maybe it is a rhetorical question. The clinical commissioning groups will need to heed public health advice, as any commissioner would now. You make better decisions if you heed it. The Health and Well-being Boards are going to be critical inasmuch as they can refer back. They have teeth. Certainly within local authorities they will have the power they choose to take. It is significant if they choose to use those powers, so they will be in a position to be able to refer—

Q487 Rosie Cooper: Could you describe those powers, Minister?

Anne Milton: They will be able to refer up to the NHS Commissioning Board if they are unhappy with the clinical commissioning group's decisions and processes. Heeding public health advice, I have no doubt, will be one of those. With the directors of public health in local authorities—and of course the director of public health is a key part—sitting in those Health and Well-being Boards and bringing together all those different sorts of strands of health and well-being, if they choose to exercise their power, they will be enormously powerful. I would not underestimate it. Power is something that is rarely given to you. It is usually something you claim.

Q488 Rosie Cooper: If the only power that people have is to refer to the National Commissioning Board, then, in the end, the National Commissioning Board is not going to be able to carry out much work because they are going to be completely jammed with people objecting to X, Y and Z because they are not being listened to.

Anne Milton: You have very little—

Q489 Rosie Cooper: I have 30 years of local government experience.

Anne Milton: So do I. I have 25 years in the NHS and as a local councillor. Some of the clinical commissioning groups will make good commissioning plans. I do not think they will all be bad and all end up being referred.

Q490 Rosie Cooper: Come on, Minister. The reality is that, yes, a lot of those decisions will be absolutely superb, but the real critical clinically­required decisions will not necessarily meet the will of the local population. When those decisions are about, there will be some very difficult times. You cannot run away from that. It is going to be very difficult.

Chair: We are probably straying into the effect of commissioning decisions on health care services.

Anne Milton: The only thing I will say—because although it might not have been your intention, you raised the issue of the will of the local people—is this. There is what people want and what people need and there is what people need to have and what people choose to have. They are not necessarily the same things. There will be some tensions—you are absolutely right—and it will be interesting to see how those play out. However, that is a tension that we, as local Members of Parliament, have felt, necessarily, being unhappy with decisions that PCTs have made. This will bring it all under one roof and the Health and Well-being Board, in a way, will be a forum where all that tension is harnessed.

Q491 Rosie Cooper: Can I throw in one very last point? You need to get local doctors involved in the part of the Bill about clinical senates, and that kind of thing. However, if you are going to get local GPs really involved, it is going to cost them time. They have made it very clear that they would be required to be paid to give up that time. Do you see that impacting on the public health agenda?

Anne Milton: Now we are straying into areas in which I do not have the expertise, the clinical commissioning groups. It will take time. There are quite a lot of structures and organisations GPs are currently involved in which I do not think are terribly effective. I could name a number where a lot of time is spent achieving very little. I would hope their time is better spent. Less time is not necessarily worse time. Less time can be better time.

Q492 Chair: May I move the discussion on to the question of the structure of the commissioning of public health services? When this policy started off, 12 months ago, it was attractively simple. The responsibility for public health was going to be transferred into local government and, to some extent at least, it owed its parentage to the old concept of a medical officer of health. As the months have gone by, it seems to me, it has become more and more complicated. First of all, how do we define the function of public health? Secondly, what is the amount of money we devote to it currently and how much are we going to devote to it in future? Thirdly, who is responsible for the public health budget that started off being conceived as one budget and now seems to me to be broken down into three sorts of budget: the NHS Commissioning Board public health budget, the Public Health England public health budget and that part that actually does end up with local government? I would be interested to hear how you articulate that move from the proposition last year, that we were going to transfer it into local government, to a proposition now that seems more complicated.

Anne Milton: Yes. May I share your disappointment? I like things that are simple and they have to have some fit for me. You are right it is a shame, but probably necessary—and I am convinced that some of it is necessary—if you start from the point of view that all those things which can be commissioned locally should be. I think there are some things we probably have to do from the centre—if you take immunisation programmes—because of their reach. Screening programmes would be another. Public health for those in prison or custody would be something else. We have also sat in, at a national level, child public health services. This is in line with Coalition commitments to early years, to improving or having an impact on the lives of young families. It sits there for now as we drive it forward. If you like, we are almost kick-starting a new service. Certainly, the political will would be there to move everything possible to local commissioning, if we could.

As to Public Health England, one of the difficulties is when one is talking about theoretical things. It is important sometimes to have a check that we all have the same vision in our head—the same picture, if you like. For me, there is quite a lot of clarity in things like immunisation and screening sitting very sensibly at the centre. It is a nationwide and a population­wide thing. I do not think there is much opportunity for local intervention and local discussion, although there might be—

Q493 Chair: Even accepting that, there is a decision that has been made, apparently, that it sits with the Commissioning Board of the NHS rather than with Public Health England.

Anne Milton: Yes.

Q494 Chair: I am not quite clear why that is.

Anne Milton: I see Public Health England, which is the third strand of this, almost providing, in some ways, the direct line of sight for the Secretary of State. That is important. Public Health England has a crucial role on health protection. I hesitate to say that it is the admin organ because we are cutting administration. It is not administrative. It is the policy and the evidence driver of interventions further down the tree. It is the engine room.

Q495 Chair: If it is responsible for making decisions about priorities—even take it as a ring­fenced area of health protection—if the commissioning process for immunisation programmes, for example, is the responsibility of the Commissioning Board, has that not taken most of the budget out of Public Health England?

Anne Milton: No. There must be some budget left. We have talked about Public Health Observatories and we have talked about all the health protection services, so, no, it will not have done.

Q496 Chair: It must have taken a significant amount.

Anne Milton: It must have taken some. It depends what you consider to be significant.

Q497 Chair: May I just ask the question: why is the Commissioning Board being introduced to do this rather than Public Health England?

Professor Harper: If I could use the example of immunisation, one of the concerns expressed, quite understandably, from a number of quarters was about fragmentation of delivery—different parts of the system responsible for different parts of delivery. So far, and this is still work in progress, the suggestion is that the coherence is brought about through the commissioning route, through the NHS Commissioning Board. However, there will be procurement of vaccines, there will be a vaccine policy and there will be the Joint Committee on Vaccination and Immunisation still providing that essential independent advice to the Department and to Ministers, to the Secretary of State. That will be where the policy is developed, but, of course, we have to recognise—and much of the immunisation programme is delivered through primary care, through general practitioners and some through school programmes—that in order to have that coherence and to benefit from the new system, at the moment the thinking is to have that coherence through the NHS Commissioning Board.

Anne Milton: Professor Harper has put much better into words what I was trying to describe. The NHS Commissioning Board has those links with the local commissioning groups. Immunisation is a good one to pick, but it would also apply to screening programmes. There is a natural synergy. I suppose Public Health England, except for health protection services, is not going to be involved in that relationship directly and on a day­to­day basis. It is about providing expertise, evidence, support and leadership.

May I use this opportunity, Chairman, to say that I think political leadership is very important and we do not talk enough about it. There is an opportunity to provide political leadership in an area—and I do not mean this on any sort of party political basis—where there has not been political leadership before.

Q498 Chair: May I take Professor Harper back to a phrase he used in his answer. He said "for the moment" it was planned this should go into the Commissioning Board. Was there any significance in that remark?

Professor Harper: Simply that, with many of the areas we are talking about today and we talked about last week, they are work in progress.

Q499 Chair: That decision remains at the moment—

Professor Harper: For the specific areas—I picked only one specific area—those are discussions that are currently underway.

Q500 Chair: Thank you. The same applies to all the other allocations of commissioning responsibility, does it?

Anne Milton: Yes.

Q501 Chair: How much commissioning responsibility for public health services do you think will rest with local authorities outside the six core areas that are identified in the Command Paper?

Anne Milton: Did you say how much responsibility?

Q502 Chair: There are six core areas defined in the Command Paper as being core areas that local authorities have to be responsible for. My question is: what is the scope of their public health responsibility beyond the six core areas?

Anne Milton: I would say, to some extent, they have those areas of responsibility and they have—

Q503 Chair: The reason for my question is that, if that is their core area, they have to do that. The risk is, is it not, that any resource currently associated with public health that goes to local authorities that is not in those six core areas gets siphoned off into pothole filling?

Anne Milton: Then what is surprising maybe—and I look forward to the Committee's report because it might shed some light on the fact—is that, currently, local authorities have some responsibilities for the health and well-being of their population, and things like community safety are a health and well-being issue. What is quite surprising is how much local authorities are already spending on what we would consider to be public health interventions and the provision of many services. They are not compelled or obliged, but they do it because that is what they believe their local residents want. What this will do is beef up the pressure—coming back to Rosie Cooper's point—to apply those more evenly across their population, particularly in areas where there are wide variations in deprivation.

Professor Harper: If I understand the question right, Chair, you are referring to what we have called mandated services in the policy statement.

Chair: Correct, yes.

Professor Harper: Those are services that are considered to be special, for whatever reason. Of course, as the Minister has said, as to the outcomes framework, the broader areas of public health, you will not find, in these mandated services, areas around smoking cessation, for example. Those are very important public health areas and those will absolutely be part of the local authority responsibility. I think the six areas that you were alluding to or that you referred to are simply the mandated services.

Q504 Chair: Yes. The reason I have picked them out is, as I read it—if I am honest, I have only read the summary of the Command Paper so far—it defined six core areas and it remains, twelve months on, unclear what services, currently delivered, fall under the heading of "Public Health Services".

Professor Harper: These are services that are considered to be of a special nature.

Q505 Chair: I understand that about those six. It is the rest of it that I am interested in.

Professor Harper: The rest will be covered, in due course, by the publication of the outcomes framework and all the other areas we have been talking about this morning.

Q506 Dr Poulter: On that, interestingly, in these six areas you have chosen "appropriate access to sexual health services." Why, out of interest, was that chosen rather than, as you raised yourself, the issue of smoking cessation being, maybe, an essential ingredient in some of the criteria? Why, particularly, did you pick and fall upon some of these areas? That is quite specific criteria about sexual health.

Professor Harper: Yes. There are a number of special features about sexual health services—how they are delivered and what is required of local authorities as part of the overarching system. Without going into too much of the detail, if you took something like smoking cessation services, it would seem entirely appropriate for local authorities to decide, having the outcomes set, if that is one of the outcomes—whatever the indicators might prove to be in due course, as we said earlier—and to do whatever they considered necessary to deliver those outcomes. With sexual health services, there are some very specific characteristics. It is hard to pick them at the moment, but if you take Chlamydia screening or STI treatment—if you take the services that, at the moment, we consider are appropriate for local authorities but not, for example, HIV treatment, there are some very particular elements which, together, have led to this relatively short list.

Anne Milton: You have a Committee Member, Chairman, who is not convinced. I can tell by his face.

Q507 Dr Poulter: We could debate the key points, but I struggle to follow why this has been something that has been specifically set around sexual health. This is specifically framed, and why I say smoking cessation—

Professor Harper: Across the entire country, if we looked to help public health, if you take the national child measurement programme as another good example, it would not be very helpful if a number of local authorities opted out of that, whereas, according to the Joint Strategic Needs Assessment, and in the light of the outcomes framework, if a local authority chooses to resource, out of the ring fencing, more or less on smoking cessation services, that is about a local decision, which is the way the new system is being set up. It would not be appropriate for a local authority not to do the things that are indicated in this list.

Q508 Dr Poulter: My only concern on this is that it seems to be saying access to sexual health services is an issue out there on its own that is being made crucially important, more so than if you only put the others in the outcomes framework and more so than issues around alcohol awareness and smoking cessation. We know that, if you smoke, you are going to die probably a lot younger than if you do not smoke. That seems to be possibly a bit of an imbalance in the Command Paper. I am simply curious as to why sexual health has been chosen and put out there. If you were going to pick out, say, on national statistics, that there is a key issue with smoking cessation, why has that not been? It seems to suggest that is much more important.

Anne Milton: Can I come in on that, if it is helpful? Each issue has to be looked at on its own and it is about looking at a number of different things. Wouldn't it be easy if public health fitted into nice, neat boxes, which is how we used to do public health—indulge me, Chairman, if I may, for a minute—sexual health and alcohol? In previous public health White Papers, that is how they did it. We are taking a very much broader look at it. In each area you need to look at what the fit is with local authorities and where you need more local intervention and local decision making because areas will do this differently. One of the dangers and one of the problems with this—Professor Harper mentioned TB earlier and said that there a danger of mentioning one thing—is assuming an importance attached to something because of where it is commissioned. That is not the case. It is about where we will be most likely to get better results. Each area can be looked at on its own. Is that any help?

Q509 Dr Poulter: I do not fully follow what you are saying. Nevertheless, I will move on. I still think there is an issue around the fact that putting sexual health out there gives it a special status and elevates it above other public health issues—which may be covered in the local framework—and there is perhaps a legitimate concern around that, which I do not think is probably the intention at all. However, the other thing I am interested in is the issue around HIV treatment and why that is not necessarily considered part of sexual health.

Professor Harper: It is considered part of sexual health.

Q510 Dr Poulter: It is but it is being treated alongside infectious diseases as an issue. Is that correct?

Professor Harper: It is the HIV treatment not the diagnosis—not the early detection, if you like, which is obviously one of the key features of how we are looking to deal with HIV in the future. Treatment is considered to be an integral part of the NHS business. This is core business for the NHS.

Anne Milton: It is very specialist stuff.

Q511 Dr Poulter: The Commissioning Board is going to commission HIV treatment alongside its responsibility for commissioning treatment for other infectious diseases and I am curious as to why HIV is grouped with infectious diseases rather than with sexual health, which would seem a more logical pairing to me.

Anne Milton: It is both. You could argue both sides. What has been fascinating about this is that I meet one group of people who say, "We would agree with you absolutely," and I will meet another group, equally qualified and articulate, who will argue precisely the opposite. This is why, maybe, it is quite challenging for us to articulate why we have come to the decisions we have. There are very diverse views. HIV is not exclusively a sexually­transmitted disease, as you know. It sits in both areas and what we have had to do is to come down to a decision on where it sits best. The important thing is that there is not necessarily a right or wrong answer.

Q512 Dr Poulter: If I can continue on that—sorry, Chairman—my concern is that the majority of HIV in this country is sexually transmitted. It is either men having sex with men or is often, with migrant communities who come into the country, by heterosexual transmission. The amount of transmission through drug use is much reduced now we have real statistics.

Anne Milton: It is.

Q513 Dr Poulter: Probably 90% plus is coupled with sexual transmission, which is where I am struggling to follow this. Logically, if it is coupled with sexual transmission, why is it not coupled with sexual health?

Professor Harper: It certainly is not an epidemiological feature of this. This is not the reason it has been put there. It has been put there for a number of other reasons, for example, the length of treatment. There are other factors that are being taken into account for HIV—the way treatment is provided. These are features of HIV treatment that are quite different from, say, syphilis, gonorrhoea or whatever else you might want to consider in sexually transmitted infections. That is the sort of thinking behind separating it. It is the type of treatment, the duration of treatment, where the treatment is best delivered in the new system and how, therefore, the responsibilities will lie. There were a large number of responses during the consultation to these sorts of questions.

Anne Milton: There are different component parts. The big issue is late diagnosis. That is what we are struggling with.

Chair: We have probably covered that. Chris wants to ask some questions about workforce.

Q514 Chris Skidmore: I want to turn, in particular, to the issue of professional regulation. Obviously, within public health, you are going to have to have strong leadership, both locally and nationally, to be able to deliver your outcome objectives and within public health to have staff who are professionally qualified and appropriately registered. From your evidence in paragraph 50, I see your approach to professional regulation remains that it is going to be set out in the professional regulation Command Paper, Enabling Excellence, which was published in February, and provided for in Part 7 of the Health and Social Care Bill. In particular you state: "The Government believes that statutory regulation should be a last resort, when less burdensome regimes are insufficient to protect the public from poor professional practice."

Since the Command Paper was published in February we have obviously had a number of changes to the Health and Social Care Bill, notably the pause and the advice and recommendations of the Future Forum. I was interested that the clinical advice and leadership group of the NHS Future Forum had specifically recommended that registration should not be voluntary but, instead, should be by an appropriate national body and be compulsory for non­medically qualified public health staff. I think you would also admit, in your evidence at paragraph 49, that that would reflect the recommendations made by the Scally report as well, that it should be compulsory. I was intrigued why, given the Government's enthusiasm for the Future Forum and all their recommendations, you did not decide to them take them up on this particular recommendation.

Anne Milton: We have not decided yet.

Q515 Chris Skidmore: You have anticipated my second point, actually.

Anne Milton: There is a lot of strength of feeling generally, without straying into other areas of my brief, about regulation and whether it should be statutory or voluntary. There are number of things you have to consider. You have to consider the risk posed. The important thing with regulation—and it is a word that I think is often missed out—is about it being effective. It has to be effective. It has to do what it says on the tin. I think it is also important to recognise the limitations of any regulation. Regulation would rarely stop the likes of Harold Shipman—or any sort of scheme—from happening again, so there are limits to regulation. It has to be effective. In order to define whether it is effective and you understand the limits, you have also to define what the risks are. There are a number of things we are looking at.

As you say, the feeling came through very firmly in the Scally report that it should be a statutory regulatory system. The Royal Society for Public Health has proposed a system where public health professionals could be offered charter status. We are looking at all of these. As I say, the decision will be based on, "What is the risk posed to the public?", which is what regulation is all about; "Would making it statutory mitigate the risk?" and "Would we get rid of the risk?" Also we should always understand that we will never get rid of risk entirely.

Q516 Chris Skidmore: You would not entirely get rid of risk, but you would, in a way, "cover your back" more effectively than if an assured voluntary regulation meant that, suddenly, if something was exposed, it exposed the fault of the system itself.

Anne Milton: "Covering your back" is so useful. It gives me the opportunity to say that there are two types of regulation. There are "covering your back" regulations, which are devices for politicians to be able to stand up and say, "We have done A, B and C so the public is safe," and then there is a regulation that is effective. I am very keen that we get it to be effective. We will be producing final proposals in the autumn, but you are right in saying that there is strong feeling about statutory regulation.

Q517 Chris Skidmore: Yes. It is an issue of communicating the policy effectively, that you can deliver and that you will assure people that those professionals getting involved in public health have the necessary qualifications and capabilities to do the job.

Anne Milton: They have to have the necessary qualifications and this comes up in a lot of other fields. Anybody who is employed to do a job needs to be fit and able to do the job for which they were employed, which is not only that they are regulated or registered with the appropriate bodies. It is that they have the skills in order to do the job, and regulation itself does not necessarily mean that somebody does have the skills to do the job. We have talked about the need for leadership skills. It is going to be very important. What, as a Government, we have to do is assure the public that we have taken appropriate measures to reduce any risk to them.

Q518 Chris Skidmore: You are not, on record, opposed to statutory regulation.

Anne Milton: No, I am not opposed to it. We would always favour a non­regulatory route, but I am not opposed to it, no.

Q519 Chris Skidmore: In terms of the process, I know the Command Paper, and you have just mentioned that you are welcoming "further evidence from the profession on significant risk to the public," and "This evidence will be considered carefully over the summer with the profession, employers and other interested parties and final proposals will be put forward in the autumn."

Anne Milton: Yes.

Q520 Chris Skidmore: In terms of what is taking place this summer, you are still actively considering taking submissions. Is that through the Future Forum continuing work? Who is involved?

Anne Milton: Anybody who wants to be. This is very live. In fact I saw the president of the Faculty of Public Health yesterday and there are a number of organisations that have already given—

Q521 Chris Skidmore: I am not sure when our report is being published, but I guess you will actively consider any recommendations we will make as part of the autumn strategy.

Anne Milton: Chairman, we will look forward to seeing your report and hope that it is published in time to inform our decisions.

Chair: Our ambition is to get it done when we come back in September. We will see.

Anne Milton: My experience of Government is that the autumn lasts from about September through to Christmas.

Chair: Or indeed to March, quite often.

Anne Milton: Or indeed to March, depending.

Chair: We are now moving beyond institutions towards public health policy.

Q522 Dr Wollaston: I know that, in your opening remarks, you gave the commitment that you wanted to see real improvements in health inequalities. One area that repeatedly comes to mind, because it is so cross­cutting, is the issue of alcohol policy and looking at the impact that that has on public health in everything from the sexual health agenda, teenage pregnancies across the board, indicators for child health, early morality, suicide, violent crime, and the list goes on. Yet, to my mind, it is quite shocking the Government finds it difficult to introduce evidence­based policies and even today this is reflected in the House of Lords Science and Technology Select Committee report. Also, they highlight the fact that, with the nudging philosophy, in many aspects, whilst it might be evidence base for some nudge policies, for others there is both a lack of evidence or even in some cases evidence that it does not work.

Can I ask you to clarify at what point, if voluntary approaches are not working in industry partnerships, will you review the evidence and then take a regulatory approach rather than a nudge approach?

Anne Milton: Yes, and you are right to raise alcohol because it is one of the more difficult ones. Smoking is easy, to some extent, inasmuch as we do not want people to smoke. With alcohol, we are happy for people to drink a bit, but not too much. There are also two dimensions to alcohol, which you absolutely rightly raise. There is the health impact and then there are the wider societal impacts, which go as far reaching as domestic violence. The harms of alcohol are almost impossible to quantify because they reach so far.

I have had a brief look at the House of Lords report. I am slightly disappointed that they have jumped the gun a bit because, certainly on the Responsibility Deal, we have not got there yet. In fact, I chaired a meeting yesterday where we were discussing exactly the point they are making. The Committee, I am sure, Chairman, will be aware of the Nuffield ladder of interventions.

Your point is at what point we will punch in. If you look at what is going on in the Responsibility Deal, we are looking at how we monitor and evaluate and the timescale on that. I think we have to have yearly ones, although we would be looking at possibly interim ones as well in some areas. We have to see an impact quite soon, and I think all those involved—and it goes much wider than industry—are very aware of that. In a way, the regulatory route is a sword of Damocles. The difficulty with things like alcohol is that we are also banging up against European legislation and saying, "If you look at pricing, European competition law." Therefore, it is not solely in our hands, which is why getting on and doing some voluntary things, if they work—and time will tell—are important because we can do them now and we do not need European agreement.

What matters is how we monitor and evaluate and the robustness of this, and we were talking about the crucial role of NGOs in that. They are absolutely vital. At the end of the day, the NGOs are very good. It is they who will judge whether the monitoring and evaluation is robust enough to stand up and whether we have made a difference. However, we have an unusual and unhelpful relationship with alcohol, without a doubt, in this country. We saw it with the Licensing Act. We cannot necessarily import ideas from other countries. We have a relationship with alcohol that harms our health and creates significant problems for law and order.

I apologise for going on, but it is important to realise this is not that simple. You know it is not that simple. I was talking to the Director­General of the World Health Organization about the fact that if you look at guidelines on physical activity—you know, 30 minutes of exercise five times a week, or whatever it is—it is simple and cheap. It doesn't cost anything but maybe a pair of running shoes and it certainly does not take up much time out of our day. The impact it has on our health is profound, reducing rates of stroke and heart disease significantly, and yet we do not do it. Thus we have a very big mountain to climb, which is where the behaviour change ideas come in.

Q523 Dr Wollaston: Can I take you back to alcohol policy because there is some very specific evidence­based material out there. It is all around price, availability and marketing. You mentioned earlier that you are often constrained by European law, which is true, but, for some areas, like marketing, there is very clear evidence in other countries, such as France, where they have the Loi Evin, that that has already been upheld in the European Court and is widely supported by organisations like the WHO, for example. There are measures that we could take. You are absolutely right that there is not a single magic bullet here, but it needs to be across the board. Looking at the partners for the Public Health Responsibility Deal who have withdrawn, it is a measure of the strength of their feeling that our current policies will not go far enough in addressing a real crisis in public health.

Anne Milton: Yes, and it is very useful that you brought up the alcohol network and the Responsibility Deal. We have five networks, food, physical activity, behaviour change, alcohol and obesity. All of them have gone extremely well. Interestingly, the health and well-being at work is absolutely scooting ahead and there is fantastic stuff coming through.

Q524 Dr Wollaston: I am not denigrating the entire thing.

Anne Milton: The alcohol one is interesting and it is important to bring it up.

Q525 Dr Wollaston: As to obesity and alcohol, there are real concerns about them.

Anne Milton: The NGOs are quite happy with the obesity one, but the alcohol one has produced immense tension. There are, without a doubt, people who believe—I feel—that price and price alone is the only thing that needs to happen in order to alter this.

Q526 Dr Wollaston: I don't feel that. I agree with you, that it is cross-cutting.

Anne Milton: The test of whether voluntary action will work is in that Responsibility Deal and we do not have a lot of time to demonstrate it. At the end of the day, the Government will be judged, as will local councils, on our progress towards what we have said we want to achieve. We start with the voluntary route, acknowledging there are some hurdles, and indeed the Treasury has made some changes. They are small and a lot of NGOs feel they are insignificant but I suppose it sends signals that we will do something. It makes quite clear to industry that this is a ladder and we will climb up it if that is what we have to do.

Q527 Dr Wollaston: Can I ask for a timescale on that, on when you will make that assessment?

Anne Milton: I am happy to get back to you, because again we were discussing this yesterday with some of the key organisations and the NGOs, but my understanding is that a lot of the pledges have been made and they are available on the Department of Health website. We will monitor that at the year end, so it will be spring or early next year. Then we will have a benchmark from which to see progress. I cannot tell you at what point we would have to look at regulation and take the next step up the ladder.

Q528 Dr Wollaston: The alcohol strategy is due to come out in the October. Is that going to commit us to a policy, if we then find in the spring that it is not working?

Anne Milton: The alcohol strategy will lay down exactly what the Government's intentions are. It will lay down what we will be judged against.

Dr Wollaston: Thank you.

Q529 Dr Poulter: This is a key issue around alcohol strategy. What we are talking about here is a greater demonstration of corporate responsibility. It is a good thing to encourage, but there is not a simple solution. There is a culture in this country, particularly around binge drinking and those sorts of things, which is almost unique to Britain compared with a number of our European neighbours. In terms of achieving that corporate responsibility, it has proven quite difficult. If we look elsewhere, we want to support British agriculture, for example, and we have found difficulty in getting fairer prices for our farmers despite some very active campaigns, sometimes we see that supermarkets do not always show that corporate responsibility, even though there is a demand for it. The concern is, if this nudge theory does not work, about how we are going to act. One of the key issues is around cut­price alcohol in supermarkets and, although I am instinctively against regulation on this, that is probably the one intervention that might be effective in dealing with it. Is that an area, if the nudge theory does not work, where you would envisage some form of legislation coming in later on?

Anne Milton: We will regulate if that is what we have to do. Your point about the supermarkets is very obvious. We recently got into trouble because we applauded, I think it was, ASDA who said they would take promotions out of their fronts of stores. Then Waitrose and one other supermarket, Morrisons, got very upset because they never put them in their fronts of stores. We have to be slightly careful.

The issue of minimum pricing is a European competition issue and it is very live. I have responsibility for European matters and I talk to other Health Ministers in Europe. You are right that our association with drinking is northern European. There is something about the northern European countries. Without a doubt, price alone will not do it, but we will consider regulation if regulation is the route we have to go. I hope we do not. I think the mood has changed a bit. In the short period of time that I have been a Member of Parliament, living in a constituency with a significant night­time economy, certainly the licence trade and some of the retail outlets have become much more acutely aware of what drunken people in the High Street do to their brand, so there is a brand issue out there, which we are clearly tapping into. If I think of the progress that has been made in some of the other networks, it is about corporate responsibilities and retailers and producers feeling they have to tick some of these boxes now.

Q530 Dr Poulter: Thank you for that. Moving on, one of the other key challenges is dealing with the issues about smoking, which I do not want to talk about, but also about obesity and promoting healthy lifestyles. In health care you may well see local GPs incentivising someone who has had a heart attack, afterwards, to then take up exercise, effective dietary and nutrition mechanisms or go to the local gym as part of their rehabilitation. That is obviously important because it will hopefully improve their long­term chances of survival and recovery from their acute event. However, we often need to get in much earlier than that—before these acute events happen in the first place. On the issues of, for example, promoting healthy living with gyms, fitness and healthy eating, what specifically is the Government looking to do in terms of incentivising the industry, business and people to get engaged with that?

Anne Milton: That raises a huge number of important issues. To go back to alcohol, and it plugs into what you have just asked, one of the issues is that people do not understand how harmful alcohol is. Most people understand that eating too much causes you harm and smoking too much causes you harm. I do not think they always understand that drinking too much does cause harm. There is a major issue on information that we need to address, and that is something Government can do.

There is no one point at which you can punch into changing the way people lead their lives and their understanding both their responsibilities and Government taking action to reinforce that. The work that we are doing on early years and with young families is critically important to this, particularly if you consider Marmot—if you consider the poorest and improving their health the fastest. Some people will never come into contact with the public services. The only time they do is when they are pregnant. You have, sometimes, a once­in­a­lifetime opportunity to have an impact on how they lead their lives when they are very vulnerable to positive messages because they want to do the best for themselves and their children. It might not last and you might not see them again.

The early years stuff is important because what we want to do is make sure young people grow up with the skills they need to make good decisions when faced with what I consider to be a wide array of quite difficult choices. That is about what they eat, what they drink, whether they smoke, whether they take drugs, whether they have unprotected sex, whether they fall pregnant and so on. I am talking quite closely to colleagues in education about what work we need to be doing in schools. There are massive opportunities for local authorities because we always tend to think of schools, but, of course, some of the most vulnerable families and children are not desperately good attenders in schools and you need to think about such things as sports clubs. There is a wide variety of organisations out there that can deliver some of these messages. This is about public health being everybody's business because in some areas it is faith communities and in some areas it is other community groups. Messages have to be tailored to the population that you are dealing with.

Q531 Dr Poulter: We see sport as being very much something that reaches out, particularly in more deprived communities—football or whatever. It is often simply about engaging people in community activities, but is there a role for sport and the sports industry, or different sports, to take an active leadership in this and the Government to help promote and encourage that?

Anne Milton: Yes, very much so. Our physical activity network is massive, enthusiastic and doing exactly that. There is also the role of sport in building self­esteem and we have an important opportunity with the Olympics and the legacy. It is quite important to note, when mentioning sport, that anybody who was not any good at football tends to switch off and think that it does not apply to them.

Chair: Correct.

Anne Milton: Surely not, Chairman. Therefore, it is quite important there is not an elite flag over sport. We have to be slightly careful. This is about growing up children with the skills they need, and, my goodness, they need some skills. They really do. If you look at what you are faced with, and we have talked about marketing, and you look at the messages they are bombarded with, there is a danger—and it is one of the challenges that we face—that Government is always slightly behind the curve. We are talking about the next form of communication when people have already moved on to the one after that.

If I think of my own children, bringing in a personal point of view—I have a child of 27 and one of 15—the media outlets they have accessed are completely different. The world has changed enormously. We have to keep up to date and we have some quite good vehicles. Change4Life is one which has been important and powerful. It does not look as if it was run by the Government and, therefore, has been quite successful. If I think of advice, the FRANK website has been a very, very successful tool. We are reviewing the content of that. It is for young people to access information on drugs and they trust it and use it. Therefore, we have some good examples of what works. We have to get information out there and then we have to get the support in to help people make better decisions.

Q532 Dr Wollaston: On the very subject of football, which you mentioned, you can spend as much as you want telling young people sensible messages about alcohol, but next year they are going to watch the FA Cup and be bombarded with messages about alcohol, which will be subliminally making the link between sporting success and alcohol.

Anne Milton: You are absolutely right. In fact, when I first became a Minister, I did something during the World Cup, and it was a challenge because the consumption of alcohol, particularly at home—and you only need to look at the mini fridges that are marketed that save you the trouble of having to go to the kitchen to get your alcohol—and the consumption of pizzas rises dramatically. With alcohol we have a major challenge on information. I do not believe that most people even know—and if they do know, they do not acknowledge—the danger alcohol causes them, and I mean young people. We are dealing with a population between the ages of 14 and 25 and the difficulty, between the ages of 14 and 25, is that you feel you are immortal.

Q533 Dr Wollaston: Yes, but we are giving them mixed messages. On the one hand we are talking about the Government having programmes to give people education, and in fact my understanding is that the evidence base is around them having a fairly short­term impact, but—

Anne Milton: About what? I am sorry.

Q534 Dr Wollaston: Educating young people about the dangers of alcohol has a relatively short­term shelf life. There they go now, outside.

Chair: The bottles are out there ready.

Anne Milton: Are they water or alcohol?

Q535 Dr Wollaston: We are giving them a mixed message. On the one hand we are saying that we want to tell them about how they have to drink sensibly, but the overwhelming amount of marketing that they are being bombarded with, through the FA Cup, linking sporting success with alcohol cannot be right.

Anne Milton: That is why it is everybody's business. I have made a point of trying to gather information such as what happened in France and what is quite interesting is that if you dig down into the research things don't necessarily correlate. One of the difficulties with some of these interventions is to demonstrate causality. If you look at some of the legislation that has been passed on smoking—and indeed it is ongoing and in the courts at the moment—with some of the issues around smoking and displays of tobacco at the time at which legislation is passed, of course, a number of other things come into play, and not least that it is widely discussed in the media. Therefore, awareness is raised and it is quite difficult to do. Nevertheless, you are right, and it raises the issue that this is not only a matter for the Department of Health. The Cabinet Sub­Committee on Public Health is there and all the Departments are represented but, more to the point, all the Departments turn up, which is, as the Chairman will know, not necessarily always the case. Thus everybody recognises that it is important and is part of their remit.

Maybe on another occasion, the Health Select Committee would like to discuss this further with the Department for Culture Media and Sport when they have perhaps less to do than they have at the moment.

Chair: On that note, there is the opportunity to draw this to a close. Thank you very much. You have been extremely patient with us. You have certainly convinced us of your passion for the subject. Thank you both very much for coming.

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